Politicians, media muckrakers, and blood thirsty legal corporations have launched an all-out attack on prescribing clinicians for causing and/or contributing to the presumed “opioid epidemic”. It’s no secret that Big Pharma manufacturers of various opioids have been sued by several states and numerous well-respected physician thought-leaders have variously been named in these suits because of their educational and peer reviewed writing activities irrespective of the academic quality.
The first question in my mind is whether it’s really an “opioid epidemic”, or if it’s an “illicit fentanyl epidemic crisis” that has spun out of control as eloquently presented by Rose last April in Pain Medicine.1 And when I say fentanyl, I don’t mean prescription fentanyl – I mean products not intended for human consumption that are up to 10,000x more potent than morphine and 1000x more potent than prescription fentanyl, most of which are used to lace heroin obtained on the street. The DEA has not been made accountable for their inability to control this, and blame has indeed shifted to everyone but the DEA and the sources from which the arrive, namely China and Mexico.
Instead, politicians and media blame Big Pharma and prescribing clinicians for causing this problem, respectively by manufacturing and prescribing legitimate FDA approved opioids – there is a huge disconnect here! The truth is, somewhere between 1-8% of persons that receive these prescriptions end up with an opioid abuse disorder.2 I don’t mean to minimize the risks, because they are in fact real. Nevertheless, of those that overdose on prescription opioids, the far majority obtained them, not from a legitimate prescriber, but from a friend, family member or another source. In many, if not most death instances of late that involve prescription opioids, they are often combined with other drugs including illicit fentanyl derivatives, alcohol, benzodiazepines, and/or other legal or illegal sedative hypnotics, and/or they are manipulated and ingested in a way other than prescribed or intended.3
It is mindboggling to me that the one entity that is probably most responsible for abusable prescription opioids getting into the wrong hands has not been held accountable, nor have they been sued by state governments, or exposed as the nemesis behind a much larger issue. That group is third party insurance payers who for years have driven the opioid supply bus. And today, when we have safer opioid options, various validated monitoring tools (i.e. SOAPP, COMM, ORT)4 such as abuse deterrent long-acting opioid formulations and various dosage forms of buprenorphine, and non-medication alternatives, payers continue to promote and mandate the least safe alternatives unchecked. Why do they get away with it you ask? Simple, because they have a strong lobby in Congress and because prescribing clinicians and patients have succumbed to Learned Helplessness, a behavior defined in the early 70’s by Seligman.5
At the core, prescribing clinicians are bullied into various prescribing habits by what the insurance company mandates or allows according to their formulary policy. And, the prescriber is the one ostracized for poor outcomes. So why do prescribers go along with this? That is the million-dollar question! The answer again is Learned Helplessness.
By definition, LEARNED HELPLESSNESS is “a mental state in which an organism forced to bear aversive stimuli, or stimuli that are painful or otherwise unpleasant, becomes unable or unwilling to avoid subsequent encounters with those stimuli, even if they are “escapable,” presumably because it has learned that it cannot control the situation”. It is this concept that helps to explain and influences a clinician’s decision to select a more dangerous drug over a safer but more expensive alternative. And when I say “more dangerous”, that includes less clinically desirable alternative that affords the highest profitability for the insurance company and pharmacy benefits managers, the latter of which presents another conflict because PBMs are owned by large chain pharmacies and insurance companies. [See previous blog on PBMs HERE] In short, it’s easier for a prescriber to accept the insurance payer’s influence in drug selection than to fill out reams of paperwork and argue on the telephone for an hour than it is to prescribe the best therapeutic option, as patients sit in the waiting room for a 10-15 minute visit which has also been snipped short because of the assembly line approach insurance companies encourage to maximize profitability and minimize much needed clinician-patient interactions. Below is a real and typical example which influenced my decision to write this blog. This is a copy of a prior authorization denial from a Medicaid in Kentucky, one of the worst hit states in terms of the opioid crisis.
It is unconscionable that a payer is recommending these full opioid agonists morphine, fentanyl, or methadone over a partial opioid agonist tramadol ER, for the sole purpose of maximizing profitability without consideration to the safety or appropriateness for this particular patient or the dangers of the end user to whom these commandeered opioids may land.
