This morning, I happened to read an article where a Senator was grandstanding about the supposed opiate abuse epidemic. He was blaming the epidemic on everyone. Doctors, the “evil” pharmaceutical industry, and even the DEA for not “doing something.” Because whenever something is in the news, politicians want to “do something!”
I don’t deny that we have an epidemic of opiate abuse. But at the most fundamental level, there is someone to blame — namely, politicians. Our politicians have created government involvement in healthcare. (Whether that’s a good thing or a bad thing is another debate for another time.) With government involvement comes the need to “measure” how effective the government interventions are. And as we’ve all found when the government studies medicine, they like things that are easy to measure and sound good. In EMS, that’s usually cardiac arrest survival — because dead or not dead is easy to measure and by golly, we don’t want dead people.
So, the government decided that “pain” was something worth measuring and studying for Medicare and Medicaid. And then, the various accrediting bodies jumped on board because the government had already decided that pain management was a “good thing” and therefore measuring it for accreditation purposes was also a “good thing.” So, along came the messages. Pain scale charts everywhere. Providers being judged for pain management. Providers being told that the goal is to get the pain to a zero on a zero to ten schedule.
But the reality kicks in. In most acute settings (including EMS), we have limited pain management tools — mostly opiates. And for the average person, pain is an emergency. And I’ve already mentioned how hard it can be to get in to see a primary care provider and the inevitable referrals to specialists, labs, and imaging for all but the most minor complaints. In short, if you’re in pain, you have two choices — be in pain until your doctor can see you and then get an opinion as to what’s wrong or seek immediate care and get opiates.
So, here we are. People are rational and usually want relief now. So, the tool of choice for acute pain management remains opiates. And people are now expecting their pain to be managed and they’ve almost come to expect that the relief will come in the form of an opiate. We’re now at the point where patients feel they have right to opiates for pain management. Is it any wonder that we’ve created addicts?
And at the same time that CMS and the healthcare accreditation world demand that we “DO SOMETHING” about pain, the DEA and many state medical boards have differing opinions. The current opiate “crisis” has led to a concern about overprescribing, which, in many cases, is rightfully justified. Especially in Texas, we’ve had a crisis with “pill mills” writing narcotic prescriptions way too easily for virtually no medical reason. Those providers can and should be sanctioned. But the DEA and the various state medical boards have also created a climate of fear where physicians feel as if their professional prerogative to treat patients is questioned, thus causing most chronic pain patients to be referred to pain management clinics, where again, there’s a wait to be seen, thus sending patients back to the acute care world and/or street drugs.
And as for the DEA, let’s not forget their unusual interpretations of the various controlled substances laws. Because most laws (including controlled substances laws) aren’t written to consider EMS, we’ve had some bizarre implementations of the laws by DEA in particular. There are several DEA regional offices that have determined that EMS has no authority to administer any controlled substances (pain management and sedation). Others have held that each ambulance and station (or posting location in system status management) has to be licensed as a facility by the DEA. These competing interpretations have reached the point there’s legislation pending before Congress to clarify EMS providers’ authority to administer controlled substances.
And in the EMS setting, let’s not even discuss that the only pain management option we have in most systems is an opiate. Opiates aren’t great for chronic pain or mild pain, but if the only tool you have is a hammer, everything starts to look like a nail.
I’ve been a lawyer in government practice for over twelve years now. I don’t expect that you can get various government agencies to all get along or even use the same playbook. But what I have come to expect is that if you get government involved in healthcare, you’re going to have some unintended consequences. The only thing you can consistently expect from government interfering in the physician (or nurse or medic) relationship with a patient is that there will be consequences. And said consequences will be unexpected. More often than not, they may even be worse than the problem they were addressing.