Anyone reading health care news today must be aware that American medicine – particularly pain medicine – is in crisis. Doctors are experiencing high levels of burnout due to administrative burdens, prior authorization demands, and a health care system that often prioritizes efficiency over patient care. This burnout is leading to mental health issues and, in some cases, physician suicides.
Medicare payments to physicians have decreased by 26 precent since 2001 when adjusted for inflation, putting financial strain on medical practices. Yet the high cost of health care in the U.S. compared to other countries is an ongoing significant issue. The U.S. system of tying health care to employment has left millions uninsured or underinsured, especially during economic downturns.
Just as doctors are under enormous pressure, so also are patients dying of medical collapse and suicide due to doctor desertion. Conditions are especially critical among the 50-million-plus U.S. citizens who suffer yearly with debilitating chronic pain sufficiently intense to bring them to a doctor’s office for help. Increasingly, there is no help to be had. The practice of medicine in America has been criminalized by vast government overreach. Doctors are being intimidated by an ongoing National witch hunt conducted by the U.S. Drug Enforcement Agency. Some clinicians are leaving practice. Others are posting prominent notices in their offices, stating that they do not prescribe opioids.
Contrast this picture to the 2016 declarations of one of America’s most prominent subject matter experts on addiction, Dr. Nora Volkow, Director of the U.S. National Institute on Drug Abuse:
Unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with preexisting vulnerabilities (Table 3). Older medical texts and several versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) either overemphasized the role of tolerance and physical dependence in the definition of addiction or equated these processes (DSM-III and DSM-IV). However, more recent studies have shown that the molecular mechanisms underlying addiction are distinct from those responsible for tolerance and physical dependence, in that they evolve much more slowly, last much longer, and disrupt multiple brain processes.
Dr. Volkow and her coauthor, A. Thomas McLellan, may have been too kind to the American Psychiatric Association (APA). “Opioid use disorder” is, in fact, a hugely erroneous term. Its origin is the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5), issued by the APA in 2013.
Prior to the DSM-5, substance use problems were categorized as either “substance abuse” or “substance dependence.” The DSM-5 combined these categories into a single disorder called “substance use disorder,” with opioid use disorder being a specific type within this broader classification.
However, it is now widely understood among practicing clinicians that substance dependence is not a psychiatric disorder at all. As acknowledged by Dr. Volkow and others, substance dependence is a physiologic (not mental health) problem characterized by physical withdrawal symptoms when someone is withdrawn too rapidly after a period of extended use. Some clinicians also characterize breakthrough pain experienced by patients during forced tapering of opioid medications to be a different form of “substance dependence.”
“Substance abuse” is a very different beast: it is characterized by continuing cravings and use of opioids even when the user knows that such use is harmful to their relationships and quality of life. The DSM-5 identifies a spectrum of symptoms to characterize the severity of substance abuse. However, nowhere in that deeply flawed document is a clinical framework offered within which clinicians may choose a therapeutic course of action that is appropriate to the patient’s needs if they suffer from both chronic pain and substance abuse. Likewise, the consequence of patient exposure to prescription opioids is almost always an improvement in quality of life.
It is deeply telling that the field research behind the DSM-5 was extremely poor. Two weeks before publication, the National Institute of Mental Health publicly repudiated the DSM-5 as a framework for organizing research on mental health disorders. That did not keep the U.S. CDC from using the term extensively in its revised and greatly expanded 2022 opioid prescribing guidelines.
We now know definitively that — despite repeated misdirection from the U.S. CDC and DEA — there is no relationship between physician prescribing and either opioid addiction or overdose-related mortality. Many so-called “diagnoses” of opioid use disorder by clinicians actually reflect a disorder called “pseudo-addiction,” suffered not by patients but by clinicians intimidated by the risk of possible criminal sanctions. Such doctors may render a diagnosis of substance use disorder or enter case notes on “drug seeking” for any patient who complains of inadequate pain relief or who informs them of a record of successful previous treatment with prescription opioids. Such notes are a “kiss of death” for further effective treatment of pain employing safe and effective prescription opioids. Sometimes that kiss of death directly results in suicide.
We also know that the best predictors of bad outcomes from treating patients with prescription opioids have very little to do with past prescribing as such. As established by a highly accurate predictive model for one-year risk of opioid overdose or suicide events, risks are four to 20 times higher in patients who have a history of severe mental health disorders or past hospitalizations for overdose than they are in patients who have no such history. For populations at the highest risk, only one factor among eleven in patient history is related to prescribing: the use of multiple sedating medications. The probability of overdose or near-term suicide events from all causes was on the order of 2 percent or less in a population of over a million Veterans Administration patients. Such an incidence falls within the range of diagnostic error, exacerbated by the noise generated from high patient loads and inadequate clinician education on pain management.
It is now time to purge the term “opioid use disorder” from medical practice and public health policy. It is also time to publicly repudiate and withdraw 2022 CDC guidelines on the prescription of opioids – without replacement. By their unqualified use of this term and their scientifically unsupported emphasis on risks of substance abuse disorder, the CDC has revealed itself to be acting from sloppy research and either gross incompetence or bad faith.
Richard A. Lawhern is a patient advocate.
