DOCTOR NONCOMPLIANCE AND DANGEROUS PRESCRIBING CONTINUE TO FUEL THE OPIOID EPIDEMIC

Decades into the increasingly lethal opioid epidemic, prescription tracking systems designed to support doctors to more safely prescribe have no effects on opioids dispensed

by Clark Miller

Published November 6, 2022

Prescription drug monitoring programs (PDMPs) have emerged as state‐level interventions intended to curb opioid abuse and over‐prescription. While some states have voluntary PDMPs, others have enacted mandatory or “must-access” programs in which authorized individuals must consult the PDMP before prescribing certain controlled substances. An analysis published in Contemporary Economic Policy reveals that must‐access PDMP implementation does not uniformly reduce prescription retail opioid sales across eight commonly prescribed opioids.

Must-access PDMP implementation had no statistically significant effect on the retail sales of the treatment drugs methadone and buprenorphine.

The findings suggest that PDMP implementation is best considered as part of a broader policy response to the opioid crisis.

“The United States opioid epidemic is a complex problem. These results suggest that must-access PDMP implementation alone cannot fully address the public health issues associated with this ongoing public health crisis,” said corresponding author Collin Hodges, Ph.D., of the University of Central Arkansas.

Let’s take a look at what’s being said here. 

PDMPs are data bases that can be accessed by prescribers (licensed medical professionals LMP) to search for any patient’s history of prescription of opioids and other drugs, thereby useful in detecting “doctor shopping” for multiple, excess prescriptions of a drug or for prescribed substances that are often abused and are potentially dangerous in combination with opioid use. 

Consistent with a similar earlier (2018) study, these results don’t support PDMP availability as changing behaviors of doctors entrusted with prescribing opioids safely.

That’s particularly relevant for prescriptions of methadone and buprenorphine

(Subutex, Suboxone), American Medicine’s medical fix for the opioid crisis provided under medication assisted treatment (MAT) programs. Prescription benzodiazepines, for example, are commonly abused by users of Suboxone (“bupe) due to the enhanced euphoric effect. That abuse increases risk of abuse of either substance, challenging revival efforts with the lethal overdose-reversing drug naloxone, And signals failure of the intended purpose of the prescribed bupe under MAT – to reduce overdoses and treat problem opioid use by stopping high-risk use of opioids. 

That’s why it is particularly significant that “Must-access PDMP implementation had no statistically significant effect on the retail sales of the treatment drugs methadone and buprenorphine.”

It’s known (also here) and has been for decades, that those MAT “medications” are commonly diverted, abused, and used as currency for “real dope”including fentanyl in street economies of illicit, high-risk opioid use, and are commonly used with high risk in in combination with other prescribed and illicit drugs of abuse

And in more recent research, a large sample study found the predicted: association of abuse of fentanyl with prescription opioids associated with subjects being in MAT programs. 

So, LMPs using PDMPs to research prescription histories prior to prescribing opioids and other drugs would seem the most basic of ethical and professional standards and almost certain, given the levels of established misuse, to alter opioid prescribing. But they haven’t. 

Oregon is one state where PDMP use has been voluntary.

From a recent post –  

In progressive Oregon, a state with the highest rate of seniors hospitalized for opioid overdoses, abuse and dependence and the sixth-highest percentage of teenage drug users in a 2018 audit, medical prescribers aren’t changing much about their opioid prescribing. 

As a deadly drug epidemic continues to rage in Oregon, state officials have only made a few changes recommended by the Secretary of State’s Office nearly four years ago to curb opioid misuse.

That was the overarching finding of an audit released Wednesday of the state’s Prescription Drug Monitoring Program, which tracks prescriptions of controlled substances, including painkillers, stimulants and tranquilizers. 

. .

In the 2000s, amid an opioid epidemic fueled by overprescriptions, various states created databases to track them as a way of limiting excessive prescribing of opioids. Fifty states now have a monitoring program but many have tighter rules than Oregon and they don’t have a drug problem as severe as Oregon, said Kip Mennott, the Secretary of State’s audit director. Tightening the program’s requirements will help stem the problem but it’s not the only answer, he said.

. . . 

The program requires pharmacies to file information about prescriptions of controlled substances. Prescribers are supposed to register so state officials can identify excessive prescribers. Prescribers also search the database to identify patients who “doctor shopped” to obtain more prescriptions than they need.

But Oregon providers are not required to check the database when they prescribe controlled substances, the latest audit said. This is something auditors recommended in 2018 and is common in other states.

