What I am about write about in this series of posts on the opioid prescription drug abuse epidemic attempt to to make sense of the ironic confluence of many national, medical, regulatory and social factors that came together to facilitate this epidemic and massive social problem.
It basically started in the 1990’s with the rise of two movements in medicine that were very MUCH needed: 1) increased access to and growing awareness of the need for hospice based care for the terminally ill; 2) the growing pressure upon physicians to more “adequately treat chronic pain” in all its forms and it was adjudged that that was not being done well or humanely.
I agree with the first assertion wholeheartedly. I remember from my medical school training days early on in the in late 1960’s and 1970’s that people died more in hospitals than at home it seemed. A nascent but increasing movement of medical health care ethicists, as I would call them nowadays began to rightly question this social phenomenon. In the more rural, more agricultural, less sophisticated, (and I realize this is a gross oversimplification) members of families were literally brought to the hospital to die. I can remember when medical and oncology units were more full than nowadays of death vigils by families. The hospice movement changed all that recognizing that death was a natural process and needed a better setting and culture of medical care. The dying began to be cared for so much more personally than before in newly established hospice centers. Pain and suffering began to be treated much more effectively and humanely and under more sophisticated conditions that made a positive difference for all. Families could spend more time with loved ones in their final days, weeks or months. It went from a closet process to a more open, supported and supportive process that was better for everyone. Then the hospice movement evolved even further for the better. Physicians who often initially served as hospice attendings were the brave, the more compassionate pioneers, and often were the critical care MDs such as intensive unit pulmonologists and the occasional internist/cardiologist who were more accustomed to working regularly with the dying patient and had their emotional “stuff” together and could emotionally tolerate this very difficult work. Back then, physicians more often took it personally and reacted adversely emotionally to the death of the patient. The ethos was then that death had to be delayed as long as possible. The hospice movement, by and large, a non physician ‘movement’ took a different, gentler more accepting view of death, often based in strong ideas of faith of religion that helped its philosophy evolve in a different and healthier direction.
The above implied second issue will be thoroughly discussed in another following post in this series and concerns the Joint Commission for the Accreditation of Health Care Organizations.
It was natural as a result of all this that a more compassionate approach to pain control developed. Pain control thorough more routine, non-“stingy” use of opioid narcotics became the norm and helped dying become a more humane process especially in advanced cases of certain kinds of cancers that had indescribably high levels of near constant pain, liver cancers, bone cancers etc. I remember my wife dying in pain from multiple myeloma in the early 1980’s with pain so severe that when she would awaken she would be in a pain driven pitiful delirium that made visits to her bedside “painful” and incredibly upsetting to the family who almost all lived close around her since this was a Cherokee Indian extended family with strong ties to the Reservation, the “Qualla Boundary” of western North Carolina where she lived. Fortunately she was mostly treated pretty adequately with opioids and none of us, not even me, the only physician in the entourage of family, worried about the absurdity of her “getting addicted.” Physicians in nursing homes, oncologists, and medical ethicists pressed the issues publicly and hospice care came thankfully to be a routine part of communities, some large enough to have independent of the hospitals, others inheriting donated, set aside areas in larger nursing homes as this care came to be financially supported and recognized as legitimate standard of care in medicine. Hospicare moved into the homes as well which overall was a good thing as well. But in my mind this is where the problems started in hospice care; drug diversion off narcotics, a term we did not even use in those days, came to be. Unscrupulous addict or enterprising members of some families, starting sneaking smaller and then larger amount of ‘granny’s narcotics for themselves or for quick profit, substituting similar looking generic pills. I suspect that if we had the massive Big Data tools applied to those trends we would find, not to much surprise, that this diversion trend started in the years leading up to our recent economic slides, bubbles and collapses that made persons suddenly facing unforeseen poverty, resort to such survival means as diverting and selling such sources of opioids. To me it is not something to jump up and down on my law enforcement belligerent hobby horse podium or outrage, but an understandable, even predictable phenomenon. A number of times I had to open up this can of worms in colleagues’ patients’ families and ‘do an intervention’ and it was never a clean or pleasant process.
To follow, part II in the next blog.
Regards to all