Doctors Blamed For the Opioid Crisis

 

Everyone by now realizes there is an opioid crisis in this country. It has become a political football kicked around by politicians trying to win votes from those Americans whose families have been impacted by this crisis. Naturally, it is easier to find people to blame than solutions to the problem.

Doctors are to blame because they just insist on giving patients opioids. That’s the opinion of at least one journalist. Keith Humphries, writing in The Washington Post says there are many other drugs besides opioids that could be used for pain relief except for the ignorance of doctors.

Humphries blames doctors for not using opioid alternatives on the following:

  • Opioid manufacturers’ “ruthless” marketing
  • Inadequate training in pain management
  • Insufficient referrals to a pain psychologist
  • Insufficient insurance coverage for pain management and physical therapy

 

Humphries says doctors get only an average of seven hours of pain management training in medical school. He says the solution is “enhancing insurance benefits (Medicaid and Medicare) for psychological and behavioral pain care services provided by interdisciplinary pain management clinics as well as funding training on pain management in medical schools and continuing education programs serving physicians and other health professionals.”

Who knew it was so easy to solve the problem?

This is typical journalistic pabulum we’ve come to expect from mainstream media like The Washington Post. The solution is always government funding of more insurance benefits, more education and more government control.

In reality, doctors continue to educate themselves long after medical school. I am required to have 40 hours of continuing medical education (CME) every two years just to maintain my medical license – and more to retain specialty board certification. Last month I attended the American Academy of Orthopaedic Surgeons (AAOS) meeting and spent three full days in CME classes. About five hours of that time I spent in learning modern methods of pain management after surgery.

Here are a few observations that Mr. Humphries should consider:

  • Opioids are more effective in managing pain than the alternatives
  • Patients expect (demand) opioids for serious pain
  • Alternatives are generally available OTC and have been previously tried
  • Experience rather than training has proven opioids effective
  • Pharmaceutical marketing to physicians is practically non-existent for opioids in the last twenty plus years (in my experience)
  • Medicaid expansion under ObamaCare has contributed to the opioid crisis – not relieved it (see Medicaid and The Killer Drugs)

 

Doctors would prefer to prescribe non-opioids except for the following:

  • Patients have been programmed to believe non-opioids are ineffective
  • Non-opioids can be prescribed over the phone – but patients in real pain will usually refuse them
  • Non-opioids usually have fewer side effects, like constipation and addiction – yet patient acceptance is poor
  • Opioids are generally less expensive than non-opioids

 

Most doctors would be ecstatic if there were truly effective non-opioid alternatives to prescribe for their patients in pain. The last of these was Vioxx, a non-steroid anti-inflammatory drug that was very effective in pain relief. Unfortunately, it was taken off the market in 2004 for dubious claims of cardiac toxicity. I’m still waiting for its replacement.

Growing Old – Life’s Most Difficult Challenge – Part II

 

Perspective is everything. It determines how you view the world and the life you are living. Anyone from the United States who has traveled to a third world country will immediately understand what I’m saying. It gives you a whole new appreciation for the blessings we enjoy in this country.

Dr. Atul Gawande, a Harvard general surgeon, discusses the importance of perspective in his book Being Mortal. Gawande tells us of important research by Stanford psychologist Laura Carstensen. She studied the emotional experiences of nearly two hundred people over many years of their lives. The subjects ranged in age from 18 to 94 when they entered the study.

Before her study, the assumption was made by others that the narrowing of life runs against people’s greatest sources of fulfillment and therefore you would expect people to grow unhappier as they aged. But Carstensen’s research found the opposite.

This raised another question. If we shift as we age toward appreciating everyday pleasures and relationships rather than toward achieving, having, and getting, and if we find this more fulfilling, then why do we take so long to do it? Is this just a learned behavior that comes with age?

A personal experience changed Carstensen’s perspective on this crucial question. She was nearly killed in a car accident when she was only twenty-one. Riding in a VW minibus with friends, the drunk driver rolled the vehicle over an embankment. She suffered severe head injuries and internal bleeding and barely survived.

She spent a long time in rehabilitation, surrounded mostly by elderly patients. The road to recovery included studying psychology by listening to audiotapes brought to her by her father. She quickly realized she was living the phenomena she was studying. She decided to make studying the elderly her life’s work.

Fifteen years later she developed a new hypothesis to test: How we seek to spend our time may depend on how much time we perceive ourselves to have.

This brings us back to the word perspective. If you’re young and healthy you have a perspective that there are no limits to what you can do. If you’re old and sick you have an entirely different perspective. This determines your outlook and your priorities.