The audit identified patients with opioid prescriptions from “excessive numbers of prescribers” and “dangerous prescription drug combinations,” which includes mixing opioids such as OxyContin with sedatives, like Xanax.

It also said that state laws prevent the database from being shared with health licensing boards and law enforcement to monitor and address questionable prescription activity, another area of concern. 

“Questionable prescribing habits seen within the data, even those that are egregious, cannot be elevated to any regulatory or enforcement entities to directly look into those situations,” the 2018 audit said.

The Oregon Health Authority, overseeing Oregon’s use of Measure 110 decriminalization funds for substance use treatment improvements, responded to the concerns without indications of commitment to action –

“The agency is pleased with the performance of the (program) in ensuring appropriate use of prescription drugs, and helping people work with their health care providers and pharmacists to determine what medications are best for them,” the statement said.

But the agency will not play a major role in pursuing legislative changes.

With or without legislative and statutory compulsion to access data bases and more closely protect patients safety in their prescribing practices, Oregon medical prescribers have had access to those tools for protecting patients and the public for nearly a decade. They have chosen to not use them. 

That is, LMP use of this important tool for protecting public health and moderating American Medicine’s worsening opioid crisis, whether voluntary or mandated, is not happening. And in a state like Oregon, legislative and healthcare oversight regulators are essentially providing LMPs protection from consequences for failing to modify prescribing to those ends. As has the U.S. Supreme Court

Back to the Medical Xpress report – 

The findings suggest that PDMP implementation is best considered as part of a broader policy response to the opioid crisis.

“The United States opioid epidemic is a complex problem. These results suggest that must-access PDMP implementation alone cannot fully address the public health issues associated with this ongoing public health crisis,” said corresponding author Collin Hodges, Ph.D., of the University of Central Arkansas.

One could characterize that phrasing of the results – “that must-access PDMP implementation alone cannot fully address the public health issues associated with this ongoing public health crisis” – as “spin” or a “distortion”, but only if one were too cowardly to accurately highlight the lie it represents. 

To say “alone cannot fully address” clearly provides the message that America’s medical professionals are using the data bases to better manage their opioid prescribing with significant positive outcomes for public health and moderation of the opioid crisis, the significant positive outcomes unfortunately “alone cannot fully” end harms from American LMP opioid prescribing. Not “fully”. By half? By 10 percent, but not fully? There was the prediction or research hypothesis that PDMP use would fully address the opioid crisis? 

It’s a constructed lie, of course, constructed to avoid the outcome of these studies – that the availability of the tools for safer prescribing has had no significant effect on dispensing of opioids including MAT opioids established as contributing to high-risk use and fueling the epidemic. 

doctor writing prescription

But what about direct, pharmacy-generated warnings

for dangerous opioid prescribing that is not in question, for example the high-risk prescription of a benzodiazepine with an opioid? That combination that has been commonly used by MAT patients and others in the longstanding, pervasive illicit economies and lethal misuse of doctor-prescribed MAT opioids like Suboxone and methadone? The combination that makes life-saving revival with naloxone less predictably life-saving? What about direct warnings to LMP prescribers from pharmacists when that combination is identified? 

Email alerts to practitioners from pharmacists did not reduce concurrent prescribing of opioids and benzodiazepines, a randomized trial showed.

Huh! That’s troubling, a shock. 

As shocking as if American doctors, decades into American Medicine’s lethal crisis, had continued to fail to provide informed consent – i.e. to discuss potential dangers – to patients being prescribed opioids. 

As troubling as if states mandating LMP prescribers to use a database designed to help them avoid dangerous prescribing made no difference in that prescribing

As pathological as a state health authority enabling that failure and continual misprescribing. 

But we’ve gotten distracted. It was the Sacklers, big pharma, pharmacies. How could that be in doubt? Those truths are provided everywhere. 

30 percent? Not 8 pecent? 

The importance and potential harm of noncompliance with Medical practice and ethical standards over decades of the persistently worsening crisis is reinforced by new evidence that estimates of potential for development of compulsive high-risk opioid use (“dependence”) – persistently asserted to be no more than about 8 percent of newly-prescribed opioid users – appears to have been much higher in the U.S. Medicaid population, from this report at MedCity News. 

Healthcare providers need better algorithms to predict opioid dependency, especially among Medicaid patients, according to new research from Stanford University and Gainwell.

