Pain or Feign?

Frederic W. Grannis Jr., MD

There is an old story, perhaps apocryphal, about a young missionary who arrives to give his first sermon in a rural district of sub-Saharan Africa. He is gratified by the large turnout where an altar and lectern have been set up out of doors in a pasture. As he delivers his sermon in English, his only language, the parishioners enthusiastically chant “mbolea” in unison after each homily, to his considerable gratification.

Following the completion of the service, as they walk across the pasture he queries his deacon, “ ‘Mbolea,’ is that something like ‘amen’ in Swahili?”

The deacon appears nervous and mumbles, “Yes, something like ‘amen.’ ”

Puzzled by this new colleague’s reticence, the pastor fails to watch where he is walking and is stopped by a child who cautions him to be more careful: “You almost stepped in the mbolea.”

The moral of this story for young doctors is not to be afraid to say “mbolea” where appropriate.

A case in point is a 1980s movement to change focus from strict regulation of prescription oral narcotics, in order to prevent drug diversion, toward more relaxed regulation designed to ensure that patients would have access to adequate opioid medications to prevent needless pain. It was widely understood at that time that cancer patients often experienced difficulty obtaining sufficient narcotic medications to control pain because Drug Enforcement Administration and California state requirements for triplicate pain prescription documentation for oral narcotic medications frightened many physicians who were reluctant to prescribe Schedule II and III opioid pain medications.

Physicians were told that the only way to decide how much pain a patient was having was to accept what they told us and not insist upon objective evidence. This new standard was simple and elegant. Over the succeeding years, cancer patients have benefited from improved pain management. But as Henry Louis Mencken has observed, “For every complex problem, there is a solution that is simple, neat, and wrong.” Perhaps the new standard was just too good to be true.

I, for one, should have known better. In my first year in clinical medicine as a fourth-year medical student on the wards and in the emergency room of New York City’s Metropolitan Hospital-a city hospital serving literally tens of thousands of heroin addicts-in the late 1960s, I quickly learned that a large proportion of requests for narcotics in this population were spurious. Patients would simulate renal stone, acute myocardial infarction, and many other painful illnesses in order to obtain narcotic drugs. Known addicts exaggerated their current daily heroin dosage in order to receive larger doses of methadone.

I also learned from hard experience that when scams failed, many addicts would steal or rob to obtain their drugs. Any untended object of even minimal value disappeared from the Met within minutes. I had to reclaim my impounded Volkswagen bus after NYPD arrested three teens who had broken into it on a cold winter’s night to shoot up heroin. A few years after I graduated, I learned that a medical student had been killed in nearby Spanish Harlem during an armed robbery by an addict who mistakenly assumed that his physician’s black bag contained narcotics.

Thus, even before I received my MD degree, the school of hard knocks had taught me many of the stratagems addicts deploy to scam physicians into providing their recreational drugs. These lessons were reinforced during residency and the early years of private practice. “Tourists” who had lost their narcotic medications and their prescriptions while on vacation requested refills. I also observed that some local physicians appeared to be prescribing these drugs irresponsibly or even criminally.

When told that what the patient said about their pain had to be believed, I thought “mbolea,” but did not speak the word.

The initial goal, to solve the problem of inadequate pain relief for suffering patients, was a noble one. But now, a few decades down the line, it is becoming increasingly clear that the oversimplified response to the problem, (ie, to unquestioningly accept the patient’s report of pain and prescribe based upon that report alone), was nave, and in the wake of the subsequent relaxation of regulatory standards, we are reaping a whirlwind that I and others of my generation should have anticipated.

A remarkable series of front-page articles, dating to last year, in the Los Angeles Times by Lisa Girion and Scott Glover has documented an alarming upsurge of deaths caused by narcotic overdose of oral opioids, and noted that a large proportion of these deaths are caused by diversion of prescription drugs. They reported that of 3,733 drug overdose deaths in California, almost half involved prescribed drugs and that 71 physicians in the state had three or more patients die; several had 12 or more overdose deaths among their patients. A quarter (945) of overdose deaths involved hydrocodone preparations, like Vicodin.

This is not a problem localized to my home state. The Los Angeles Timesreported on March 30 of this year that drug overdose deaths have reached epidemic proportions, overtaking car accidents as the number one cause of accidental death in the United States, accounting for 16,651 deaths in 2010. The 2010 National Survey on Drug Use and Health identified 343,000 emergency room visits and more than 14,000 deaths related to opioid analgesics. This represents 43% of fatal overdoses.

Although oxycodone (OxyContin, aka “hillbilly heroin”) is a Schedule II narcotic, hydrocodone, under 15-mg doses, in combination with another analgesic, remains a Schedule III drug. Girion and Glover report the startling fact that 99% of all hydrocodone produced worldwide is consumed in the United States-Vicodin is our most commonly prescribed drug. It is not clear to me whether these reported deaths include cases of hepatic failure from acetaminophen overdose often combined with alcohol ingestion.

Solutions to this enormous problem will inevitably involve a combination of returning to a more rigorous system of control of prescription opioids, including perhaps moving combination hydrocodone drugs like Vicodin to Schedule II status, and also incorporating active surveillance of state and federal narcotic prescription databases to identify overprescribing, “doctor shopping,” and other forms of drug diversion. But in the process of so doing, we must remember Mencken’s admonition and understand that this is a very complex problem that will not yield to simple palliatives.

Navigating between the Scylla and Charybdis of drug diversion prevention and inadequate pain management represents a very difficult task. A knee-jerk response in getting tougher on narcotic prescribing will merely reset the problem back to the 1980s rather than solve the dilemma. An effective solution will prove to be very complex indeed, and will certainly be assisted by innovative utilization of data from electronic prescription databases with collaboration between physicians, drug companies, pharmaceutical chains, and regulatory agencies.

It is of critical importance that the new regulations must not compromise the care of patients with genuine pain-management needs. Also of major importance, the physicians who specialize in the treatment of these patients and who have a high percentage of end-stage cancer patients in their practices, eg, supportive care physicians and medical oncologists, will of necessity have high rates of prescribing narcotic analgesics. These true Samaritans will be at risk of investigation, harassment, and possible prosecution, if data-mining in narcotic prescription databases like California’s CURES is not conducted responsibly and intelligently.

If things look too good to be true, remember to just say “mbolea.”