Death and Pain and the Failure of the War on Drugs
The ethical vice of Moral Injury
This article is not aimed at physicians. Speaking about the danger of moral injury to physicians in terms of prescribing opioids is a way to center the conversation.
The article covers most of the major stakeholders who are concerned with pain relief and addiction.
I list the major players, although I will not cover all of them in the body of the piece.
Those involved are:
1-At the center of the controversy involving opiates needs to be patients in pain. Without pain and the tradition and need of treating pain with opiates, there would not be the supposed problem with prescribing opioids. Doctors would not be in trouble. State boards and the DEA would not be bothering patients or doctors. The DEA would be doing the job of hunting down drug traffickers.
2-In another sense the center of the problem has to be the thousands of people that are dying from overdoses from illicit drugs, mostly fentanyl. After all, that is where the harm is first being done. It is only after this, reality that the pain patient started to be harmed by removing their treatment. The question is then how did that connection take place between group one and group two?
3-A next group follows from groups one and two, but it is yet to be thoroughly determined what percentage of those people dying of illicit drugs is because they have been taken off prescription drugs. That is what percentage of the 100,000 deaths of a recent year are from an overdose from patients accidentally being killed looking for pain relief versus suicides, versus accidental death as a consequence of addiction?
4-The next group of stakeholders is physicians and other medical professionals that can deliver pain treatment and are sanctioned to prescribe opiates. They have all been put in an ethical vice because of a false narrative.
5-The next group consists of legal and administrative agencies charged with protecting the public. This includes the Department of Justice, the Drug Enforcement Agency, the State Criminal Justice System, and the state medical boards, and not to forget the fraud patrols of Medicare and Medicaid.
6-A subgroup of the previous one cannot be forgotten and they are the attorneys whether prosecutors or defense attorneys. Unfortunately, both groups contribute to the confusion. I will just say that there are financial incentives of tremendous and corrupting magnitude for the defense. And, among other things, career incentives for the prosecution. Certainly not always the case.
7-Next would be all those involved around the world in the production and distribution of dangerous opiates.
8-Next we circle back to group two on the list and ask about the larger group of people that the deaths come from. If we are fair, we realize that the opiate overdose group is part and parcel of a huge group of Americans that indulge in all kinds of harmful activities and realize that the opiate problem, and I emphasize the Illicit opiate problem, should not be particularly separate from the 600,000 deaths a year from tobacco and alcohol.
As I hope the reader already sees the focus should always have been on group number eight. How do we make a healthy society?
Moral injury
Confronting opiate deaths due to illicit fentanyl and the physicians’ responsibility.
From the introduction, we see that there’s enough moral hazard and moral injury to go around. I highlight the problem by focusing on physicians who are at the center of the storm.
There is a risk of moral injury in treating patients at risk of abusing and or being addicted to unsanctioned opiates. From the start let us be clear that sanctioned medications are prescribed by registered doctors who are authorized to prescribe such medication. Those medications become unsanctioned when they are used other than how they were prescribed and/or mixed with other medications not prescribed. However, the vast majority of unsanctioned opiates or illicit and illegal drugs that are either synthesized in a lab or come from plant sources such as poppies and the marijuana plant among others are not from the sanctioned pharmaceutical supply.
I will argue that this hazard of injury is mainly born by physicians who choose to treat those unfortunate enough to be addicted to opiates. That said, I will not ignore patients in the general medical population being treated for pain or the physicians that do that work.
The concept of moral hazard comes from economic theory. Hazard is a good word and I think we can learn from combining the two terms hazard and injury. They are not the same as there is a hazard of being injured. It doesn’t mean you’re going to be injured.
Traditionally “moral hazard” has been a technical term that means the following:
“When two entities enter into an agreement and where one party has fixed obligations to the other there is a hazard that the second party may abuse the constraints dictated by the first party.”
This concept has been used extensively in the insurance industry. An insurance contract will stipulate that the insurance company has fixed obligations to fulfill what is in the contract, say, insuring a house. For the homeowner, there will be stipulations about what the homeowner is obligated to do to keep up the house, but this does not mean that the owner will be diligent in the upkeep. This may be hard to prove for the insurance company. Say, the house burns down. Was the homeowner reckless and how does one assess the risk of the homeowner being reckless before you write the contract?