Carstensen’s hypothesis has stood up under testing. In general, the younger the subjects were, the less they valued time with people they were emotionally close to and the more they valued time with people who were potential sources of information or new friendship. However, among the ill, the age differences disappeared. The preferences of a young person with AIDS were the same as those of an old person.

When your perspective says “the sky is the limit”, you’re willing to delay gratification, invest years in gaining skills or knowledge, to plan for a brighter future. When your horizons contract – when the future is finite and uncertain – then your focus shifts to the here and now. Everyday pleasures and people closest to you become your priority. These findings held up across cultural and racial differences.

When you understand the dynamic of perspective then you are better able to determine the best way to spend your declining years. You better prioritize your time and better appreciate your blessings. Sounds like a good idea at any time in life.

Growing Old – Life’s Most Difficult Challenge – Part I

 

Growing old isn’t for cowards. Just ask anyone who’s been there. While only in my seventh decade, I’m beginning to understand what they mean.

Average life expectancy in the United States in 2017 is 78.6 years according to the National Center for Health Statistics. That’s actually a decline of 0.1 years from previous studies in 2015.

The average life expectancy in 1967 was just 67 years. Therefore, in the last fifty years modern medicine has increased our life expectancy by nearly twelve years. That means a lot of people living longer and needing assistance in their later years.

The Rise of Eldercare

If you’re in your eighth or more decade, you realize that time is getting short. If you’ve enjoyed good health thus far, you might even live into your nineties, but you’re certainly on borrowed time. If you’re a man your chances of reaching 100 are 0.48%; if you’re a woman they’re 1.66%. Do you feel that lucky?

Fifty years ago most people lived out their last years at home with the help of family members, friends, and the occasional assistance of home nursing. Today, an increasing number of people will end up in nursing homes as their health declines.

Dr. Atul Gawande, a Harvard general surgeon, writes in his book Being Mortal that nursing homes proliferated after a 1954 law was passed that provided funding to relieve hospital overcrowding. Then Medicare was enacted in 1965, which raised the federal standards and provided additional government support for hospitals and nursing homes. The number of nursing homes exploded and by 1970 some thirteen thousand had been built.

Naturally this wave of nursing homes was followed by reports of elder-abuse and tragedies. Gawande reports a nursing home fire trapped and killed thirty-two residents in Marietta, Ohio, that same year. In Baltimore, a Salmonella epidemic in a nursing home killed thirty-six elderly residents.

All of us have heard such stories and all of us have probably visited a nursing home to see a friend or relative at one time or another. Most come away from such experiences thinking, “I’ll never live in a nursing home myself!”

The Value of Freedom

Many modern nursing homes are beautiful structures and boast of nutritional meals, exercise facilities, activities coordinators and readily available medical care when needed. But residents of these facilities yearn for one thing that is seldom available – freedom. The interests of the nursing home management are principally safety and efficiency and that means rules and regulations that minimize risk.

But the interests of elderly residents conflict with these institutional goals. Most residents want to retain the freedom to live their lives on their own terms – with assistance only when absolutely necessary. They want to get up when they’re ready, eat when they’re hungry, and sleep when it’s necessary. They want to retain their mobility as much as possible, even at the risk of a fall that might be serious.

Keren Brown Wilson originated the concept of Assisted Living in the 1980s to serve the needs of her mother who refused to live in a nursing home. The concept was built around a facility that was as much like home as possible. At home you decide how you spend your time, how you share your space, and how you manage your possessions.

Wilson opened Park Place, in Portland, Oregon, in 1983 and the concept was an immediate hit. The State of Oregon closely monitored the residents and in 1988 they issued their findings. The residents’ satisfaction with their lives increased, and their health was maintained. Their physical and cognitive functioning actually improved. The incidence of major depression fell. And the cost for those on government support was 20 percent lower than it would have been in a nursing home.

Since that time the number of Assisted Living facilities has grown tremendously. Wilson’s company, Assisted Living Concepts, went public. By 2000, the company had grown to more than three thousand employees and by 2010 the number of people in assisted living facilities was approaching the number in nursing homes.

But that’s when the good news stops. Since that time the concept became so popular that developers started calling all kinds of facilities “assisted living” but without following the model that made Wilson’s original idea so successful. These newer facilities fell into the same trap that made nursing homes intolerable for many before – the loss of freedom.

Concern over safety and lawsuits increasingly limited what people could have in their assisted living apartments and what activities they were allowed to do. In many places it became a mere layover on the continuum from independent living to full nursing home care. If you’re in the market for an assisted living facility be sure it will provide the freedom you want. Remember, it’s your life – make the most of it while you still can.

 

(Next post: Growing Old – Life’s Most Difficult Challenge – Part II)