Stanford researchers teamed up with healthcare technology company Gainwell to use the company’s datasets —  180,000 de-identified Medicaid claims from six states (three in the Southeast, two in the West and one in the Midwest). Their research revealed that among patients who had never taken an opioid, 30% developed an opioid dependency following their first prescription. The study was published last week in PLOS Digital Health.

Potential harm from medical practice noncompliance over the decades of a worsening crisis is also reinforced by apparent failure to effectively provide a most fundamental, protective patient right and protect patient autonomy to choose or decline treatments based on being fully informed of aspects of treatments bearing on safety and potential for harm.

“Informed consent” is that practice by which a health care provider explains and affirms understanding of those risks and benefits of any treatment suggested, to ensure patients have the information needed to accurately appraise risk, an important right when addictive, controlled substances are involved.

From this recent post – 

The Patient Opioid Notification Act requires that medical practitioners discuss the addictive potential of opioid-based painkillers with their patients – and parents of minor patients – as well as discuss, when appropriate, safer non-opioid pain relief alternatives.

. . . 

Prior to enactment, only 18% of the participants warned patients about the risk of opioid addiction when prescribing opioids. After enactment, 95% routinely warned patients about the risk of addiction.

. . . 

Dr. Andrew Kolodny said, “These findings show that very few opioid prescribers were warning patients about the risk of addiction before New Jersey required them to do so.”

That’s less than half the story.

All medical practitioners were already required – by the most fundamental of their ethical duties and standards of practice – to provide explanations of risks, benefits, and alternatives for any recommended or provided medical procedure or prescription. They just weren’t doing that over the decades that their opioid prescribing was leading to dependence and death for more and more Americans. It would take enactment of new state law and risk of violation to get them to follow their medical training and existing ethical standards protecting patients’ health and rights. 

Consent without being fully informed of real risks of a medical intervention – including risk of illness and death – is not consent, it’s reckless neglect, or deception. 

America’s medical practitioners appear to have been little more compelled to provide informed consent for prescribed opioids – required for patients to make choices protecting their own safety –  than to protect public safety by use of PDMPs.

Or to apply in practice knowledge of consistent indicators against use of opioids for chronic pain generally, from research and information that had been available for decades.

Or, described in this post, to comply with the ethical and practice obligation to confidently monitor safe use of the medications they prescribe – 

A fundamentally relevant and troubling body of evidence –

disallowed for public messaging and discourse – points to what the results reveal about the clinical practices of American Medicine

In a related study, surveyed medical doctors reported they were confident in their ability  to detect misuse of substances, yet 50 percent of samples indicated misuse

Telehealth offered numerous benefits to patients during the COVID-19 pandemic, providing access to care when in-person visits weren’t safe or feasible for many. But a new report shows providers worry that virtual visits allowed signs of drug abuse to slip by unnoticed.

In a report from Quest Diagnostics released Monday, 67% of the over 500 primary care physicians surveyed said they fear they missed signs of drug abuse in their patients during the pandemic.

And nearly all of them were prescribing those often-misused drugs—a whopping 97% reported prescribing opioids within 6 months of taking the survey.

Their concerns extend beyond the pandemic into telemedicine use today. Only 50% of physicians said they were confident they could recognize signs of drug misuse during telehealth visits, a far cry from the 91% that said the same of in-person patient interactions.

. . .

But Quest’s data indicates that just because a physician thinks they can spot patient signs of drug misuse doesn’t always mean they do.

While 88% of the physicians reported feeling confident they could identify patients at risk for drug abuse, nearly half of all patients tested by Quest in 2020 showed signs of drug abuse.

Here’s the report these interpretations were based on, analyzing “nearly 5 million de-identified aggregated Quest Diagnostics test results, including over 475,000 from 2020 alone, with a survey from the Harris Poll of more than 500 primary care physicians”. 

SECAUCUS, N.J., Nov. 15, 2021 /PRNewswire/ — A new Health Trends® report from Quest Diagnostics (NYSE: DGX) finds that almost 70% of physicians fear they missed signs of drug misuse during the pandemic, and, given how the global health crisis disrupted medical care, anticipate rising overdose deaths – especially those involving prescribed and non-prescribed (illicit) fentanyl – even as the pandemic subsides.