The use of the term moral in this case is a proxy for the idea of taking a certain amount of risk on the part of the insurance company and therefore not strictly an ethical idea. On the other hand, the insured has an ethical obligation to maintain their property.
Physicians are ethically obligated more than insurance companies.
The physician-patient relationship is analogous to the Insurance company and the insured.
Using the traditional term moral hazard in the context of medical insurance is the same as insuring your house. Blue Cross blue shield insures me. What obligation do I have to protect my health?
The relationship between doctor-patient goes beyond that. The ethical one is the doctor ensures that they will do the best for their patient. One difference is the patient ultimately has little responsibility because the information gradient between the doctor and the patient is great.
The AMA code of ethics says that the physician is to put the patient’s well-being above his own. It states that medicine is primarily a moral endeavor. Therefore, it is not primarily a legal endeavor. We speak of law and ethics. They are two distinct words and for the most part, we hope that they agree. We know throughout history, they have often not agreed. What does the physician do when he is caught between the law or regulation and his ethical duty?
It needs to be clear that treating pain in the normal course of medical practice is distinct from addiction medicine. In society, at the moment, there is much confusion about this. The confusion stems from not making the distinction between treating pain and addiction and focusing on the substance, the opiate itself. This leads directly to the present situation of many doctors, if not the majority, not giving anyone pain relief through opiates.
The following is a review of the facts to put all this in context.
-The main conclusion is that illegal, illicit drugs have driven the overdose crisis. And this has been true of overdose deaths throughout the last hundred years.
-In the last 10 years, due to government pressure, mainly from the Centers for Disease Control(CDC), the number of prescription opiates has fallen dramatically. At the same time, illicit drug use has skyrocketed as have overdoses leading to death mostly due to fentanyl. And fentanyl is a synthetic, that is made in a laboratory drug. The fentanyl is both licit and illicit. The overdoses come from illicit sources.
-It is clear that if medical patients, in the normal course of medical practice, take opiates at most 3% become addicted. And I’m using 3%, which is the highest legitimate number I have found and others claim as low as 1%.
-Given the above, it should be kept in mind that addiction is not a death sentence. Many of those people will not stay addicted.
-Considering the last two items it is to be understood that what an addiction is, is not even clear among doctors.
-I believe the cause of this confusion is a lack of interest and a phobia of opiates. A phobia will cause one not to think clearly about an issue or just ignore it. Therefore, many doctors, in an unthinking way, do not prescribe opiates.
-This phobia has profound roots and is well beyond what I’m going to say here, but keep in mind that pain management and addiction management are barely covered in medical school. It is simply not on the radar of a medical student or most resident physicians.
-Is addiction limited to a genetic predisposition or is it also a psychosocial phenomenon? I claim that addiction is very much tied to emotional turmoil and trauma albeit most of the time there is a necessary genetic component.
-One thing is clear millions of doses of opiates are given every day in hospitals. This is an ongoing, live, real-time clinical study of addiction. Given what is already been said the conclusion should be that out of those millions of doses and millions of patients at most 3/100 will have a problem. And, again, how we define those problems is still unclear.
-Further, many people confuse medical dependence with addiction. Almost all people that take opiates for any length of time will, if they stop them, especially abruptly, have withdrawal symptoms. That is a type of addiction, but it is a necessary medical addiction. It is better-called dependence, not addiction. It does not mean that the patient is taking more than they were prescribed or getting secondary gain, i.e. getting "high" from taking the medicine. In fact, most people that take opiates do not have mental changes or feel bad from the medication. Withdrawal symptoms are not unique to opiates as certain blood pressure medications and psychiatric medicines cause withdrawal symptoms if you stop them.
-It is also true that pain is an antidote to addiction. This is the case whether or not you’ve suffered from addiction before or are naïve to opiates
-What is called abuse is often also confused with addiction. It’s been my feeling that abuse is a strong word for many of the things that are listed by various organizations as abuse such as giving your spouse one of your pain pills. Again, that is considered abuse and people confound it with addiction.
Addiction treatment
With that background, we move to treating patients addicted to opiates.
I argue that the landscape for addiction medicine has changed dramatically in the last 20 years and especially in the last 10 years. This is due to fentanyl sold on the street that comes from China and Mexico. Fentanyl is at least 50 times more potent than heroin. A very small amount can cause death.
