Regulators and administrators took notice and got active.  Beginning in the Veterans Affairs medical system, then from JCAHO (Joint Commission on Accreditation of Healthcare Organizations- who regulates hospitals across the country),pain management standards were developed.  And the Centers for Medicare and Medicaid Services (CMS) developed quality indicators around successful treatment of pain– not attempting to treat pain, or ameliorating pain, but successfully treating pain.  And somehow, treating pain essentially became interpreted to mean make the pain go away.

So now under-treatment of pain was going to hit providers and medical systems where they lived, in their pocketbook.  Because now a portion of reimbursements was going to be linked to the results of patient satisfaction surveys which now prominently included questions regarding pain treatment.

I think what Dr Campbell hoped for was that by bringing attention to the problem of untreated pain, more education and research would be done to help improve pain management.

While blood pressure, heart rate, respiratory rate, and temperature can be accurately measured, pain is much more complicated to quantify.  In truth- we still don’t have a good way to do this even many years later.

My bias is that one thing that may have contributed to the entire problem, is that in the years before all of this, something changed in medicine.  Reimbursements for doctor visits, i.e., non-procedural interventions, dramatically decreased.  Providers now needed to see more patients to stay afloat, and so the amount of time that providers spent with patients contracted.

Perhaps the studies showing an increase in patients with under-treated pain was actually a symptom of a sick health care delivery system crying out for attention….

No, because that requires a serious undertaking and time.  The providers/health care organizations were hit pretty quickly with these quality measures, so a fix had to be found quickly- or else they would face serious financial consequences.

Into this space walked pharmaceutical companies- with their “miracle” drugs.  This was handy because in the US, where our patients often want a prescription for every ailment (ex. the demand for antibiotics for a cold), writing a prescription for an opioid was way easier and took less time than any other possible intervention.  And it made patients feel as if-finally- they were being taken seriously.  At least in the short term, opioid medications do help make the pain go away.  So win-win, right?

Pharmaceutical companies did their best to capitalize on this, and we are only now learning of the lies they told and the truths they hid.

So in an attempt to help, our regulations harmed.  And created an opioid addiction epidemic and unimaginable crisis.

One positive from the federal government is that the CMS has changed their survey questions regarding pain, so that communication about pain is the issue, as opposed to absolute improvement in pain symptoms.  What’s still critically needed is research, but the NIH still inadequately funds chronic pain research.

Doctors are now being told they write too many opioid prescriptions.  While this is undoubtedly true, there are still patients in need of opioids.  New regulations make it harder and harder for all patients to get opioid medications and this includes patients with advanced cancer and those who are in pain and nearing end of life.   And the patients hooked on opioids, often still have pain, and now can’t get any help.  So they go to the illicit drug market- where more powerful drugs are available, and overdose results.

The terrible situation gets worse…

The proponents of marijuana and its derivatives tout its many wonderful effects:  improved appetite, relief of pain, relief from nausea, improved sleep, among others.  And many believe it may be an answer to the current opioid crisis.  In fact, 2 states (Illinois and New York) have decided to allow certain patients to substitute medical marijuana for opioid medications for pain control.

But because marijuana has been a schedule 1 drug, its use in well-designed research studies has been nearly impossible.  So there is a paucity of good research, and what is available is limited and contradictory.  A systematic review of cannabinoids for medical use-last updated in JAMA in 2016 looks at randomized clinical trials of cannabinoids for multiple indications (ex:  nausea/vomiting due to chemotherapy, appetite stimulation in patients with HIV/AIDs, chronic pain, spasticity in patients with multiple sclerosis).  Of these 79 studies, only 4 were judged to have a low risk of bias.  That is a problem.  And while there was some improvement in pain reduction- it was not great.

There are concerns about the increased availability and use of marijuana.  In a recent New Yorker article (yes I realize this is not a medical journal, but author Malcolm Gladwell really does his research) gives a good overview about how little we know about marijuana.  And its potential ill-effects demand serious consideration and study and should give us all pause about its widespread use.

While states allowing marijuana as an opioid substitue could be a good thing, if for example these patients are enrolled in a well-designed clinical study so real information could be gleaned which could then help other patients, I’m not seeing evidence that this is the case.  And with all the questions surrounding marijuana, how can we be sure these types of legislative interventions won’t make things worse?

Are well-meaning legislators just adding a new crisis on top of the current one?

And our health care delivery system has still not gotten the attention it so desperately needs….