Senator Clair McCaskill (D-Mo) made the headlines with a demand for documents to help Congress determine if opioid makers fueled the current drug epidemic.

Good to see Congress taking an interest. Still, there’s so much blame to go round, it might be difficult to fix it at any one point. Here’s an example.

Dr. Whatsit and his investors want to open a medical clinic in an area where the residents are prone to chronic health problems– chronic pain, heart and lung disease, diabetes, to name a few. Those conditions are often related to lifestyle, or work environment, or lack of adequate medical care (perhaps why Whatsit chose the area in the first place). The new clinic announces itself, begins advertising its services, throws open its doors to new patients. Come one, come all.

When those new patients show up, they’re assessed, including for pain. Many will be experiencing pain, and even more will reply: “well, now that you bring it up…” The practitioner might then recommend a painkiller. Just in case. The patient accepts the prescription, fills it at the local pharmacy, schedules a followup visit, and the payer– insurance company, Medicare or Medicaid– gets a bill.

Next patient.

At first, the painkiller seems to help. As time passes, however, that effect is diminished. This could be the result of growing tolerance to the drug– something opioids can produce in just a few weeks. Or it could be a sign of increased pain sensitivity, or hyperalgesia, another common response of some patients to opioid use.

The two processes are different, but it isn’t easy to determine which is at fault in a particular case. A doctor might reasonably conclude the pain is not yet adequately medicated, and increase the dose.

A bill is sent, a followup visit is scheduled, and so forth.

Next.

At some point, the doctor begins to worry about the dose and frequency of the patient’s medication. Maybe the pharmacist questions it. The physician urges the patient to cut back. The patient tries, finds it a challenge, demands more painkillers. Concerned about the license to practice, the doctor decides to stop the medication.

Meanwhile, a neighbor happens to know a guy who knows a guy who deals drugs. Including heroin.

Connection made.

Who’s to blame? The doctor, who wrote the script and continued it despite the red flags? The Big Pharma firm that developed and promoted it? The insurance company or Medicaid for adding it to the formulary, or the FDA for understating the risks, or the patient, for continuing to take the medication?

Modern healthcare, for all its spectacular innovation, still lacks a genuinely safe, effective remedy for certain types of pain. Who’s addressing that problem? I haven’t seen many articles on the subject. Pharma is now marketing new drugs to relieve the constipation from opioid use (lot of that going around) as well other new drugs to reverse ODs. But how much are we doing to come up with new ways to manage pain without depending on opioids?


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