It was 1996, and I was walking from the emergency department to the doctor's lounge, a trip I have made a few thousand times since that day. But I was joined this time by a man in a suit with a business card. He was a sales rep from a large pharmaceutical company, and wanted to tell me about a new pain drug that he said would improve my life and the lives of my patients. That drug was OxyContin. I remember the hair on the back of my neck stood up as he talked. Something wasn't quite right. Little did I realize this was my introduction to the perfect storm that would wreck the lives of millions of Americans.
The monitoring system for controlled substances in the '80s was a list of drug-seekers kept in the doctor's area of the ED. It was common back then to get a call on a night shift from an emergency physician on the other side of town warning you that one of these patients had just left his ED empty-handed and was likely coming your way.
By the mid-1990s, however, medicine had entered the era of “pain as the fifth vital sign.” Clinicians were deluged with mandates to obtain pain assessments on all patients. Nurses were told to ask patients to rate their pain on a 10-point scale, and kids' pain levels were rated by their facial patterns regardless of whether they were in pain or just wanted their sippy cup. The government mandated that the medical establishment could not let any pain go untreated, even questionably subjective forms.
Looking back, the whole thing slowly took over our professional lives. It became the Vietnam of medicine: We got into a war against an enemy we really did not understand. Everyone acted emotionally, and mission creep set in. We had to treat not only acute pain but also any pain that might linger for weeks, if not months. It was overwhelming, and many physicians reached for the easiest solution to please patients and administrative watchers—they handed out lots and lots of pills.
You have almost certainly been overexposed to numerous reports on the opioid epidemic crushing entire neighborhoods, towns, and states. Dead Americans found in cars with syringes hanging out of their arms make for good news stories. You have also likely become numb to hearing about it. Emergency physicians are used to witnessing misery.
Complicated and Messy
Most of America, however, is not. Many of our citizens had their lives of comparative bliss interrupted by an endless stream of men, women, and children dying over the past decade. This was not the same as the crack cocaine and methamphetamine epidemics that ravaged predominantly poor communities, which were largely ignored. Rather, this killed well-off, suburban white kids as well, which sent the media into a frenzy. They demanded to know how this happened and who was responsible.
The answers to these questions are complicated and messy, and a lot of them involve looking in a mirror. The book Dreamland: The True Tale of America's Opiate Epidemic by journalist Sam Quinones weaves together this complicated story. He details how a host of factors created the monster that became widespread opiate addiction: the public outcry for increased treatment of pain, the profit-driven response of the pharmaceutical industry to leverage the public's desire for cheap and immediately effective methods to relieve pain, the government's overreaching policies to mandate pain treatment, the profit-driven explosion of “pain clinics” prescribing unheard-of quantities of narcotics without appropriate regulation, the production and distribution of massive amounts of cheap heroin from a small area on the west coast of Mexico feeding the insatiable hunger of Americans for more and more narcotics, and how innovations in communication technology poured gas on the fire.
The book is an incredibly thorough description of the events that created the problem as well as a collection of stories about the committed men and women who figured it out. Of course, the quick and cheap fix of taking pills to relieve pain generates problems that require time-consuming, expensive processes to correct. Emergency departments can only do so much.
Treating overdoses while advocating that first responders, teachers, and other Good Samaritans carry Narcan is only a Band-Aid, and it will not stop the endless pursuit of opiate-addicted patients to get high and avoid withdrawal. Reading Dreamland will provide a real understanding of how we got into this mess and facilitate a collective dialogue to find solutions to this problem. Get this book. Read it. It will blow you away.
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