One additional monumental regulatory national policy mistake made in this country in the early 1990’s accelerated the easier access to prescribed narcotics. This came from the organization, the JCAHO, that certifies hospitals to stay open and operate through every three year or so on site reviews, “inspections,” made the ‘adequate treatment of pain,’ a national priority and requirement. This is when the “smiley face” pain quantification chart came out. Suddenly if you are old enough to recall those days, your medical practice’s nurse or physician began asking you at EVERY contact if you had any physical pain and if so to rate. The “Joint Commission” as the above mentioned hospital accreditation body, made it clear the so-called “undertreatment” of pain had to be corrected. Physicians reacted defensively and began to drastically change their opioid prescribing practices and the veritable floodgates opened. Again many many physicians who lived through that time felt that opioid prescribed was at least somewhat more rational but after the machinations of the Joint Commission (JCAHO or “Jayco”) in the have felt this was one of the most misguided bureaucratic maneuvers in modern American medical history. The informal consensus is that this helped wrongly educate patients to expect narcotics as more regular interventions and helped to form the ‘perfect storm’ along with all the other opioid facilitating developments discussed in this series.

The emerging subspecialty of pain management specialists arose to try to fill the need along with physical medicine specialists, both of which specialists there are woefully too few. Consider that just a few years ago the pain management fellowship programs graduated less than 300 such physicians a year in this country. Their rise to recognition coincided and in essence was a result of new technology of invasive spinal column endoscopy in which we could fairly safely insert these wondrous flexible minicathter tubes with little tiny camera lenses on their ends, much as had been done in gastroenterology used to visualize the insides of stomachs to see ulcers, colonic polyps and cancers, etc. This was a giant boost to the diagnostic and treatment potentials and approaches of GI medicine. It started to be applied a few decades ago in investigative learning efforts all over the country in big medical centers to spinal cord pathology. At first of course it was applied to the simpler, VISIBLE conditions such as fractures of the pedicles (like Cam Newton recently had in his truck accident), to bulging disks that were physically accessible to the threading of these “photographic catheters.” Thee had had decades of safer and safer experience in “invasive” or “interventional cardiology” in which these miniature cameras on a catheter had displayed for medical science the insides and blockages in coronary (heart) arteries, permitting “clot busters” therapy in strokes, placement of coronary artery stents or aid in determining that coronary artery bypass graft surgery was the proper next therapeutic step.

So pain management practitioners had a “tool,” and in modern medicine, having a ‘real too’ to borrow a phrase is always a boon and usually an advance in the practice of that phase of medicine. Consider the use of anesthesia, the airway, the ventilator, in surgery etc. Pain management MDs began to have a means to do something physical that often led to dramatic seeming advances in the management of pain. Injections of local slowly absorbed “depot” anesthetics akin to what dentists ‘deposit’ or inject (the “hurt” word in my grandchildren’s lexicon, could suppress pain for months on end. Combined with anti-inflammatory steroids, results were new and wonderful. But not everyone could, should or like to undergo this somewhat arduous procedure forever. And besides for many its effectiveness waned with time.

The next development derived from the then nascent (young, growing) use of insulin pumps for children and the horribly brittle diabetics. Smaller and smaller boxes holding insulin in little pump thingamajiggies with small catheters were implanted on/in diabetics’ bodies with wonderful glucose level control as these gizmos had the new capacities to measure the glucose levels and then to administer a “squish” or bolus of insulin calculated to bring the glucose back to a more normal range, obviating the need for very frequent finger pricks and use of external glucometers wherever the diabetic person went or was found. The external reservoir of the glucose pump could be refilled easily by injecting through a small but durable membrane into its reservoir.

It was similarly small leap and idea to place/run/thread the catheter by the pain management investigators into the intra-spinal canal itself and place the catheter under radiologic visualization control in the immediate vicinity of pressure on a “pinched” nerve root outlet, one of the common sources of severe back pain due to bulging vertebral disks. But the opioid narcotics came to be used instead the almost “dental” anesthetics. This level of pain control was a godsend to back pain patients who had the right anatomic circumstances to respond to such an intervention. The use of the “spinal pump’ virtually exploded in this era in the early 1990’s. As part of the routine of care, oral narcotics still had to be often used in patients for “break-through pain.” The spinal pain pump was not perfect as dosing with high powered narcotics was and still is a very approximate art and the unspoken rule was not to squirt in too much liquid morphine or whatever narcotic was used in order to constantly avoid overdosing the patient, putting a patient into a coma or worse.

So oral measurable or discrete, ‘controlled doses’ of narcotics had to be increasingly utilized in a relatively new patient population not so treated before. Drug Diversion burst upon the medical lexicon as patients having these new ready supplies of opioids, diverted them to sell in the underground drug market. Many disabled persons with chronic pain from the recent decades of skyrocketing industrial injuries, were on the financial edge of economic disintegration since the Great Recession. Selling their oral opioid only made sense and things went from there in predictable directions and the new “epidemic” of prescription drugs was ON. Without the stats readily at hand as I write this, I can confidently state though that through the years when a pain management specialist set up practice in a community, the street availability of oral opioids always increased. Pain management physicians the country over put into place “pain contracts” which were routine by the early 1990’s and a few missteps and tell tale signs of diversion, such as repeatedly calling in for early refills of narcotics, claims of lost or stolen prescription resulted in expulsion from the pain practices. This did not cure the problem it merely displaced it to the streets in great numbers. Family practice groups and solo practice groups began to have to take over the pain management of their long term patients but since they did not have the credentialing or experience to utilize pain pumps, not that many of them wished to do that, they had to prescribe oral narcotics. Then for the abusing patients who in some studies were the majority of pain patients, went through the same odious process of witnessing signs of escalating opioid abuse/use/consumption. Non addiction experienced MDs which until lately has been the vast majority of MDs, struggled with this in often the following pattern which I as a psychiatrist saw over and over for more than a decade and a half. Family docs, internists, surgeons, all often had little or no experience in saying “no” a la Nancy Reagan advocated years ago in a different context, and could not set firm limits, did not know how to incorporate pain contracts into their practices routinely and mostly did not have the time needed to monitor these patients closely. This usually involves at least weekly visits, urine drug screens with supervised collection of urine with a same sexed observer/practice aide such as a CNA, LPN, RN or MD themselves and pill counts at every visit. This left a bad taste in most MDs’ mouths as they felt the trust between patient and physician was being made a very unpleasant element of treatment, sort of like the old saw of the interrogatory legal question of “How many times do you beat your wife a week?” in which the operating assumption is of a high likelihood of lying, cheating, relapse and dissimulation. Physicians in their training are not and have not been trained to be clinically suspicious except in the more medical or surgical phenomena we deal with. This exemplified in our phrase of having a “high index of suspicion” for say, cancer when a patient presents with even a partial pattern of symptoms suggestive of the possibility of cancer. Always in the physicians’ minds we are taught from day one to ever endeavor “not to miss” some dread and/or deadly disease.