The War on Pain vs. the War on Addiction

Every prescriber in New York State was required to take an opioid prescribing course mandated by New York State by July 1, 2017. The stated purpose for this training is to make physicians aware of appropriate opioid prescribing practices.

Over the past ten plus years, there has been an explosion in opioid addiction in this country, including New York State. It is well understood that many individuals who develop addictions to these substances will move over to heroin, a cheaper and more potent alternative.

The government on national, state and local levels has been chasing its tail trying to get ahead of this continuously increasing trend of opioid addiction. They have developed numerous opioid addiction coalitions, have allotted funding for more and more addiction treatment programs, have increased law enforcement programs, have enacted physician regulations to prescribe all medications electronically and enacted a prescription monitoring program which requires prescribers to check a state prescription database prior to prescribing the patient in their office a controlled substance. Although all of these changes are positive, we still continue to see both heroin addiction and fatal overdoses from these drugs increase at an alarming rate.

How did we get here? Many blame physicians who have overprescribed opioid medications in hospitals and offices. This may be partly true but there is a larger issue. As a psychiatric resident in the late 1990’s, I can recall being required to assess every patient’s physical pain score. In order to receive a top score by the Joint Commission, a national organization that grades and accredits health care facilities, every single patient who came into the emergency room (including the psychiatric emergency room) needed to complete a pain scale, letting us know how much physical pain they were currently experiencing. Any score over four had to include documentation by the health care professional about what was done to address the pain. The message was clear: Do something about your patient’s pain. Physicians felt vilified if they ignored their patient’s complaints of physical pain, even if they came into the emergency room with something completely unrelated like a panic attack.

The pharmaceutical industry was not a great help. That industry encouraged physicians to use opioids in order to manage their patient’s pain. Opioid medications worked, and they worked quickly. Physicians were assured that there were new formulations of opioids that were much less addictive and were less prone to abuse and diversion. Prescribers who helped their patients in pain were happy, patients were pain free and happy, and with opioid prescriptions being one of the highest prescribed medications in this nation, you can bet the pharmaceutical industry was happy.

Fast forward to the present day. The majority of prescribers are much more informed about the risks of opioid prescribing. They have no interest in creating a cohort of patients who move on to develop opioid addictions. Of course there are the few prescribers that we hear about in the media who, after investigation by the Drug Enforcement Agency (DEA), are deemed to be inappropriately prescribing and contributing to this epidemic. However, this is the exception, not the rule. Most prescribers are interested in helping their patients while “doing no harm”.

Regulations and imposed expectations on physicians and other health care prescribers continue to increase. Time and expenses to meet these imposed regulations are not compensated. The message to prescribers is clear once again: We will tell you how to treat your patients. But if something goes awry, you are responsible. This is the continued double bind that government regulations put physicians in.

A nurse practitioner wrote to me recently, “First it was the war on pain. Now it is the war on addiction.” To clinicians today the message is clear: There is an art to practicing medicine that is quickly evaporating in this climate of increased government regulation. Let us all try to be the healers we intended to be with less government interference.