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Addicted to blame

Reed, Harrison MMSc, PA-C

Journal of the American Academy of PAs: August 2016 - Volume 29 - Issue 8 - p 15–16
doi: 10.1097/01.JAA.0000488699.24797.00

Harrison Reed practices critical care medicine at the University of Maryland Medical Center's R. Adams Cowley Shock Trauma Center in Baltimore, Md., and is associate editor of JAAPA.



A 20-year-old on a ventilator in the ICU will never wake up. He took too many pills, was down too long; his brain had too little oxygen. There are 77 more like him in hospitals today and another 78 will arrive tomorrow.

Overdose deaths have piled up over the last decade and a half and show no signs of slowing down.

But when the CDC introduced new opioid prescribing guidelines earlier this year, elements of the medical community (like those highlighted in a recent Medscape article) reacted with a mixture of praise, frustration, and even contempt.1,2

Why have the CDC's commonsense recommendations found such a defensive, and even hostile, reception? For one, the CDC's call for the conservative use of opioids contradicts common prescription patterns. The CDC advises avoiding opioids or using short, low-dose courses—a suggestion that, although wise, appears disingenuous given the tendency of these drugs to snowball into tolerance, dependence, and addiction. The recommendation also is an embarrassment for thousands of medical providers prescribing long-term opioid regimens who must now contend with opposition from the CDC instead of just a lack of supporting scientific evidence.3

The CDC's move also sounds, to some, like government doublespeak. Touting the restrictive use of opioids appears to contradict one of the more prominent examples of government regulation in medical practice: the connection of financial reimbursement to performance measures.

You don't need to question a clinician very long to trigger a rant about performance measures, government-mandated standards that track everything from ECGs in chest pain to catheter-associated infections. But one performance measure in particular seems to set healthcare workers off like a gouty flare: patient satisfaction scores. These postcare surveys administered by companies such as Press Ganey are supposed to measure providers' communication and compassion, and hit poor performers in the wallet by limiting Medicare and Medicaid reimbursement.4

Some clinicians feel these measures have gone too far in influencing medical practice. Patient surveys single out pain control as a key element of satisfaction, giving it heavy weight in overall scores. A 2013 poll by the Ohio State Medical Association showed that 74% of Ohio physician respondents felt pressured to increase pain medication prescriptions.5 Ohio is in the throes of an historic heroin epidemic with many users turning to the illicit drug after abuse of prescription painkillers.6

But don't expect those enforcing federal performance mandates, or the companies they use to gather the data, to apologize. Press Ganey CEO Patrick Ryan wasn't eager to backpedal when in 2013 he told Forbes “...the train has left the station. (Performance) measurement is going to occur.”7 When the company went public in 2015, Press Ganey's prospectus estimated the value of the “patient experience measurement and performance improvement solutions” market at $3.7 billion, expected to grow to $6 billion by 2018.8

Just because Ryan is defending a gargantuan cash cow, however, doesn't mean he is wrong. Performance measurement is not going out of style. But if that means medical providers have abandoned good judgment for a bump in survey scores, then we have sold our souls for Medicare dollars.

Our professions, once the guardians of tools too powerful for the masses, now claim to have been bullied into turning over the very reins we were supposed to safeguard. By relying on long-term opioid use, we have turned our backs on the science of medicine. By genuflecting to arbitrary performance measures, we also have abandoned the art of medicine.

In the last 15 years, nearly half a million people have died from drug overdoses.9 If the quest for the elusive satisfied patient has contributed to opioid-related deaths, then we have violated our oath to never inflict harm on those under our care. If outside pressure has herded clinicians down the easy path rather than the right one, it is the responsibility of those holding the prescription pad to push back.

Patients will make demands. It is the inevitable product of a society of empowered consumers, one that increasingly sees health maintenance as an obstacle rather than a priority. But when patients try to use medicine to shortcut their pathology rather than to promote their health, clinicians must present unified boundaries.

No party is faultless. In linking patient satisfaction to reimbursement, the government lit a fuse without knowing where it led. As with many performance measures, the approach set a plan in motion and allowed a nationwide experiment to reveal the consequences. National survey companies, relishing their newfound importance and the income it brings, hold their methods faultless despite drastic shortcomings. Some hospital administrations and practice managers have focused on bottom-line numbers rather than frontline workers. Clinicians, faced with a terrible choice, have too often protected their jobs rather than their patients. And patients have channeled a convenience-obsessed societal viewpoint into self-destructive demands.

Every shareholder in the opioid crisis can shift blame back to the others. We are left with a crossfire of accusations that means every hand is pointing fingers and none are holding responsibility. Of course, everyone can agree on one thing: many more people will die of opioid addiction unless we find a solution.

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1. Centersfor Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR. 2016;65(1):1–49. Accessed June 6, 2016.
2. Cohen B. CDC opioid prescribing guidelines misguided, docs say. Accessed June 6, 2016.
3. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162(4):276–286.
5. Maglione T, Weisel M. Ohio State Medical Association. Support for House Bill 224 [memorandum]. June 24, 2015. Accessed June 6, 2016.
6. Ohio Governor's Cabinet Opioid Action Team. Increasing heroin overdoses in Ohio: understanding the issue. Accessed June 6, 2016.
7. Falkenberg K. Why rating your doctor is bad for your health. Forbes. Jan. 2, 2013. Accessed June 6, 2016.
8. US Securities and Exchange Commission. Press Ganey Holdings, Inc., registration statement. May 11, 2015. Accessed June 6, 2016.
9. Centers for Disease Control and Prevention. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR. 2015;64:1–5.
Copyright © 2016 American Academy of Physician Assistants