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!
- 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.