By Ajay K. Singh, MBBS, FRCP, MBA
December 27, 2016
In a December 16, 2016 interview with NPR’s Terry Gross, Dr. Anna Lembke, author of a book titled Drug Dealer, MD, talks about the role of doctors in the opioid use disorder.
Dr. Lembke claims that in the 1980s doctors were sold the idea that there was an evidence basis for opioids as effective treatment for chronic pain. She says this idea was propagated by “big medicine” that was “in cahoots with big pharma”.
The Terry Gross interview goes on and Dr. Lembke claims that companies like Purdue, the manufacturer of Oxycontin, then ” joined forces with the Joint Commission, and the Joint Commission is an organization that accredits hospitals, and Purdue Pharma gave all kinds of teaching material to the Joint Commission and said, “You really need to make doctors treat pain more aggressively and that needs to be a quality measure.” So the Joint Commission said, “You know what? You’re absolutely right, and we’re going to do that and we’re going to take your videos that you made that tell doctors that opioids aren’t addictive as long as they’re treating them for pain.”
On reading this interview, my first thoughts were in the realm of substantial skepticism – not with the comments about Purdue, but that the Joint Commission would “join” the pharma industry, and that doctors would passively go along. While it is true that in 2001, the Joint Commission did roll out its Pain Management Standards that required healthcare providers to ask every patient about their pain, they introduced this after a 4-year period of collaborative work on the issue that involved multiple stakeholders.
While some specialist societies, like the American Cancer Society Cancer Action Network have advocated for opioid treatment of cancer-related pain, this is in the context a real clinical problem among cancer patients. In a letter to the CDC Director agreeing with urgent action directed at the opioid crisis, the ACSCAN president wrote: “But we must do so in a balanced way that recognizes the need to maintain access for individuals fighting pain from cancer and other diseases and conditions that disable thousands of Americans from working, living independently, and enjoying a productive quality of life.”
Some have claimed that the Joint Commission was responsible for the idea of pain as a “fifth vital sign.” The Joint Commission denies this. Indeed, in a Medpage article, Dr. David Baker, the Joint Commission vice president states: “The standards do not require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.” The idea that the Joint Commission was compromised seems unsupported, at least to me.
That said, there does appear to be an opioid lobby as noted by Propublica in a December 15, 2016 article. The Propublica article claims that drug makers and allied advocacy groups have spent over 880 million dollars on lobbying and campaign contributions from 2006 through 2015. The Propublica article also claims “powerful doctors’ groups are part of the fight in several states, arguing that lawmakers should not tell them how to practice medicine.” A coalition of pharma companies, doctor groups, and others have collectively opposed medical guidelines, including the CDC guidelines introduced early in 2016, as well as “opioid-friendly” state legislation.
Another factor seems to have played a role in fueling opioid use: the introduction by Centers for Medicare and Medicaid Services (CMS) of a survey called “Hospital Consumer Survey of Healthcare Providers and Systems” (HCAHPS). This standardized survey was initially voluntary and targeted to HCAHPS to measure patient perspectives and satisfaction on the care they receive in hospital settings. In 2010, as part of the enactment of the Affordable Care Act (ACA), HCAHPS was integrated into the calculation of reimbursement for physicians and hospitals: This “pay for performance” according to Physicians For Responsible Opioid Prescribing (PROP) introduced a perverse incentive because the reimbursement linked to survey scores would induce doctors and hospitals toward excessive prescribing of pain meds.
Earlier in 2016, the bipartisan Promoting Responsible Opioid Prescribing (PROP) Act was introduced, and over this past summer CMS agreed, but has not finalized, the rule that would eliminate the questions. However, it is very likely that in FY 2018 the questions will be dropped.
The legislators and physician advocacy groups (e.g PROP) backing this legislation are hoping that severing the relationship between the HCAHPS questions on pain management and reimbursement will relieve hospitals and individual physicians of the undue pressure to prescribe opioid narcotics.
So my take on the swilling controversy that doctors should take the blame for the opioid crisis is that this is far too simplistic. There is lots of blame to go around.
The Opioid Use Disorder Education Program
The Opioid Use Disorder Education Program (OUDEP) is now available from HMS Global Academy. OUDEP is comprised of 3 free online CE/CME courses produced by Harvard Medical School (HMS) with scientific contributions from The National Institute on Drug Abuse (NIDA). These courses are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.
Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.