If there was ever a corporate sponsored scourge as great as American Tobacco’s unleashing of tobacco products upon this country over a century ago (from Durham NC) where I trained, or the famous beer monopolies in every town in America in the late 1800’s as documented in Daniel Okrent’s landmark book, The Last Call, on the history of alcohol, the temperance movement, Prohibition and the rise of the Mafia, as well of all things, the Suffragette Movement for Women to Vote, it has been the last 20 years of marketing of OxyContin.How Big Pharma Gave America Its Heroin Problem.” It is more than well worth reading. It is jarring and appalling in its history and backed up by multiple references to such unimpeachable sources as the National Institute of Drug Abuse among others. It also diligently references one of the seminal recent public health articles of the rise of opiate abuse in this country, “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction,” published in the Annual Review of Public Health 2015. 36:559–74 [sorry I could not get this reference to make a link as this is a pre-publication edition, but search using the title and you will find it easily enough].
Mr. McGraw relates his experience with percutaneous cholecystectomy, removal of his gall bladder, and furthermore his explicit instructions, as an addict in recovery, not to give him addicting pain medications. Imagine his stupefaction when he arrived home and found one of the computer generated prescriptions printed out for #30 OxyContin opiate tablets. He recounts his dilemma and “close call” with full relapse. The experience I infer, launched his journalistic piece for the Pacific Standard on the shameful history of OxyContin which in my medical opinion has not been adequately put right yet even though the company who manufactures it still, was fined $600M, which I suppose was just “the cost of doing business,” compared to the billions of revenue the drug has generated that company.
Mr. McGraw recounts the blatantly dishonest and shameless marketing that the manfacturer engaged in, during the years of promotion of Oxycontin to mostly nonpsychiatric physicians. I long had a practice of not seeing or accepting speaking engagements, ball point pens, lunches for the office staff, junkets to posh resorts like so many other “spinal wilting, ethically challenged physicians engaged in during those times. It was not lost on me and many of my fellow and lady psychiatric colleagues during those years that the manufacturer NEVER approached our practices with their evil sales pitches to get us to advocate for, be practice community leaders [as they call medical shills for new drugs back then], or prescribe OxyContin. Perhaps it was truly a numbers decisions, meaning the segment of psychiatrists in this country was too small a market to waste the drug “reps” time on. However, I like to think that they knew we were too smart and pharmacologically better trained and wise in the ways of addictionology, to fall for their hogwash.
Again as I have written elsewhere and as Mr. McGraw, makes reference to, one of our most important medical regulatory agencies, “the Joint,” or the Joint Commission for the Accreditation of Health Care Organizations, bears equally full and shameful responsibility for the present day “opiate prescription drug epidemic” that we have now. In the early 1990’s the Joint decreed that pain had to be assessed in every patient entering a health care portal, whether a hospital bed, ER, private practice clinic, free clinic, nursing home etc. The mandated assessment, not measured, as pain still cannot be scientifically measured, just described, came to be known as Mr. McGraw recalls in his article cited above, “the fifth vital sign,” ranking up there in importance with blood pressure, pulse rate, respiratory rate and temperature. I recall that to comply everywhere and everyone in the healthcare system in this country had to start posting those stupid laminated posters or the 10 gradations of pain severity using the 10 smiley faces to frowning to agonized faces. It was “medical practice by emoticons” as I call nowadays, one of the greatest medical farces ever perpetuated. And if a patient said they were an 8, or a 9, or a 10, and they always did if they were trying to cage the provider out of a narcotic script, one felt an enormous pressure to furnish such. One reason was the patients could complain to the local state board of medicine and for a while MDs lived in fear or reprisals if they exercized good judgment and denied obvious manipulators narcotic prescriptions. It was a bad time. Then the advertising went into high gear for years and the climate changed and the times and training in the medical profession shamefully lagged years behind. There was little training in addictionology in medical schools; I was lucky, I had two mentors who saw to it I was well educated in those arenas, otherwise I would be a physician who could not say no and would dozens of patients in my practice hounding me to opiate scripts, hoodwinking my partners on the weekends by phone, lying and inflating my supposed doses, and being driven to distraction by the hordes of addicts calling, abusing the secretaries, stealing script pads of the offices, forging my signature and so on.