One might argue, “the doctor doesn’t have to prescribe the options offered”. Perhaps that’s true, but then a decision needs to be made of what can be offered to a patient that requires medication options because all other alternatives have been unsuccessful and/or payment was also denied. So, what does a prescriber do? They give in to the payer so they can do something, anything, to help the patient. This serves to influence unsafe prescribing.
Now consider that certain key pain thought leaders have been sued by various state governments. These are the very same clinicians that are required by the Sunshine Act to report any gift including a simple cup of coffee if provided by a Pharma employee. Yet, the insurance payers who are really influencing which opioid is prescribed based on maximizing profit have not disclosed their financial conflicts in guiding opioid selection. This has been and remains a dangerous precedent that is without a doubt responsible for opioid deaths. And, to make matters worse, the very lawmakers that allow such nonsense are receiving millions in contributions from major healthcare companies as outlined on Open Secrets.
A more personal example of our readers might relate to is the all too familiar air travel debacle. If you’re a frequent flier, it is common to be bumped from a flight, have your seat sold twice, be sitting in a seat with your knees in your face or against the back bathroom wall, pay 4-times the price of a ticket due to a family illness emergency, sit in the airport while enduring delayed flight updates each 15-minutes until 3-hours later the flight is cancelled. And what do you do about it? Nothing, because by Learned Helplessness you’ve decided it’s just not worth it. You think you have no voice, you’re worn down, and you’re frankly BROKEN! This is what prescribing clinicians endure daily with insurance companies – it’s just not worth the fight.
So, to all you attorneys and state agencies looking to make a fast million bucks on Big Pharma and some pretty smart clinicians that have patient safety, education, and the patient’s best interest at heart, you might want to gear up to go after the real money that is buried within the insurance industry bureaucracy. My advice is to sue the pants off of them, because it is the insurance industry that influences prescribing, not the doctors, and it’s pretty easy to prove.
The opioid crisis as we know it is due to illicit fentanyl and government negligence in controlling just that, and a greedy insurance industry on the legal side of the fence. Blaming Big Pharma, educators, and pain therapeutics experts on the opioid crisis is like blaming the ground on a faulty parachute after jumping from your plane that was delayed for 6-hours.
As always, comments are encouraged and welcome!
References:
- Rose ME. Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts. Pain medicine (Malden, Mass.). 2018 Apr;19(4):793-807.
- Volkow ND, McLellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. New England Journal of Medicine. 2016 Mar 31;374(13):1253-63.
- Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain medicine. 2016 Jan 1;17(1):85-98.
- Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain. 2009 Feb 1;10(2):113-30.
- Seligman ME. Learned helplessness. Annual review of medicine. 1972 Feb;23(1):407-12.
Absolutely great article/ post! Truly breaks it down what happening here in America concerning who is driving the bus!
Great post !
Thanks for a cogent review, Dr Fudin. Like you, I am very active in public advocacy and writing on the subject of America’s misnamed “opioid epidemic”. An article published this morning on The Crime Report dovetails nicely with your own. I have offered evidence from published data of the CDC itself, that prescription drugs did not start our public health problem with addiction, and are not sustaining that problem. See
https://thecrimereport.org/2018/06/21/the-phony-war-against-opioids-some-inconvenient-truths/
Parenthetically, I would imagine that when States Attorney Generals confront pharmaceutical companies that are aware of the article published this morning, there’s going to be a lot of gnashing of teeth and crying “foul”. Because the data put forward in the article will devastate many of the cases that government prosecutors hope to turn into cash cows.
Keep up the good work|
Red Lawhern,
Co-Founder and Corresponding Secretary
Alliance for the Treatment of Intractable Pain
There is no one group to blame for the over prescribing of opiates. Patients asked for the medication because of pain and while some doctors handed them out like candy that is certainly not the case today. It is time to stop blaming doctors, pharmaceutical and insurance companies, and patients because they all had a place in this. However the people who are most responsible (the addict) gets a free walk. Maybe when we put in prescription monitoring programs in and those who were caught doctor shopping got referred for help that may have helped some but until a addict is ready there is not much you can do as you watch them ruin their lives. My guess is that most of those people who went to abuse opiates also where abusing other drugs before hand.
