If you have a broken leg, see a physician. If you have cancer, see a physician. If you have a heart attack, see a physician. If you want to change somebody’s behavior, don’t even talk to a physician. The New York Times demonstrates.
A pain management specialist, Dr. Nathaniel Katz, was stunned in 2012 when the Food and Drug Administration rejected a recommendation from an expert panel that had urged mandatory training for doctors who prescribed powerful painkillers like OxyContin.
That panel had concluded that the training might help stem the epidemic of overdose deaths involving prescription narcotics, or opiods. At first, Dr. Katz, who had been on the panel, thought that drug makers had pressured the F.D.A. to kill the proposal. Then an agency official told him that another group had fought the recommendation: the American Medical Association, the nation’s largest doctors organization.
“I was shocked,” said Dr. Katz, the president of Analgesic Solutions, a company in Natick, Mass. “You go to medical school to help public health and here we have an area where you have 15,000 people a year dying.”
I wonder whether Katz is still shocked to learn that physicians have been decreasing opiod prescriptions since, get this, 2012. That’s right. Even the New York Times knows it.
For much of the past two decades, doctors were writing so many prescriptions for the powerful opioid painkillers that, in recent years, there have been enough for every American adult to have a bottle. But for each of the past three years — 2013, 2014 and 2015 — prescriptions have declined, a review of several sources of data shows.
IMS Health, an information firm whose data on prescribing is used throughout the health care industry, found a 12 percent decline in opioid prescriptions nationally since a peak in 2012. Another data company, Symphony Health Solutions, reported a drop of about 18 percent during those years. Opioid prescriptions have fallen in 49 states since 2013, according to IMS, with some of the sharpest decreases coming in West Virginia, the state considered the center of the opioid epidemic, and in Texas and Oklahoma. (Only South Dakota showed an increase.)
In other words, physicians have been ahead of Katz and the Federal government for the past four years. So, who needs to go to school?
We are in a dangerous, complicated, and messy Local. The US is truly in the midst of a sudden increase in deaths from drug overdoses, particularly with opiod painkillers, available through prescription. While the pop press has simplified this TACT, it is much more complicated than Some Guys Die In Overdoses. If you read the research you realize the TACT is extremely tricky.
Who is the Target?
Almost anyone. Typically when you think of drug overdose you think about all those junkie scenes in Hollywood movies with fringy characters doing stupid things. With opiod overdoses, the Who is anyone who can see a physician who diagnoses a pain problem that requires a prescription. Old people. Young people. People with work injuries. People in car wrecks. The Who in this TACT is almost anyone.
What is the Action?
Generally speaking, the research indicates that Other Guys rarely kill themselves with just the opiod prescription drug alone. They often are taking other legal and illegal drugs. They are often drinking. Most Other Guys die from the combination of drugs that they control.
Where is the Context?
Almost anywhere. Home. Office. Hotel room. Partying with friends. In the back of a taxi. Anywhere the Other Guy can combine the opiod with other drugs, the fatal overdose can occur.
When is the Time?
Almost anytime. First light of day. Last light of day. Again, anytime the Other Guy can combine the drugs – all of them legal, remember – the fatal overdose can arise.
It should be apparent that Dr. Katz, who believes in retraining physicians about opiod prescriptions, knows nothing about behavior change because his solution cannot possibly hit the TACT we’ve just looked at. And, while I’ve been extremely critical of the medical field and the AMA, in this case, I strongly agree with their disagreement with Dr. Katz and the proposed FDA training regulations. As debaters say, the plan doesn’t meet the need.
Consider only this very nice and close comparison. Physicians are trained to prescribe antibiotics. And they still misprescribe them after that training and nearly two decades of nagging from well-meaning people like the hapless Dr. Katz. If training and nagging doesn’t work with antibiotics, why would anyone expect training and nagging to work with any other drug prescription? Physicians are making very deliberate decisions with these prescriptions. Training won’t matter.
Past the obvious flaws of the proposed FDA training, you realize from our TACT and Local analysis that the overdose is most directly under the control of the Other Guy with the drug, not the physician or pharmacist (and why aren’t pharmacists in this equation from the FDA and Katz?). This is like requiring car dealers to Do Something with customers about drunk driving. Nothing a car dealer could say or do would possibly make any difference. The Other Guy makes the fatal choice.
