Tuesday, November 6, 2012
Is Managed Care Pushing Opiate Addiction?
America's new addiction, which I wrote about in June in the Huffington Post, is the epidemic of opiate pain killers, which, aptly named, last year resulted in over 16,000 overdose deaths. This is not the stereotyped drug problem that can be solved by Miami Vice style drug busts of traffickers and periodic round-up of street-addicts and pushers. In this epidemic, the traffickers are our respected pharmaceutical companies acting entirely within the law seeking only to bring legitimate pain relief to sufferers; the addicts are, for the most part, upstanding citizens seeking a medical solution to their pain, and the "pushers" are, with few exceptions, dedicated doctors attempting to alleviate the suffering of their patients. So how can the interaction of decent people, pursuing well intentioned and legitimate ends, result in a truly disastrous narcotics epidemic?
The answer, as counter-intuitive as it may seems, is that in large part the epidemic is an unanticipated consequence of "managed care"; which swept the country in the 1980's to contain rising medical costs.
Almost every week, I have received more calls from new patients searching for a pain specialist willing to take on the prescribing of their drug. In each case the reason given for the need for a new doctor was their previous doctor's retiring or otherwise no longer being available for the task. In each case a brief interview revealed the nature of the injury or physical problem to be either minor or at best partially diagnosed. Further, there is a turn of phrase, an urgency, a worn thin quality to their stories, which informs the practiced listener that driving the call is addiction. The previous prescriber had created a demon and had withdrawn.
As I reflect on why this wave of opiate addiction is so rapidly gaining hold in America, I realize that the answer lies in the new realities of how doctors must practice to earn their livelihood. Listening to Bill Clinton, the only campaign speaker to try to get across the mechanics of Obamacare, I learned for the first time where the funding ($617 billion) for the proposed expansion of medical insurance coverage was to come from: Hospitals, private insurers and doctors.
A proposed 27% cut in Medicare payments to physicians, already so low as to drive many physicians to refuse to see Medicare patients, is part of the agreed legislation. It is not clear that private medical practice as we know it will survive at all under these cuts. In the past five years physicians have annually fought off a pending far smaller cut, as the austere economics of managed care compels them to compromise and see increasing numbers of patients each hour. This requisite for what government administrators might call “efficiency”, cuts deeply into a commodity precious to diagnosis and patient care, especially precious in pain management; adequate time for listening, for which, under managed care, there is no commensurate reimbursement. Pain has its own special, unfortunate place in this new cut-costs at all cost system. Back and neck problems, vague complaints of limb pain can be challenging at the best of times and may take long and repeated visits, interviewing and examining to fathom and correctly treat. It takes not so much diligence as time to apply skill in getting to the bottom of some of these complaints. And time is what is rationed under this new system. In this time-is-at-a-premium climate one understands how for a harried physician, prescribing a pain killer becomes an expedient substitute for a lengthy diagnostic encounter. Indeed, in the last decade, the use of opiates in general practice pain management has become increasingly the norm. The sad truth is that under economic exigency prescribing in all fields, whether it be drugs or expensive laboratory or imaging testing, is dramatically escalating; too often replacing appropriate, in-depth office encounters between physician and patient, such that a precious gem of spoken information, which might provide the key, is never heard. This pattern is only growing: Enough pain killers were prescribed in 2010 to medicate every American adult around-the-clock for a month.
If one examines the whole story of opiate use more closely, one finds that (here too) there is another hidden and costly outcome: these prescription drugs can readily reach those for whom they were never intended. A bottle of half finished opiates lying somewhere at home can tempt a teenager, and these drugs have the power to addict within three days of use. Further, less well intentioned callers at doctors' offices have learned to mimic pain, to see multiple doctors with the same story, and then sell the prescribed drugs for handsome profits.
Looking ahead one sees that in a system where symptoms are treated, but the source of pain remains, a growing number of patients will become chronic pain sufferers. And as long as managed care continues to manifest as "efficiencies" in medical practices; doctors’ remuneration for office visits progressively is whittled down, and opiate-based pills become faster acting and more powerful, the inevitable outcome tragically is even greater opiate addiction in America.
at 12:54 PM