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U.S. SURGEON GENERAL ON THE OPIOID CRISIS: MEDICAL TRAINING AND PRACTICE FAILS TO PROTECT PATIENTS FROM HARM – BECAUSE BIG PHARMA MAKES US DO THINGS

By Clark Miller

Published December 14, 2018

Updated April 5, 2021

In a series of TV news interviews on the opioid crisis, past Obama Surgeon General Vivek Murthy, newly appointed as Surgeon General in the Biden administration, repeatedly blames the runaway over-prescribing by American doctors creating the crisis on: 1) doctors’ beliefs that the opioids – which have been listed since 1970 as Schedule II Controlled Substances due to risk of abuse and addiction – “are not addictive when prescribed for pain” and 2) “marketing” by drug companies – in effect questioning the medical profession’s ability to independently use clinical and ethical judgment to protect patients.

The remarkable series of interviews  includes the nation’s former and newly re-appointed chief medical officer and public health authority explaining the runaway over-prescription of opioids that created the opioid crisis by asserting that “practitioners were urged to treat pain aggressively”  

and that “many of us were even taught –  incorrectly – that opioids are not addictive” (starting at 4:10 in the CBSN clip).

In another interview, also from 2016, the Surgeon General repeats (starting at about 2:38 in the MSNBC clip) that “clinicians were urged to treat pain aggressively”, that he personally was trained, 20 years ago, opioids “were not addictive so long as they were given to someone with legitimate pain”. He adds, “Even today I encounter doctors who still believe that [that opioids are not addictive] because they haven’t been taught any different”.

Murthy’s response to the runaway overprescribing that created the opioid crisis was to send a letter to medical prescribers, as part of a “turn the tide campaign”, asking them if they wouldn’t mind working “to sharpen their prescribing practices”. 

These are remarkable and remarkably disturbing statements on a number of counts, and demand our examination of them, a critical discourse about them.

But first, some background. The high abuse and addictive potential of opioids including those prescribed for chronic pain is long-established, generating a long history of statutory control e.g. Harrison Act (1914); Boggs Act (1951) and others.

The 1970 Controlled Substances Act lists opioid drugs commonly prescribed for chronic pain as Schedule II Substances, highly controlled as “drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence”.

Those histories and basic facts would almost certainly be part of the training of any professional in healthcare administering or prescribing the drugs.

Opioid drugs and their potential for misuse have been part of American culture and mass media reports for many decades. Common cultural knowledge.

In that undeniable historical and cultural context, Dr. Vivek Murtha’s statements, barely challenged by his interviewers, taken at face value constitute a frank condemnation of both U.S. medical schools and education, and of the capacity for medically-trained professionals to independently use clinical competence and reasoning along with ethical judgment to protect Americans seeking medical care.

“Even today I encounter doctors who still believe that [that opioids are not addictive] because they haven’t been taught any different”.

– past Obama Surgeon General Vivek Murthy, newly appointed as Surgeon General in the Biden administration, in 2016

The assertions by the nation’s top medical official demand explanation from the medical community and institutions protecting healthcare consumers from harm:

 

As to how it is possible that U.S. medical schools were teaching that opioids were not generally addictive in the context of the longstanding evidence base to the contrary, the statutory control, the explicit calling-out of the “high potential for abuse, with use potentially leading to severe psychological or physical dependence” in the 1970 Controlled Substances Act, statute that controls prescribing practices of all medical professionals.

