Khatri: Congress gave birth to the opioid crisis

In 1999, Senator Orrin G. Hatch, a Utah Republican, played a pivotal role in pushing legislation in the 106th Congress that declared 2001-2010 as the “Decade of Pain Control and Research.” This bill encouraged physicians to treat pain aggressively, even when the treatment may increase the risk of death.

In fact, the government made it a criminal offense to under-treat pain. Furthermore, the Joint Commission on Accreditation of Healthcare Organizations, which accredits more than 21,000 health care facilities in the U.S., adopted the tenet that every patient has a right to have his or her pain assessed, treated, and monitored without being influenced by that individual’s social, economic, or cultural background.

Pain was now declared to be the “fifth vital sign,” along with pulse, blood pressure, temperature, and respiratory rate. And any facilities that failed to follow these requirements risked losing their accreditation.

A hospital’s revenue is greatly affected without the commission’s seal of approval, and thus committees were formed by healthcare facilities to penalize doctors who would not prescribe narcotics for pain. Doctors who failed to prescribe adequate narcotics to control pain were often referred to as “narcophobes,”and some were even forced to undergo additional training to become “narcophile” doctors. 

The commission declared that “the patient is always right” and developed a self-reporting pain scale ranging from 0-10, which was considered to be the most reliable indicator of pain intensity. Healthcare providers were told not to rely on a patient’s facial expressions or body language any longer to gauge pain management. A report of “severe pain” on the scale had to be treated, regardless of the patient’s clinical examination.

A law passed in 1999 stated that “no disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed.” That favorable provision, accompanied by other legislation that could potentially lead to the prosecution of doctors for their failure to treat pain aggressively, resulted in a dramatic increase in opioid prescriptions.

The use of painkillers quadrupled between 1999 and 2010. The doctors were now writing about 300 million prescriptions a year for painkillers. That is enough for every adult American to be medicated 24 hours a day for a month, according to the Centers for Disease Control and Prevention. Then, to compound the existing problem, stronger opioids (chemically similar to heroin) were developed for those patients who indicated their level of pain was higher on the pain scale, thus creating a more pernicious dependence.

That mandate became a marketing opportunity for the opioid pharmaceutical industry. In 2009, Purdue Pharma's pain reliever drug “Oxycontin,” had annual sales that topped $3 billion. For the Joint Commission and the Congress, which championed a “pain-free America,” that was a resounding victory, but it came with a disastrous outcome. Physicians soon realized that systematic control over how, when, and with what medications they could treat their patients would become the industry norm in the years to come. However, they did not predict that the direct intervention by regulatory agencies would have disastrous consequences unlike any our country had seen.

It has been estimated that Americans are now 6,200% more likely to die from prescription painkillers than from a gun. Unfortunately, those statistics pale in comparison to the impact that the liberalization of opioid medications have had on society in general. Congress set out to manage and alleviate pain, but the unfortunate outcome of their legislation has resulted in a dramatic increase in addiction and death.

There was a gradual shift in policy as the CDC finally declared that prescription drug abuse had reached epidemic proportions. Mandatory and labor-intensive new regulatory guidelines were introduced for prescribers, causing the pendulum to swing in the other direction.  Physicians now find it difficult to treat patients who truly deserve narcotics!

On Sept. 1, President Donald Trump nominated Tom Marino to be director of the Office of National Drug Control Policy, commonly known as the "drug czar." But he withdrew his name from nomination after reports that as a congressman his lobbying efforts had led to the passage of an industry-supported law that aimed to undercut drug enforcement efforts, which was counterproductive in the fight to remedy the crisis. That legislation basically took away the power from Drug Enforcement Administration to fight large drug companies suspected of spilling prescription narcotics onto the nation’s streets.  Hatch also promoted this bill.

It will take more than a village to end the opioid crisis. Financial commitments are crucial and let us hope that the proposed Republican tax plan, which is considered by experts to be a disaster for addiction treatment, is effectively rectified by the Congress before it is signed by the president.

Dr. Bhupendra O. Khatri is director of the Regional MS Center for Neurological Disorders in Milwaukee.