Not long ago doctors were so afraid of turning their patients into addicts that they sometimes refused opioids even to the dying. Nowadays, they are so afraid of not treating the pain of their patients that they are careless of whether or not they turn them into addicts.
A paper in the Journal of the American Medical Association for March 7 describes the pattern of opioid prescription for veterans returning from the wars in Iraq and Afghanistan. Of the 291,205 who enrolled for VA health care between October 2003 and December 2008, 141,029 received a diagnosis of a painful condition not caused by cancer; and of that number, 15,676 received a prescription of an opioid drug that lasted at least 20 days.
Of those veterans with pain who had no psychiatric diagnosis, only 6.5 per cent were prescribed such a drug; for those with post-traumatic stress disorder the figure was 17.8 per cent. Patients with non-PTSD psychiatric disorders had an intermediate rate of prescription, at 11.7 per cent.
The prescription of opioids was associated with a variety of unfortunate outcomes. It is hardly surprising that those prescribed the drugs were more likely to take deliberate or accidental overdoses of them than those not prescribed them; but they were also more likely to injure themselves deliberately, to suffer “violence-related” injuries, other forms of injury, or other kinds of overdose or alcohol-related harms. The difference was more marked among those with psychiatric diagnoses.
Of course, a statistical association does not establish causation. There is nothing in the paper that excludes the possibility that the patients prescribed opioids had a worse prognosis in a case than those not prescribed them. Physical injury is associated, not surprisingly, with the development of later psychological difficulties. Nevertheless, there is reason for unease.
The paper tells us in its introduction that:
Nationwide, the prescription of opioid analgesics has nearly doubled since 1994 because of a greater recognition of the importance of treating pain.
But in the last part of the paper we learn what every doctors knows, should know, and is easily observable on a casual basis:
Trials assessing the efficacy of opioids in treating non-cancer pain have shown only modest or equivocal benefit. In contrast, multiple studies have described numerous harms, including overdose death, from the upsurge of opioid prescribing, in recent years.
We might rightly ask: what is going on? Why are doctors prescribing dangerous drugs in large quantities, of very marginal benefit to their patients, with such well-documents dangers? (Incidentally, 40 percent of veterans with PTSD who were prescribed opioids were also prescribed sedative tranquillizers, an extremely dangerous combination as had been many times proved.)
Is it that doctors are ignorant of the dangers? I doubt it. Rather, they have before them patients who are suffering both physically and mentally, who say they are in pain, and for whom they, the doctors, naturally wish to do something; they have relatively little time in which to do it; and the patients communicate to them subliminally that they want strong drugs. Unwilling or unable to disoblige them, the doctors take the line of least resistance and prescribe what they think is being demanded of them.
Doctors, like most people, want to apply simple solutions and therefore want problems reduced to an equivalent simplicity. Unnecessary and even harmful prescription of opioid drugs is the natural result.
I look forward to a reproduction of this study among ex-Taliban fighters.