It is my contention, first and foremost, that the addiction doctor’s job is to keep people away from fentanyl and dying the afternoon they leave their office or the next day.
From the time you take on an addicted patient, you are aware or become aware of the moral hazard that is involved in treating these patients. Unlike an insurance company, you are ethically bound to protect the patient. You do not have the option the insurance company has of not renewing the contract. Certainly, patients can be discharged. Example: as a private practitioner, just as a healthcare system, you do not have an obligation to give free care. Blatantly criminal activity or unsustainable disruption of your practice need not be tolerated. However, from an ethical standpoint discharging the patient is the ultimate failure on the part of the physician. And even summarily discharging a patient due to nonpayment is questionable ethically.
Turning to the moral hazard that the state or the federal government faces when dealing with physicians, we come to realize the state is much more like an insurance company than a physician under an ethical obligation to treat a patient. The state and the federal government can revoke your privileges as a healer. For the state and the federal government, the moral hazard is the physician going outside what they consider the normal practice of medicine and harming patients. However, it is a well-codified tenant that the government does not and should not practice medicine. This is an aside that needs to be kept in mind and dealt with in other places.
Practically speaking, there comes a problem with follow through for the state in actually protecting the patient after they have terminated the doctor-patient relationship by revoking licenses. Their approach has caused fear and terror in the medical profession to the point that barely anyone wants to prescribe opiates. And this is to say nothing of the problem where discharged patients go after they lose their doctor. The states act in an “as if” world where patients can automatically find help within the system. This is the crux of the matter: they often cannot find care and they go to the street
This is a tension that has always existed. But one thing I’m arguing is that in addiction medicine and in particular, since the advent of illicit fentanyl, there is a qualitative change.
There is no other area of medicine where every patient you see is at substantial risk of dying when they walk out of your office.
There are several reasons for this. And those reasons should not include them being discharged by the physician or not being given proper treatment.
I will give two examples of the conflict between a physician and the state and that is doing urine drug screens and giving benzodiazepines with an opiate. There is much contradictory input from the state and federal government as to what you do when a patient gives you a urine sample that turns out to be contaminated with an illicit drug(s). Physicians have been sanctioned for not terminating such a patient. What exactly is the motive for this? As far as I can tell the bottom line is that the state is worried about the diversion of drugs, that is the patient giving or selling the prescriptions you give them to someone else. Of course, that thinking denies the actual patient in front of the doctor of ongoing care.
The second is the desire of the state to not give a benzodiazepine(Valium, Xanax, etc) along with an opiate. This is even though there are no controlled studies that show that this combination should never be given. Add to the problem that the government themselves are in disarray about this topic. A few years ago the FDA wrote a paper specifically addressing this issue, saying that patients on benzodiazepines should not be turned away from addiction treatment. At the same time, other guidelines hold that you should never combine these two types of drugs.
The clinical problem with it is that patients become addicted/dependent, especially on Xanax. You cannot take them off the drug easily and sometimes you can never get them off. There is a danger of seizure, fatal seizure, and severe injury. Add to this that, again, no literature specifically shows that there is increased danger to the patient’s life in giving both drugs.
From the get-go, if you accept a patient that is taking benzodiazepine you know that there’s a moral hazard built into your decision to take the patient. The hazard is not that the patient might be harmed, which again, we know that it’s not likely, but the hazard is going against some law or guideline. For the physician, the danger or the hazards shifts from the patient, and the doctor's legitimate care, to a danger from the state. The moral injury comes to the doctor if they do not do what they feel is right for the patient.
In summary, as for addicted patients, there is an ever-present hazard in today’s world of an addicted patient using fentanyl and dying. When treating such a patient one may do any number of things that might seem unconventional to keep the patient in the practice. This primarily means not discharging a patient if they relapse or you find that they have contaminated urine.
Treating Pain
Now, even though I made a clear distinction between pain patients and addiction medicine, they are the same issues.
I made the distinction because pain patients being treated with opiates are essentially a completely different class. As we have said at most 3% of them might get in trouble with addiction.
Where the groups become similar is in the present environment where doctors are highly encouraged not to give opiates. We then put all patients at risk of going to the street and dying of a fentanyl overdose.