How it is conceivable that in 2016 the Surgeon General encountered “doctors who still believe that [that opioids are not addictive] because they haven’t been taught any different”. Consider the astounding nature of that statement by imagining a survey of adult Americans in 2016. How many would not believe that opioids are addictive? How many would claim that their beliefs about the addictive nature of opioids stem from what they have or have not “been taught” as opposed to scientific information about problem opioid use they are surrounded by in culture and mass media, the same popular culture and mass media that doctors are exposed to

In that cultural and information context, how it can be that any unimpaired student in a medical school would accept at face value assertions by instructors that opioid drugs are not addictive, then practice medicine on that basis, without researching that question

How it is imaginable that medical practitioners, prescribing Controlled Substances Act Schedule II Substances, – highly controlled as “drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence” – would take at face value and base clinical practice on the drug safety advice of “pharmaceutical companies”

 

Murthy’s comments constitute weak and hollow rationalizations and excuses that miss the relevant issues and constitute disparagement of the many fine, competent, ethically practicing medical professionals – I know because I’ve worked with some of them – who have not overprescribed opioids or been directed by the “pharmaceutical companies” and who are able to use ethical and clinical reasoning to avoid contributing to the opioid crisis.

As newly appointed Surgeon General in the Biden administration, Murthy may want to resend that letter. Or instead take effective actions to reduce continued over prescription of opioids, including those that are driving the increasingly lethal epidemic in the context of regular news reports of continued, often criminal, over prescription of opioids to vulnerable Americans and of his premier medical professional organization, the AMA, attempting to block implementation of CDC prescribing guidelines being adopted by states. 

Here’s one take on that, by a health care blogger – 

There’s still lots of money in the peddling of opioids, and lots of misinformation out there about opioid control efforts going too far.

Correlated? You tell me.

The American Medical Association sent a letter to the CDC claiming  “the nation no longer has a prescription opioid-driven epidemic...the AMA urges governors and state legislators to take action [to] remove …. arbitrary dose, quantity and refill restrictions on controlled substances.” [emphasis added]

In a letter sent to the AMA that was also published in the British Medical JournalPhysicians for Responsible Opioid Prescribing took the AMA to task, noting the AMA’s position is misguided at best:

 There is compelling evidence that many of those currently struggling with opioid dependence and addiction were introduced to opioids through use of medically prescribed opioids used to treat chronic pain. Medically prescribed opioids remain a common gateway to illicit opioid use and are themselves frequent causes of opioid addiction and overdose, even if illicit opioids currently cause the greater number of deaths.

PROP’s letter goes on to state:

Suggested dose and duration restrictions are not “arbitrary”, they are based on considerable evidence of when harm far exceeds benefit.

I do not know why the AMA is mischaracterizing the CDC guidelines. I do know opioid manufacturers are very, very good at working the levers of power, expert at manipulating government officials, and extremely generous in their political contributions.

The AMA’s anti-opioid guideline stance is kind of bizarre, bizarre as in Through the Looking Glass. On the one hand, it is mischaracterizing and decrying CDC guidelines that have been instrumental in mitigating the opioid disaster.

On the other, the AMA is claiming credit for reducing opioid use, deaths from overdoses, and various other positive trends, stating “the [AMA Opioid] task force’s recommendations have led to significant progress…”

That’s rather bold, considering:

And, of course, those CDC guidelines have been widely adopted by states, and are widely credited with reducing the damage done by opioids.

At times the guidelines have been misapplied, doctors have arbitrarily applied them, and patients have been abruptly cut off. That is NOT the fault of the guidelines, that are just that – guidelines. Rather, it is the fault of those mis-applying them to patients.

Instead of a timid tool of the medical industry and allied interests serving as a press secretary, we need medical field leaders with the intellectual courage to say something like this –

 

In the medical field, we’ve gotten off track and made fundamental errors in overapplication of our scope of competence and practice. We have unreflectively overapplied our model and training to problems that are not medical at all in nature – like common chronic pain – helping to create and then meet demand by a misled public for a pill for every ailment, every distress. That created a tragic opioid crisis.

We’re making the same error by attempting to rely on a medical fix for the opioid crisis we created, instead of supporting the fields of psychology and behavioral health in treating compulsive substance use – another problem that is entirely non-medical in nature and cause, as evidenced by decades of application of medical and disease models with no public benefit.

It’s time for change.

 

And time for us to force a critical discourse.

And take the power back.

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)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

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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