You were doing great until the end. The insurance companies do not mind being snubbed, they passed cost for many years on quite gleefully. All these intermingled, inter-related, and inter-connected agencies are all sleeping together. Pharma, insurance, hospital administrations, sleep together. Have you watched any of the films or series about the narco wars? Even the drug lords sleep with the politicians, corruption pays, and pays well. The lawyers sleep together. The doctors, nurses most of them, they all sleep together. The art of doctoring is dead as a door nail, some are lions, but they are still mostly all led by donkeys. So they pull one out of their midst every once in a while and make an example out of them, throw the dog a bone, but do you think for a minute they have scratched the surface? When it comes to quack insurance, they have release forms, and otherwise, if nobody does anything, nobody can get sued, or prove that anyone was negligent, and so a new standard is born. The D.A.’s went after the pharma companies, do you see it now, they are just recycling money, shifting it from one place to another. Deceit is the facade.
We can only beat a dead horse for so long before we get tired of the decay.
Real brothers band together. We cannot find agreement, balance, or solutions when we point fingers in 10 different directions all at once. Others?, the rest?, they have already moved on, boys we will be boys, let them play, let them fight, they’re going to anyways. Please, take my words constructively, and I mean everything I say in a kind way. You did good with your write up.
https://www.webmd.com/a-to-z-guides/news/20180420/can-marijuana-be-the-answer-for-pain
Step therapies imposed on patients by insurers are directly accountable for harming stable patients and directly undermine clinical decisions.
Insurers should not be allowed to directly lobby members of congress, or to make political contributions to causes that interfere with clinical decision making.
Shame on these unholy and unhealthy alliances.
Good post, as always, Jeff.
Another finding that argues against prescribers being the primary source of opioid abuse and related deaths is the skyrocketing abuse of methamphetamine and congeners. This plague did not arise from prescribers but, as is the case of much of the opioid abuse, from the increasingly available and inexpensive imported illicit drug. It will be interesting to see how the Meth epidemic changes the narrative of prescribers being the “cause” of the “opioid epidemic.”
I do not understand and I may not be on this Earth to see it happen,why the Government will not except the fact they are killing more people than they are saving. They will never stop the true addicts that use needles and illicit drugs and mix other drugs with them just to get the euphoria and never get as high as they want to get before it kills them and they are willing to take that chance. True Chronic Pain Patients that go to reputable Pain Doctors and most of them are Anesthesiologist which know more about Medications and reactions to them than most doctors, only want enough to relieve their pain so they can have some sort of life but the Government Agencies beginning with the CDC and their Guidelines have caused so many doctors to quit treating Chronic Pain or lowered is so much further down than 90 mme that the suffering is to much we lose our families, friends and our ability to shop bath or cook so we question why are we even here we are just burdens on everyone so what do we have to look forward to anymore and that is how you are killing more people everyday instead of saving any.
Thanks Jeff, but we seem to be way past the point of using reasonable logic or scientific fact. It is now just a money grab, and look what I did, so vote for me.
Thank you! THANK YOU!! Finally, a kindred spirit in someone who lays blame at the feet of the DEA. One of the most outrageous reports I have ever read is the CDC’s MMWR concerning the 2005-2007 synthetic fentanyl outbreak. In the summary, it is stated that the DEA shut down the “one Mexican laboratory” responsible for the creation of the synthetic fentanyl, shut it down and eliminated the threat of the dangerous substance. The cocaine cartels proved that a relatively cheap illicit drug that makes money, quickly becomes an financial industry. For the CDC and DEA to claim that a single lab was creating the synthetic fentanyl is ludicrous! I believe it’s likely that that drug was responsible for many of the drug overdoses and deaths that occurred as early as 2000. And, at the risk of being a conspiracy theorist, I believe that the CDC and DEA saw their blunder in not pursuing other laboratories making synthetic fentanyl until they saw that it was about to run over them and, as a result, the “opioid prescribing guidelines” appeared, distracting the American public from the Keystone Cop-approach the DEA applied to their initial approach to preventing this deadly substance from flooding Main Street USA. (The insurance industry is another entirely too long comment I’ll write later.) Thank you for this blog!!!