Gov­ern­ment poli­cies helped cre­ate the opi­oid epi­demic

The Oklahoman (Sunday) - - OPINION - BY HADLEY HEATH MAN­NING Man­ning is pol­icy di­rec­tor at the In­de­pen­dent Women’s Fo­rum, a con­ser­va­tive or­ga­ni­za­tion. INSIDESOURCES.COM

Opi­oid over­dose is now the lead­ing cause of death for Amer­i­cans un­der the age of 50, claim­ing more than 60,000 lives per year. While many states have tried to ad­dress the opi­oid epi­demic, the fed­eral gov­ern­ment has con­sid­ered do­ing more. The Bet­ter Care Rec­on­cil­i­a­tion Act, the re­peal-and-re­place bill that failed in the Se­nate, would have in­cluded an ad­di­tional $45 bil­lion to fight the opi­oid cri­sis.

Gov­ern­ment alone surely can­not solve the na­tion’s opi­oid prob­lem, which is tied to many cul­tural and eco­nomic fac­tors. In fact, as we de­bate the broader role of gov­ern­ment in our health sec­tor, we should con­sider how bad poli­cies have ac­tu­ally con­trib­uted to the opi­oid epi­demic by over-em­pha­siz­ing pain man­age­ment.

For years, the Cen­ter for Med­i­caid and Medi­care Ser­vices in­cluded ques­tions about pain man­age­ment in pa­tient sat­is­fac­tion sur­veys that were linked to pay­ment, en­cour­ag­ing a stan­dard of pa­tient-pleas­ing over good medicine. This fos­tered a cul­ture that en­cour­aged health care providers to of­fer pain-re­liev­ing pre­scrip­tions, pop­u­lar with pa­tients, with­out ad­e­quate re­gard for the po­ten­tial long-term down­side to these drugs.

Those pain-re­lated ques­tions were re­moved this year, cer­tainly an im­prove­ment, but for too long they in­flu­enced pa­tient care and cul­ti­vated an en­vi­ron­ment of overuse of opi­oids for pain man­age­ment. This rep­re­sents the worst of gov­ern­ment in­flu­enced medicine: When doc­tors and hos­pi­tals an­swer to bu­reau­crat-de­signed sur­veys in Medi­care and Med­i­caid, two of the big­gest pay­ers in health care, they aren’t as able to treat the in­di­vid­ual needs of each pa­tient.

The Joint Com­mis­sion, pre­vi­ously known as the Joint Com­mis­sion on the Ac­cred­i­ta­tion of Health­care Or­ga­ni­za­tions, also bears some of the blame. The JC is an in­de­pen­dent or­ga­ni­za­tion, but in 1965 the fed­eral gov­ern­ment tasked JC with de­ter­min­ing which hos­pi­tals were el­i­gi­ble for par­tic­i­pa­tion in Medi­care. Most state gov­ern­ments also rec­og­nize JC ac­cred­i­ta­tion as a pre­req­ui­site to Med­i­caid re­im­burse­ment.

It would be hard to over­state JC’s in­flu­ence on hos­pi­tal pol­icy. Any ac­cred­it­ing or­ga­ni­za­tion is free to de­ter­mine stan­dards, and ac­cred­i­ta­tion is an im­por­tant mar­ket tool that al­lows con­sumers to see which sellers have cer­tain seals of ap­proval. But when gov­ern­ment is the big­gest con­sumer, and when ac­cred­i­ta­tion means the dif­fer­ence be­tween do­ing busi­ness with the gov­ern­ment or not, ac­cred­i­ta­tion stan­dards can carry the same weight as gov­ern­ment pol­icy.

Since 2001, the JC has is­sued pain man­age­ment and treat­ment stan­dards. Last year, dozens of health providers and groups sent a let­ter to the JC, say­ing that its stan­dards “en­cour­age un­nec­es­sary, un­help­ful, and un­safe pain treat­ments that in­ter­fere with pri­mary dis­ease man­age­ment.” The let­ter asked that JC change its stan­dards to al­low in­di­vid­ual clin­i­cians to use their judg­ment for pain assess­ment rather than man­dat­ing rou­tine pain assess­ment.

Some pain man­age­ment ad­vo­cacy groups like the Amer­i­can Pain So­ci­ety have ad­vo­cated for pain to be mea­sured as the “fifth vi­tal sign” along with heart rate, blood pres­sure, res­pi­ra­tory rate and tem­per­a­ture. Of course, no one wants to di­min­ish the very real pain that pa­tients can feel, and in some cases drugs may be ap­pro­pri­ate. This should be a de­ci­sion for doc­tors to make, case by case.

But pain shouldn't be con­sid­ered a vi­tal sign: Pain is a symp­tom, a mes­sage, point­ing pa­tients and doc­tors to its root cause. Sim­ply drug­ging pain away not only re­sults in the over pre­scrip­tion of drugs, but can blind us to deeper health is­sues. And un­like heart rate or blood pres­sure, there is no ob­jec­tive way to mea­sure it. Doc­tors and nurses must de­pend on pa­tients to re­port the in­ten­sity level of their pain, which pro­vides an open­ing for ad­dicts to abuse the sys­tem.

Part of the an­swer to the opi­oid epi­demic will be to re­verse course on these pain-cen­tric ac­cred­i­ta­tion stan­dards and gov­ern­ment poli­cies — some­thing that CMS and the Joint Com­mis­sion are al­ready do­ing.

Ul­ti­mately we must em­power in­di­vid­ual doc­tors to make the best de­ci­sions for pa­tients, to treat pa­tients as in­di­vid­u­als rather than nu­mer­i­cal scores on sur­veys, and to ed­u­cate the pub­lic on the short- and long-term con­se­quences of var­i­ous pain man­age­ment ap­proaches. The opi­oid epi­demic should be a cau­tion­ary tale in the over-stan­dard­iza­tion of medicine, a symp­tom of too much gov­ern­ment in­flu­ence.

Hadley Heath Man­ning

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