By combining an analysis of nearly 5 million de-identified aggregated Quest Diagnostics test results, including over 475,000 from 2020 alone, with a survey from the Harris Poll of more than 500 primary care physicians, “Drug Misuse in America 2021: Physician Perspectives and Diagnostic Insights on the Drug Crisis and COVID-19,” provides a unique snapshot of prescription and illicit drug misuse in the United States during the COVID-19 pandemic. The Partnership to End Addiction was an advisor to the report’s development.*

The new report comes on the heels of the approximately 96,779 drug overdose deaths between March 2020 and March 2021, as reported by the Centers for Disease Control and Prevention (CDC).i It also builds on prior Health Trends research, including a 2019 report that examined physician attitudes on drug misuse and a 2020 report that showed positivity increased by 35% for non-prescribed fentanyl and 44% for heroin among tested individuals during the early months of the pandemic.ii

Let’s summarize these studies, so we don’t miss the points. 

 – Doctors prescribing commonly misused and potentially lethal drugs (two thirds of prescribers surveyed) believed. they were missing signs of misuse over months of COVID pandemic relaxed prescribing controls that were initiated for patient safety, allowing prescription based on video or even telephonic contact, even for an initial visit and prescription. 

 – And they continued, knowingly prescribing.

 – Even for doctors (about 90 percent) who believed that under improved clinical conditions they were not missing signs of potentially dangerous abuse, patient samples indicated misuse in “nearly half of all patients”. 

 – Over the same period, doctors who could have used objective evidence to protect  against potentially lethal error in their impressions by using the PDMP databases, were not using them to control prescribing.

And? Institutional, doctor, medical, and other groups are lobbying hard to protect their ability to continue to use telemedicine and telephone prescribing post-pandemic. 

The cumulative findings outlined here seem to raise important questions about factors motivating practices of America’s licensed medical providers and the ability of American Medicine to protect the safety of vulnerable patients exposed to those practices.

This 2018 CNN report is now deeply buried, safely out of sight, under successive major media floods of usefully distracting and deceptive bogus cover stories on fentanyl, pandemic stressors as accounting for the continuously surging crisis, and useful scapegoat villains. 

CNN — As tens of thousands of Americans die from prescription opioid overdoses each year, an exclusive analysis by CNN and researchers at Harvard University found that opioid manufacturers are paying physicians huge sums of money – and the more opioids a doctor prescribes, the more money he or she makes. 

In 2014 and 2015, opioid manufacturers paid hundreds of doctors across the country six-figure sums for speaking, consulting and other services. Thousands of other doctors were paid over $25,000 during that time.

Physicians who prescribed particularly large amounts of the drugs were the most likely to get paid. 

“This is the first time we’ve seen this, and it’s really important,” said Dr. Andrew Kolodny, a senior scientist at the Institute for Behavioral Health at the Heller School for Social Policy and Management at Brandeis University, where he is co-director of the Opioid Policy Research Collaborative. 

“It smells like doctors being bribed to sell narcotics, and that’s very disturbing,” said Kolodny, who is also the executive director of Physicians for Responsible Opioid Prescribing.

. . .

CNN spoke with two women who’ve struggled with opioid addiction, and they described the sense of betrayal they felt when they learned that their doctors had received large sums of money from the manufacturers of the drugs that had created such havoc in their lives. 

Carey Ballou said she trusted her doctor and figured that if he was prescribing opioids, it must be because they were the best option for her pain. 

Then she learned that opioid manufacturers paid her doctor more than a million dollars over two years.

“Once I found out he was being paid, I thought, ‘was it really in my best interest, or was it in his best interest?’ ” she said.

CNN image of doctor providing opioids

A more understandable and powerful motivator

may likely have been that described by writer Chris McGreal in “American Overdose” – ethical malpractice driven by fear.

From a previous post

Not a single opioid pill provided to living or dead Americans

was supplied  to them by a member of the Sackler family, from Purdue Pharmaceuticals, from any employee of a pharmaceutical or opioid manufacturing company.

Apart from anomalous exceptions, like Sam Quinones’ unflinchingly “True Tale” in Dreamland – and a new piece in Journalist’s Resource, below – you wouldn’t get that from the necessary fabricated distortions and media focus on Big Pharma as criminal accomplice in the epidemic. As if those representatives and executives themselves were distributing the addictive Schedule II opioids, against evidence – all longstanding lines of relevant evidence – predicting harm, as if the pharmaceutical reps and execs were in the exam rooms, coercing MDs and other licensed medical providers, or forging their signatures on the prescriptions.

