Wednesday, September 11, 2019

The Opioid Epidemic. Beware Of The American Penchant For Over-Correction.

An initial over-correction of newly apparent social, economic and health problems is a particularly American cultural characteristic. (1)  It has been compared to the movements of a pendulum which swings from one extreme position (where the society completely ignores an important problem) to the opposite extreme position (where the society attacks that problem with all possible weaponry, not caring about the collateral damage this causes).

That first wild swing is ultimately followed by the pendulum moving back and, ideally,  settling somewhere in the middle where the problem,  as well as its cures and their costs,  are viewed through a more realistic lens. But that first wild swing should not happen.

A well-known example (2) of this pattern is the life cycle of the so-called crack baby epidemic of the 1980s:

For those of you who may not recall, the mid-1980s were rife with hysteria surrounding cocaine--in particular crack cocaine--and the huge social toll it was taking on the U.S. New and little-understood, crack was associated with all kinds of social ills, including rising crime rates, poverty, and (far more nebulously) the escalating HIV/AIDS crisis. But for a moment, the "crack baby" alarm sounded the loudest--the country and its social system was about to be completely overwhelmed with a generation of babies who, due to prenatal exposure to crack cocaine, would be born with all kinds of mental deficiencies and health problems.

That generation of "crack babies" never emerged. Crack, which was described by some medical doctors as being as devastating to an unborn fetus as heroin, turned out to be less damaging than alcohol (which is far more widely used and carries greater risks for long-term fetal damage). The symptoms early research associated with "crack babies" turned out to be the same as the symptoms for any prematurely born baby.
The false belief in a terrible epidemic was created by the interaction of early medical research which utterly exaggerated the damage crack caused in babies with an issue which appeared to wreak havoc among the most vulnerable among us: tiny infants.  It was exacerbated by sensationalist writing and by the ease with which the American society resorts to mother-blaming, and even more so when those mothers are black and poor (3).

And those were the individuals who ended up as the collateral damage of the first wild swing:

Predictably, reporting on the crack epidemic that focused not on public-health issues but the future criminality of crack babies and the culpability of their mothers led to politics and policies that incarcerated those children and their mothers.
Even in 1990, legal reviews and lawsuits found that state and local prosecutors were basically inventing statues and offenses out of whole cloth in order to imprison mothers who gave birth while addicted to drugs.

When I first read about the current opioid misuse epidemic I thought that the initial reaction to this truly lethal problem could be an over-correction, a wild swing of the pendulum to the opposite extreme.

Though the pendulum has not yet swung that way and much more needs to be done to control the access to opioids, we should be aware of that cultural pendulum swing tendency.  In this case it boils down to the crude thinking that if over-prescribing opioids is the problem, let's sharply cut back on all (rather than all the unnecessary) opioid prescriptions.

That could leave patients (including those who have never misused opioids), perhaps even terminally ill patients, in extreme pain with no relief,  depending on how ham-handedly the incentives aimed at physicians to reduce opioid prescriptions (4) are going to be applied.

I don't want to see this happen.  One recent study suggests that some measures adopted to make opioid prescriptions safer might have counter-intuitive effects:

Chronic-pain patients who stop taking opioids are more likely to die of an overdose than patients who stay on prescribed opioids, according to a newly published study of Harborview Medical Center patients.
The findings suggest that federal guidelines given to doctors who prescribe opioids might not be keeping patients safe, the study’s authors assert.
The study was carried out before the current federal guidelines came into force, so it's not an attempt to measure their impact.  But it offers some relevant information (5).  For instance, just discontinuing opioid prescriptions for a particular patient might not protect that patient from overdosing.

The short summary of this long post:  The control of the opioid misuse epidemic requires a large set of carefully evaluated policies, both social and medical, and those evaluations must include any collateral damage the policies could cause. 

(1)  At least I have not observed it in any other country as clearly as here.

(2)  Another example of this is the way widespread public reporting of  the abduction and killing of children by strangers (in reality a very rare event) has led to a world where American middle- and upper-class children are often overprotected, limited to supervised play dates for social interaction, not allowed to walk to school with their friends and so on, and where a parent leaving a child alone in a locked, parked and weather-insulated car for even five minutes while running into a store to get a quart of milk can be found guilty of child endangerment or neglect.

Constant media reporting on stranger violence against children triggers strong fear in most people.  This explains why the pendulum swung so severely from the historically common neglect of children's rights and safety everywhere to the present time in the US where we are still at most beginning the return from the initial over-reaction. 

That tentative return is because more collateral damage from excessive protectiveness is showing up in young adults who in childhood were not allowed to slowly learn how to take increasing risks or how to endure adversity,  and who now cannot do it.

As an aside, the reactions to this particular false epidemic hit parents (read that as mothers, to be honest) coming and going.  If they are insufficiently protective they are terrible parents and might be criminal ones.  If they try to do the job of protecting so that they cannot be blamed, ever, they are helicopter parents who destroy their children's adult lives by keeping them in the stage of helplessness.  The rules of this game are set by the wider culture, but this is rarely pointed out.

(3)  Crack cocaine was viewed as a problem specific to the African-American community.  Thus, quotes like these directly attacked black mothers:

A May 1991 Time magazine cover declares “their mother used drugs, and now it’s the children who suffer.”
A 1990 Rolling Stone article starts to attempt some empathy towards the plight of children born with dependencies, but ends up here:

Not only does it make babies only a mother could love, it wipes out that love as well. When pregnant crack addicts are asked to draw a self-portrait, they never draw themselves pregnant. They turn away from ultrasound pictures with revulsion. Drug counselors now look back to the days of heroin families with something verging on nostalgia. Heroin mothers could still buy groceries, they still occasionally gave a kid a bath.

(4)  The recent focus has been on creating incentives which would make physicians less likely to prescribe opioids.  That''s because the past incentives for physicians contributed to over-prescribing.  Patients demanded relief from pain, and alternatives to pain-killer prescriptions would have required much more office time from already time-stressed providers.

The tricky part of correcting that course is how to do it without also punishing those physicians who prescribe opioids in an appropriate manner.

(5) With the proviso that I have not read the actual study, only this summary,  and that what I have read isn't terribly clear on why a particular patient discontinued the use of opioids.