Today’s Los Angeles Times reports that Dr. Tom Frieden, head of the national Centers for Disease Control, condemns widespread prescribing of opioid/narcotic painkillers as dangerous and inappropriate. But if you read his remarks, he’s not only warning opioid prescribers, he’s giving them a ready defense against an accusation. Any medical provider who writes for opioids needs to pay attention or risk DEA, law enforcement and Medical Board wrath – criminal prosecution, conviction and imprisonment for drug dealing or homicide, and loss of license. MD’s, DO’s, PA’s, NP’s – now or never, take heed!
Frieden said two things which jumped out at me. First, here’s his bottom-line take on the U.S. epidemic of prescription drug abuse:
“These are dangerous medications, and they should be reserved for situations like severe cancer pain. In many other situations, the risks far outweigh the benefits. Prescribing an opiate may be condemning a patient to lifelong addiction and life-threatening complications.”
That’s the warning. The scientific evidence and widespread belief developing across the country are that these drugs should never have been recommended or made available to treat chronic pain. In the face of mounting evidence of the medical inadvisability of treating chronic pain (however that’s defined for each patient) with highly addictive, powerful narcotics, any provider who continues to prescribe high rates of these medications takes an ever-increasing chance of being accused of “operating outside the accepted standard of practice” or “prescribing without a legitimate medical purpose.” And as I’ve explained in this blog’s posts, if in the view of the DEA or a prosecutor you are “prescribing without a legitimate medical purpose” but you’re still prescribing like crazy, then you’re just dealing drugs. So the lesson from the CDC is to know what you’re doing, in light of the evolving prevailing science, or don’t do it. The CDC’s warning will have a big ripple effect, I’m sure, and that wouldn’t be such a bad thing, as long as ethical medical providers aren’t unfairly targeted for investigation and prosecution.
But Dr. Frieden also gave medical providers a powerful defense, a compelling argument to make in the face of criminal or administrative investigation. Here’s what he said:
“When I went to medical school, the one thing they told me about pain was if you give a patient in pain an opiate painkiller, they will not become addicted. And that was completely wrong.”
That’s a great argument, a legitimate defense, for a medical provider who faces official scrutiny over their narcotic prescription-writing. Today’s providers were all trained to treat pain as “the fifth vital sign,” and to take patient complaints about pain very seriously and respond accordingly. But if what you were taught about pain medication way back when is newly shown to have been wrong, then up until now, what crime did you commit by following accepted and scientifically validated medical practice? None, to my mind. The science changes, and with it, your obligation to keep up with the news and not put patients at risk. But who can righteously accuse you of having willfully neglected patient safety in the past, just because you followed what you were taught and what was at the time the prevailing state of medical knowledge?
The response by pain management medical providers or anyone who writes scrips for chronic pain has to be: (a) know the law, know the science, know what’s changing and stay in line with it, and (b) consider scaling back a pain practice unless even from the most skeptical perspective, you’re doing everything right. This may mean reforming your business model, it may impact income, it may mean a big change in how you’re currently practicing medicine. But a new business model sure beats an indictment or the initiation of license revocation proceedings if you insist on sticking with old ways in the face of new, possible life-saving information about patient safety.