As if those licensed medical providers, over the course of an American medical education, would not have necessarily become aware of the evidence and their clinical and ethical obligations to practice accordingly, based on the longstanding indications against the runaway provision of those Schedule II opioids: the potential for hyperalgesia; the addictive potential of opioids; the lack of evidence for effectiveness; the psychogenic nature of common chronic pain; and the effective, durable, indicated use of cognitive behavioral therapy (CBT) for common chronic pain.

All lines of evidence that were established prior to generation of the opioid crisis and would have been part of any legitimate medical training, training that would have – one presumes – been taken as more compelling than the assurances of pharmaceutical representatives. Or not.

Sam Quinones, Chris McGreal in American Overdose, and some others have outlined the sordid confluence of forces –

deception, fabrication, submission to pressure from patients and medical organizations, and failed responsibility to vulnerable, trusting Americans – driving generation of the lethal opioid epidemic: a remarkable abdication of competence, integrity and ethical behavior by players including big pharma, America’s top medical, oversight, and research institutions, and the medical profession, with mass media along for the ride.

As McGreal describes in American Overdose, the clinical environment in medical practice settings became coercive and toxic – a collusion of patients trained by decades of programming to seek a pill for every distress including opioids, supported by the medical/hospital/insurance industrial complex to report doctors who would resist providing opioids inappropriately and threaten them with complaints and action by professional and licensing boards.

McGreal talked to Dr. Charles Lucas, a surgeon in Detroit who resisted growing pressure to overprescribe opioids, ended up being subject to a complaint and summoned before a hospital ethics committee for failure to provide adequate pain treatment.

(from American Overdose pp 88 – 89)

The case was dropped, but it was not an isolated incident. Luca has worked closely with another surgeon, Anna Ledgerwood, since 1972. She too was hauled before the ethics committee on more than one occasion on the same charge. One of the investigations, for alleged inadequate pain management after a hernia operation, went all the way up to the state medical board. It cleared Ledgerwood, but Lucas said more junior surgeons buckled to the pressure to administer opioids just to stay out of trouble. “If they will give me a hard time, then they will surely give a young resident a harder time,” he said. “I tend to be a fighter. That’s my nature. But somebody who just wants to take care of patients, they want to be a professional physician, they don’t want to put up with all this crap; they’re intimidated. They’re also frustrated by it. The medical community knows that too many pain medicines are being written. Doctors talk about it among themselves. They’re not in a position to challenge the system. But they know.”

Lucas regarded the new pain orthodoxy as a growing tyranny, and he thought it was killing patients.

Of course they knew. Or should have, or should not be practicing medicine.

But the forces driving runaway, medically inappropriate dispensing of opioids were not knowledge, competence, integrity or professional courage. There were other forces at play.

It is much less discomforting – especially for America’s journalism institutions instrumental in helping to fabricate out of nothing a bogus scientific rationale for runaway use of opioids against all evidence – to focus on Big Pharma (another example of the unfortunate excesses of corporate greed) as the reason for the lethal crisis, than to accurately indict America’s most trusted institutions including the impotent and enabling watchdog press that helped to create the needed fabrications. The more attention diverted to Big Pharma, the less on the necessary roles of media, the medical profession, research and oversight institutions. Corporate greed is a given; incompetence and betrayal by the core democratic and public health institutions trusted to protect American well-being and lives must be disguised, distracted away from.

And just as blanket Medical-Media messaging has constructed pill manufacturers, somehow, as responsible for the runaway dispensing – against all longstanding lines of evidence – of addictive opioids for the non-medical condition of chronic pain, generating the increasingly lethal opioid crisis – the same collaborating forces successfully fabricate a STORY of street fentanyl as explaining continuously mounting opioid-related deaths, those deaths correlated with increasing provision of the Medical-Media “treatment”.

Quinones spilled the truth, more directly, as part of a cover story in the LA Times, when he noted, simply, that

Doctors told me they misprescribed the addictive opioids – Schedule II Controlled Substances – knowing it was medically not indicated. 

Right, they disclosed the obvious which must be covered, hidden – the purpose of the cowardly LA Times Op-Ed. 

Again, from Chris McGreal’s “American Overdose” – 

“The medical community knows that too many pain medicines are being written. Doctors talk about it among themselves. They’re not in a position to challenge the system. But they know.”

Lucas regarded the new pain orthodoxy as a growing tyranny, and he thought it was killing patients.

In their generation of an increasingly lethal opioid crisis, American medical professionals chose protection of medical careers and self interest over patient safety absent levels of moral development and courage to choose otherwise. 

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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