I had a personal experience with a physician who tried to prescribe an opiate for me and illustrates what is wrong in American medical practice. I came down with four broken ribs for which nothing could really be done except intermediate pain management [notice I did NOT use the word “control” as I knew the best I could do or expected to accomplish was to “manage” the pain so I could work]. I saw a reputable and very skilled and likeable orthopedist and he was frank with me, “we don’t use corsets anymore,” etc., and I said I knew that. He assessed as best one could my pain, and I told I had a high pain tolerance, but coughing or laughing heartily at a good joke or rising from a sitting position elicited such severe instant pain that “it takes my breath away.” I added I did not want narcotics but something better than Advil or aspirin as I had been taking rheumatoid arthritic level doses of 16 aspirin tablets a day to manage the pain and “it is tearing up my stomach.” Without listening to me, he wrote out quickly a prescription for high dose oxycodone, the “regular” short duration form of OxyContin. I stared at the script after he handed it me in inward shock and handed it back to me and sternly said, “I said: no narcotics.” He was very surprised at my refusal as I instantly thought to myself something like, “Ah we have a physician with a problem, this is not a common experience for him and he has no idea why I did that…” I suggested another stronger non-narcotic anti-inflammatory medication and he started to realize he had erred big time and wrote a script for that medication. I then sat there not moving signaling that contrary to his starting to get up and terminate the interview, the interview was NOT over. I then apologized for the question I told him I was going to ask him, explaining as he knew I was a psychiatrist, and that I dealt with addiction very frequently and had done so all my career. He began to grow uncomfortable but was mature enough to permit me to continue. I then bluntly asked him “How many patients on opiates do you have in your group practice?” The number exceeded even my skeptical internal guess. I then asked him a series of practice questions I use with “physicians in trouble,” such has ‘do you get a lot of calls on the weekends for opiates, calls for early refills, patients switching drug stores with no good reason’ and several others. He answered truthfully in the alternative. I then asked him”not to take this in the wrong way and don’t be offended as you don’t know me well and this is our first meeting, but I am here to tell you that you all have a big problem in your practice. You had better talk to your older partners and do something about this or you all be talking to the Board sometime in the future and it won’t be pleasant.” I again apologized for being so “forward and blunt,” and but “I have dealt with this sort of thing for years,” and told him that I hoped he would take my words to heart. At my next follow-up appointment with him, he was frank with me and informed me that he and his partners had assessed their situation and asked my advice on specific measures they should take. I offered first taking good medical education courses on prescribing opiates such as at the University of Florida School of Medicine or Vanderbilt, and then start setting limits. I frankly told him this would be the hard part. He asked anxiously as do all physicians who start to confront this problem, words to the effect of what do I do if they quit my practice and bad mouth us in the community. Answers: “Then you will be rid of them and all the addicts will no longer come to your practice because they will know you all won’t tolerate their mess.”
My last point is that I was heartened and got a good laugh out of Mr. McGraw’s article in which he noted near the end that now we have the NEW syndrome of “OIC” [ladies and gentleman this is a drug company made up name of a syndrome for advertising purposes only!!] He wrote he had seen this on football game commercials which is exactly where I saw it this past week as well. What is “OIC” you may ask? It is “Opioid Induced Constipation.” It is now a touted ‘syndrome for which another brand new probably blatantly expensive medication that I will not grace by mentioning its fancy catchy name, that helps to manage opiate induced constipation since that is a long known side effect of opiates. I prefer to call it “It costs a lot to drop a lot.” My apologies for the bad joke but until things change for the better in the world of the prescription drug epidemic and tens of thousands of opiate induced overdoses we have annually, a good stiff sense of ironic biting sarcastic ugly humor is about all we’ve got to fight the forces of runaway modern robber baron’ism in the medical world.