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].
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.