Ippel: The Unintended Consequences of Pill Policy

May 26, 2014

by Bruce Ippel, M.D.

My libertarian bent makes me skeptical of any government program, especially one that is thrown together to “solve” a crisis. The particular crisis I’m writing about is the marked increase in the abuse of prescribed pain medication in our country.

Before the 1980s, doctors in our country rarely prescribed strong pain medication for chronic pain. These highly potent opioids were mostly reserved for acute injuries like chain-saw wounds and those dying in agony . . . say from bone cancer.

But about that time, there were some lawsuits that contended for treatment of chronic real pain — disabling arthritis, nerve damage from chronic diseases such as diabetes, weird causes of agony with strange medical names such as tic douloureux. Heretofore, people were expected to just suck it up and suffer in silence, stuck out of sight in their bedrooms.

A long story shortened, the sufferers won their suits and the courts ordered us doctors to have enough compassion for those in misery to use our highly effective pain medications to help return some semblance of quality to their lives. Well, nothing motivates like a malpractice suit.

I am pretty certain that this required behavior change was the right thing to do — but no good deed goes unpunished. Fast forward 20 years: Florida becomes a hotbed of prescription pain-pill abuse. Fortunes are being made there and elsewhere by unscrupulous doctors writing thousands of doses on each prescription in exchange for bags of unmarked 50s and 100s.

Needless to say, these megadoses aren’t being used for grandpa’s bad back. Whatever pleasure that drug abusers get from taking 30 pills at a time sometimes gets mixed with too much Jack Daniels and their party is over — permanently. Now we have a crisis that makes the nightly news.

And big government loves to solve a crisis. The Drug Enforcement Administration (DEA) and then the legislature hammer the pharmacies and the doctors with stringent new requirements. Here in Indiana, Gov. Mike Pence signed legislation last year that provided doctors with an on-line manual of close to 200 pages. It includes new “guidelines” we must follow to write grandpa his prescription of three pain pills a day. And grandpa has to come in every few months to be treated like any other drug offender out there on probation.

So we doctors are now the police. Not surprisingly, few of us care to brave this ongoing storm. We now usually send patients to the “pain clinics” springing up all over.

I have to admit that it has worked in a way. The prescriptions for pain killers and the abuse of pain pills have plummeted; our government can claim a big victory there. But I’m not sure anyone has pointed out the possible relationship to the concomitant explosion in the use of heroin. Do we think it is an unrelated coincidence that the pill abusers have happened to stumble on a cheaper and “better” drug high?

In my practice over the years I’ve had numerous occasions to rub shoulders with intelligent, wily, motivated drug abusers. We usually become aware of their shenanigans in a few visits and show them the door. But I know they are certifiably smarter about how to abuse the system than your average doctor — and maybe even than your average politician. No, these guys have led us into what we call “unintended consequences” — again.

I will close by pointing out that the DEA is nothing if not adaptable. It has recently approved a home-use device that allows people to quickly reverse those fatal heroin overdoses becoming so commonplace.

Ain’t progress wonderful?

Bruce Ippel, M.D., is a solo rural family physician in central Indiana. He and his wife of 42 years have 10 children. For the last 38 years Dr. Ippel has run a private “hardscrabble” clinic serving the under-served.



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