Although correlation is not causation there is little other explanation of the increase in fentanyl deaths except that people are going to the streets to get pain relief after being tapered or cut back severely on their opiates. These are not suicides for the most part. I do not have the exact numbers, but I would suppose the majority of them are unintentional deaths. The person had no idea, or little idea, that they were taking fentanyl. This, of course, is also true of the heroin addict, and other types of illicit drug users, chronic or recreational, that think that they are getting the drug that is desired but instead get something laced with fentanyl.
The reader should be aware of the actual number of patients suffering. There are an estimated 100 million patients that have chronic pain in the United States. That’s almost 30% of the population, one in three people. Of those 20 million have been on some type of opiate or one in five people that have chronic pain have been treated with opiates long term.
Whether speaking of a patient addicted to opiates or a patient seeking care for their pain they both carry moral hazard for the state and doctor of going to the street to get care. It is just that I claim, leaving aside pain patients for the moment, that every patient that is addicted, due to the high relapse rate, is at risk of dying from fentanyl and no other area of medicine carries such a risk.
Finally, there is a moral risk in an ethical and philosophical sense to the physician. There is a risk of moral injury to the physician.
This goes back to the AMA admonition that the patient comes first. First, not harm. And in this essay, the harm you are avoiding is the patient dying from fentanyl.
The moral hazard for the physician is the moral transgression and the consequence to his moral integrity for not following the dictum of no harm. Whatever that may mean to him at the moment. That is the true moral hazard.
But we need to continue. The state, meaning the individual states, and the federal government, believe they are protecting patients. The validity of the present system and its past utility can be debated, however, I continue to argue that the rise of illicit opiates, and illicit drugs in general, has changed the landscape.
One question is why do we need five or more different monitoring bodies to overlook the physician's office? Those bodies are the individual state boards, the individual state criminal justice system. the drug enforcement agency (DEA)which is under the Department of justice, the Medicare audit system, and finally, we have the civil justice system covering malpractice. And I probably missed some.
All of these bodies ostensibly are there to protect the patient from harm. They seem to believe that they are taking into account the moral hazard that includes doctors practicing bad medicine by prescribing unneeded opioids and patients seeking out opiates when they don’t need them.
What has gone awry is the introduction of a false narrative the origins of which will take years to come to terms with and figure out where it came from. The basic facts of this false narrative have already been stated above. But let us review: prescription opiates are not the cause of the overdose problem in the United States. As of today, approximately 80 percent of overdoses are due to illicit fentanyl and other illicit drugs. Only 1 to 3% of people that take prescription opiates will become addicted and again, addiction does not mean that they’re going to overdose. Millions of doses of opiates are given every day to millions of patients and they do not get addicted. And finally, to repeat another item, when prescription drugs are involved in death, they are almost always found to be in conjunction with some illicit drug.
The most obvious answer as to why this has gotten out of control is that the war on drugs is and has been a dismal failure for years.
For years we have known that you cannot arrest your way out of the drug problem.
What we’ve done is only made things worse by focusing on prescription medication to emphasize (and I’m going to repeat several facts about prescription drugs): we ignore that addiction to opiates only occurs in a small percentage of patients that take legal drugs and ignore the overall addiction problem. The methamphetamine and cocaine problems do not initiate with the physician to say nothing of the major problems of alcohol and nicotine where the real harm is being done. 100,000 people may have overdosed on opiates last year, but for years we’ve been losing 600,000 people to smoking and alcohol.
If none of these problems, initiate with the doctor, why is it that opiate addiction is blamed on the doctor?
Addiction is primarily not a medical issue. Today this can be debated as the definition of what is medical is ever-expanding which is a problem in itself. I always wished that medicine was more focused on prevention, but in practice, this has never been the focus of medicine. The focus in medicine has been the clinical doctor-patient relationship where the patient comes to you with a problem and then we treat it.
Putting aside the idea of the expansive definition of medicine addiction can be looked at as primarily a psycho-social historical and economic problem.
Addiction throughout the world is a growing problem. Maybe a better phrase is addiction is a sickness of the soul and that means a sickness of the soul of the nation in great part. This is born out of the fact that we ignore that the war on drugs is a failure.
