Special articleHow Good Intentions Contributed to Bad Outcomes: The Opioid Crisis
Section snippets
Addressing Chronic Pain
In the past, opioid medications were prescribed primarily for acute pain due to injury or surgery or severe pain related to cancer or a terminal illness. Physicians were reluctant to prescribe opioids for other conditions because there was no evidence to support wider prescribing practices, and there was a concern for addiction. In addition, physicians feared investigation and state board disciplinary action if they did prescribe opioids more liberally.14, 15, 16 In 1980, a 1-paragraph letter
Monitoring Pain
The impetus for more aggressive pain treatment came from numerous studies published in the 1990s indicating that cancer and noncancer pain were ineffectively treated. In 1998, a study examining a national database of elderly patients in a nursing home with cancer found that pain was prevalent and often untreated.29 Another study of more than 1000 outpatients with metastatic cancer treated between 1990 and 1991 reported that 42% did not receive adequate pain therapy.30 Inadequate pain therapy
Reimbursing for Patient Satisfaction
The Deficit Reduction Act of 2005 required hospitals to participate in the HCAHPS Survey by submitting the results of the survey as a part of the Inpatient Prospective Payment System. The hospitals that submitted patient satisfaction data received full annual payment; those that did not incurred a 2% penalty for nonsubmission.36 By 2010, the Patient Protection and Affordable Care Act of 2010 expanded the role of patient satisfaction as a payment incentive by including the HCAHPS Survey scores
Providing Larger Amounts and More Potent Painkillers
Pharmaceutical companies, medical governing agencies, insurance companies, and retail pharmacies also had good intentions of improving patient care and decreasing cost, but these intentions also indirectly contributed to the opioid crisis. Physicians and dentists wrote prescriptions for larger supplies of opioids after procedures to not only aggressively treat pain but also limit refill requests. Some retail pharmacies and insurance companies inadvertently contributed to the opioid problem by
Summary
Many good intentions leading to specific actions contributed to the opioid crisis. It began with underestimating the addictive potential of opioids in treating chronic pain and the advocacy of opioids to treat all pain issues. The implied message was that pain, which is part of the human condition, is a vital sign that should be treated similar to abrupt changes in temperature and blood pressure. Concurrently, pain control assessments included in patient satisfaction surveys became a measure of
Possible Next Steps
To address the opioid crisis, there are a number of groups attempting to set goals, guidelines, and regulations including the IOM, the Joint Commission, the Department of Health and Human Services, the CMS, the FDA, the Centers for Disease Control and Prevention, and other federal and state government agencies. In 2011, the IOM published “Relieving Pain in America,” which advocates for a multidisciplinary and multimodal approach to pain management, and includes emphasis on prevention, not just
Conclusion
Over the past 30 years, the intentions to address and control pain and to have patients directly involved in their care were well-meaning, but the measures taken to achieve these goals contributed to the opioid crisis. Pain is not an opioid-deficient condition but a human, multidimensional disorder often involving more than just physical pain. Because it encompasses emotional, social, and spiritual, as well as physical components, it cannot be eliminated by a single drug. If we continue to
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For editorial comment, see page 269
Potential Competing Interests: The authors report no competing interests.