If you read the health and safety literature or pop press, you often see words like epidemic or tragedy or disaster over trivial problems that zealots are using for more attention to themselves. When a genuine tragedy like opiod-related deaths occurs, it is easy to hear the cries for help as just another case of PR. And, while the estimated 15,000 annual deaths does not come close to a leading cause of death in the US, this kind of death is important because it has suddenly and sharply increased with a wide variety of Other Guys. And, it is obviously the deliberate action of Other Guys. They could behave differently and reduce the death rate.
As a tricky part of this Local, you need to realize that everyone now treats pain differently than they did 10 or 20 years ago. Pain is subjective and physicians are rightly concerned about misreporting from Other Guys. But, research has grown to indicate that pain is a critical element in the quality of life and health in Other Guys, so the medical community is now leaning in on pain relief. The status quo on this problem shifted from Don’t to Do. Thus, more pain prescription are being written. And for the overwhelming majority of Other Guys, that is a Godsend.
But, now, we’ve got this unintended, but not unexpected, consequence: More overdose deaths. This is clearly more of a persuasion problem than a medical problem. And training is perhaps the dumbest play to try. Sure, it would make it look like The System is on the case and doing stuff to make the world better. But regulations and training modules over the Internet will not make a dent in this.
There is no doubt that some Other Guys are abusing these drugs. They doctor shop. They have multiple doctors and do not disclose this among all the physicians. And, there are some physicians who are nothing more than legal drug dealers who will write an opiod prescription for a headache. But, again, if you look at the best available research on this, you know that these instances are few and not the main drivers of this problem.
We are left with the reason why persuasion is so powerful: Other Guys have a lot of free choice in this country. They properly obtain a prescription for a serious problem from a physician who has thought carefully about giving it and has also extensively warned the Other Guy about the risks of using this drug. The best available evidence indicates that most of the prescriptions are done under the best standards of conduct we can expect.
And, then, we let Other Guys operate with free choice. Most handle that free choice with WATTage, prudence, and self control. Some don’t. We cannot tell in advance which category the Other Guy will fall in. It’s like with suicides. You’ll recall our earlier look which disclosed that a large risk factor for suicide was visiting a responsible health care provider earlier in the month. Over 40% of suicides occurred within 30 days of a face-to-face contact with somebody who was an expert in the problem! We just don’t know how Other Guys will behave when they leave the office.
So. Pain is now something to be aggressively treated and controlled. Most people handle the treatment correctly. Some don’t. We cannot predict who will follow treatment guidelines correctly and who won’t. Worse, we have no easy, clear, and simple markers to indicate when a particular Other Guy is going out of control with the treatment. Often we cannot make this determination until the Other Guy has a serious addiction problem that manifests itself in the recurrent misbehaviors, deceptions, and failures that characterize addiction. Worst, many of these overdose deaths occur without any preceding indication of loss of control or addiction. The Other Guy just makes one bad decision – drinking too much at a special celebration – which creates that bad combination of drugs which leads to death.
Ultimately, I think this problem revolves around external versus internal control. Do Other Guys have the right to do what they want or does someone else tell them what to do? We could, for example, require a treatment regimen that provides the drug only when the Other Guy meets face-to-face with the prescribing physician. Every day. We could pass a law that makes it a felony for Other Guys to lie to multiple physicians to obtain multiple prescriptions. We could require mandatory and random drug testing of Other Guys on opiods. Think about it and you could devise your own external program of control. And it would work.
But, then, more Other Guys would suffer considerably more pain that they could easily and responsibly relieve with a bottle of pills in their medicine cabinet. You see the trade.
And it all revolves around the very factors that make persuasion so effective. Human nature makes Other Guys think they are justified, reasonable, and in control. Free choice permits Other Guys to prove that they are not justified, reasonable, and under control.
For me, this overdose TACT is unavoidable in this Local. And, I think that we going to see more dangerous TACTs like this in the future. Peace and prosperity has made free choice cheap, easy, and widespread. Contemporary society protects Other Guys from so much danger, risk, and harm just over my lifetime. It is truly difficult to kill yourself nowadays; just look at causes and rates of mortality from 1950, then from 2010. That means free choice has become more deadly. Other Guys are much more likely today to die from their own volition than in the history of human civilization. We used to die from bacteria, viruses, lousy sanitation, terrible pregnancy and infancy care, and on and on with the external list of killers. Today, you have to work at ending your life earlier (or else suffer from a bad draw on the random assortment of genetics at conception).
What Katz and the FDA are discussing is nothing more than a Warning Label persuasion play. It won’t work, but looks like someone is in charge and on the case. Free choice, abounding free time, and human nature suggest that the persuasion for this problem is much more complicated than even I can prescribe.