Misuse of opiates in the United States is staggering, and it constitutes a major public health problem. Opioid dependence affects roughly five million people, it contributes to about 17,000 deaths per year and half of all deaths due to drug overdose.
According to a recent study published in Journal of the American Medical Association, despite the decrease in the prevalence of non-medical use of opiates from 2003-2013, the number of people with opiate-use disorders, mortality from overdose, high-frequency use and number of days of use have all increased.
While Americans make up roughly 4.6% of the world's population, we account for 80% of the consumption of the global opioid supply and 99% of the global hydrocodone supply. Sales of opioid medications -- methadone, oxycodone, morphine, meperidine and codeine -- increased from 50.7 million grams in 1997 to 126.5 million grams in 2007. These numbers are a grave reflection of a campaign, one that was based on weak data, that pain was being largely undertreated and that this was cruel.
In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the governing body on setting hospital standards and accreditation, implemented new pain management standards that shifted previously stringent regulations on prescription pain killers to a more lax regulations. This was largely supported by professional societies of pain specialists, as well as by physician groups dissatisfied with the levels of constraint when prescribing opiates.
In fact, this campaign has become so deeply imbedded into the practice of medicine that pain is considered a fifth vital sign. If you've ever been admitted to a hospital or recall filling out forms at your doctor's office, perhaps you may have seen a section with smiley or frowney faces when asking about your level of pain.
The problem is obvious. Whereas other vital signs such as heart rate, blood pressure, respiratory rate and temperature are measurable objectively, pain is subjective. In this consumer-driven culture, where the utmost stress is placed on patient satisfaction, the physician becomes mired between an ethical rock and a potentially-litigious hard place.
A patient claiming a pain level of 10 on a 1-to-10 scale and legitimately screaming in a crowded emergency room cannot adequately be distinguished from a sneaky sole simply seeking drugs. If you have a person dependent on prescription opioids, would it not be a doctor's fiduciary obligation to not have that person go into withdrawal?
The trouble is that once this wheel starts turning, it creates a considerable disaster. On the one hand, advocating for the patient is a physician's duty. Who wants to see someone suffering? On the other hand, once Pandora's box is opened a monster is created with tremendous legal, ethical and financial implications. Although, the number of cases of people suffering from opiate misuse has decreased, the morbidity and mortality associated with this behavior is cause for alarm.