There is a deadly explosion of opioid addiction in the United States. While it is clear that nothing this complex or widespread can have a single cause, it is also clear that American prescribing habits have been a significant contributing factor.
According to the Department of Health and Human Services more than 240 million prescriptions for opioids were written in 2014, and it is well established that prescription oral analgesics are the principal gateway for heroin and other injection narcotics.
It is also true that use of narcotic analgesics is much higher in the United States than in other countries. Here again, the difference between the U.S. and the rest of the world probably has multiple causes, including pharmaceutical marketing, and the easy availability of drugs. Recently, the Centers for Medicare and Medicaid Services implicitly acknowledged another cause: the creation of patient expectations around pain control, and the subsequent pressure that has had on U.S. physicians' prescribing habits.
Starting with the Joint Commission establishing pain as “the fifth vital sign” (after blood pressure, heart rate, temperature, and respiratory rate) an entire generation of U.S. physicians was trained to eradicate pain aggressively. I recall being taught that aggressive pain management was an essential element of good patient care, and that it had a low likelihood of leading to addiction or abuse.
CMS got into the act by including questions about pain management on the mandatory (Hospital Consumer Assessment of Healthcare Providers and Systems) HCAHPS hospital patient experience survey. Since HCAHPS scores are tied to hospital reimbursement, institutions nationally were incentivized to implement intensive pain assessment and treatment protocols, nearly all of which relied heavily on the use of opioid analgesics.
Reacting to the epidemic and to the perception that its policies may be counterproductive, CMS announced recently that: “Although CMS is not aware of any scientific studies that support an association between scores on the pain management dimension questions and opioid prescribing practices, we are proposing to remove the pain management dimension of the HCAHPS survey for purposes of the Hospital VBP [value based purchasing] Program in an abundance of caution.”
It won't change the landscape of opioid abuse overnight, but it seems to me like an important step in the right direction.
What do you think?
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.