Is it really a good idea give government more power over patients and doctors?
When the Commission on Combating Drug Addiction and the Opioid Crisis advised the President to declare a national emergency to deal with the overdose epidemic, HHS Secretary Tom Price wisely suggested that this step wouldn’t be particularly useful: “[T]he opioid crisis at this point can be addressed without the declaration of an emergency.” Price is, of course, a physician who understands the public health implications of opioid addiction. He is also a former congressman who knows what kind of mischief the federal government gets up to when “solving” a crisis. Price was in Congress when the “uninsured crisis” spawned Obamacare.
Sadly, President Trump listened to less sagacious counsel and declared an emergency after all. If the White House and Congress follow the other bad advice offered in the commission’s interim report, they will produce another disaster for doctors and patients while exacerbating the problem they ostensibly wish to resolve. The most pernicious recommendation offered by the commission involves what the report dubs “prescriber education.” It calls for doctors, dentists, and every other provider with a prescription pad to suffer through mandatory courses — under the watchful eye of the Drug Enforcement Administration — to learn the “proper” way to treat pain:
Mandate medical education training in opioid prescribing and risks of developing an SUD by amending the Controlled Substance Act to require all Drug Enforcement Administration (DEA) registrants to take a course in proper treatment of pain. HHS should work with partners to ensure additional training opportunities.
The primary result of this ill-conceived recommendation will be far fewer prescriptions for all types of medication. But isn’t the problem caused by too many doctors writing too many prescriptions? Nope. The authors of the interim report claim, “We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation.” In order to reach this preposterous conclusion, the commission had to studiously ignore a widely-documented decline in the number of opioid prescriptions that began at least seven years ago. In July, the Centers for Disease Control and Prevention (CDC) reported:
From 2010 to 2015, the amount of opioids prescribed in the United States decreased from 782 to 640 MME per capita.… Nationally, opioid prescribing rates leveled off from 2010 to 2012, and then decreased by 13.1% from 2012 to 2015.
Despite this decrease in opioid prescribing rates, mandatory education and increased DEA surveillance will soon render providers wary of prescribing any kind of controlled substance. Doctors will be so afraid of violating DEA rules that they will err on the side of caution. Patients with no history of, or predisposition toward, addiction will suffer needlessly because lazy politicians on a presidential commission have eschewed critical thinking and embraced hyperbole. Ironically, most controlled substances are neither narcotic nor addictive, and few patients are in any real risk of addiction. As geriatric specialist Thomas F. Kline, M.D. writes:
Out of 100 people taking pain medicine, only a very few, perhaps three or four, will develop an addiction. Restricting pain medicine in the other 97 is not good medical practice.… Deaths from narcotic overdoses usually involve multiple, non-prescribed, street drugs, not pain medicines prescribed by caring doctors.
But the report rejects dull reality in favor of sensational factoids: “The average American would likely be shocked to know that drug overdoses now kill more people than gun homicides and car crashes combined.” The average American won’t be “shocked” to learn that this is hopelessly misleading. To support their claim, the commission lumps together deaths involving all drugs, including heroin and cocaine, and fails to differentiate between overdoses and deaths resulting from the ingestion of multiple contraindicated drugs. Finally, the commission ignores the role government has played in creating the “crisis.” Which brings us to its second worst recommendation:
Grant waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases (IMD) exclusion within the Medicaid program. This will immediately open treatment to thousands of Americans in existing facilities in all 50 states.
This seems innocuous enough, at first glance, but disturbing data have emerged suggesting Medicaid is no panacea for this “epidemic.” Indeed, the program may well be driving the dramatic increase in opioid overdoses. A key provision of Obamacare involved coercing states into expanding Medicaid to able-bodied adults. The Supreme Court ruled that provision unconstitutional in 2012, permitting states to opt out of expansion. Since then, 19 states have done just that. What has all this to do with opioids? It turns out that the very real spike in overdoses seen in the Medicaid expansion states is absent from those 19 states. As Jon Cassidy wrote in this space in June:
Obamacare’s Medicaid expansion and individual insurance exchanges both went into effect in 2014. In just the next year, the fatal opioid overdose rate increased by 15.6 percent, CDC found.… The increase isn’t uniform. It’s clearly happening in 30 states, most of which accepted the Medicaid expansion. But overdose deaths have remained steady in 19 other states, according to the CDC.
How the commission missed the Medicaid connection is a mystery. Even the establishment media have taken notice. A headline in the Hill, for example, drew attention to the relationship thus: “Want to end the opioid epidemic? Start by freezing Medicaid expansion.” The author of that piece, Sam Adolphsen, points out that a patient covered by the program is 6 times more likely to die of an opioid-related death than someone with decent coverage. Adolphsen also points out that the Medicaid expansion in which Ohio governor John Kasich takes such pride has his state “on track to have more overdose deaths in 2017 than the entire United States had in 1990.”
All of this is lost on the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Chairman Chris Christie and its other members clearly believe that government meddling will end the “epidemic.” The rest of their recommendations all involve increased federal surveillance of doctors and patients, throwing taxpayer money at failed programs, and adding to the regulatory morass that is already killing our health care system. Before President Trump and Congress take further action based on the commission’s advice, they would do well to remember Ronald Reagan’s admonition about the nine most terrifying words in the English language.
The kind of “help” offered by Governor Christie and his accomplices on the commission is exactly what Reagan found terrifying. It will give government more power over patients and doctors while making the “crisis” worse. Here’s a novel idea: How about getting together a few actual physicians, people who actually treat actual patients, and see what they suggest? We have had a lot of government help during the last eight or so years. Do we really want MORE?
Michael Vadon/Creative Commons