JCAHO in Bed with the Enemy

Incredibly, the Joint Commission on Accreditation of Healthcare Organizations has joined the National Pharmaceutical Council, in coming out with a monograph for healthcare organizations to follow in pain management completely funded by the 20 drug companies who make up the council.  The NPC monograph blames inadequate pain control on "restrictive laws or regulations about the prescribing of controlled substances as well as confusion about the appropriate role of opioids in pain treatment."  In fact, restrictive laws have nothing whatsoever to do with the current disaster in pain relief.  The problem is that narcotics are being used at all and better pain treatment approaches are being ignored.  The pharmaceutical industry has lied so frequently to doctors that the vast majority of doctors actually think the narcotics are powerful pain relievers and have a massive over-reliance on them, repeatedly short-changing patients from truly beneficial treatments.

The NPC monograph is a steady attack on any restraint against prescribing more and more narcotics.  It blames "Societal issues that contribute to the undertreatment of pain include drug abuse programs and erroneous beliefs about tolerance, physical dependence, and addiction."  It mentions the definition of addiction of the American Academy of Pain Medicine and American Pain Society: “Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.” but then explains away the obvious evidence that addiction is rampant among patients treated with narcotics.  It claims that drug seeking behavior, purchasing additional illicit drugs, clock-watching, and deception by the patient are not addictive behaviors but only signs that the patient is not being given enough narcotics!

The National Pharmaceutical Council's only definition of addiction is if the patients drug seeking, illicit purchase of narcotics, clock-watching, and deception is not resolved by increasing the narcotics.  If that is the definition of addiction, then there is no narcotic addiction anywhere in the world.  Every addict wanting more narcotics will be happy if given an endless supply.  Of course, the pharmaceutical industry has been extremely irresponsible for setting up a regulatory system where narcotics leak on to the street in massive quantities.  Every Vicodin, Percocet, Lortab, and Oxycontin sold on the street represents profit for the members of the NPC and other drug companies.  These are the #1 drug pushers in the world.

The NPC admits that patients on prolonged narcotics usually become physically dependent on them (more profits).  They try to claim that genetic, social, and psychological issues are more important than the addictiveness of narcotics.  There is absolutely no evidence for this nonsense.  Sure, genetics might make a person somewhat more likely to get addicted, but you can't inherit a craving for narcotics.  Some irresponsible physician or drug pusher has to give you that first dose.  Alcoholism research is quite clear that while there are some psychological traits which increase the risk of becoming an alcoholic, the addictiveness of alcohol is by far the most important factor.

The NPC says, "Opioids are used to treat moderate to severe pain that does not respond to nonopioids alone."  Certain anti-depressants such as nortriptyline, local anesthetics, certain seizure medications, psychological therapy to learn to develop a higher threshhold to and tolerance of pain, and numerous other non-narcotic interventions are mentioned well after adding opioids.  Very few physicians use any of these alternatives.  It's easier to write a prescription for a narcotic and congratulate yourself for giving a "potent pain reliever."

The NPC says that, "Nearly all types of pain respond to opioids."  However, they fail to mention that the response is a very minimal added improvement over the NSAIDs or acetaminophen alone.  The NPC doesn't mention the massive tidal wave of prescription narcotics leaking out on to the street from patients given narcotics by their physicians.  Capsaicin, corticosteroids, triptans, beta-blockers, baclofen, and NMDA antagonists are given a brief mention.  The NPC mentions combining NSAIDs with opiates or both with one of the above adjuvants, but no mention is made of avoiding narcotics entirely.  After all, what could possibly be wrong with narcotics?

No mention is made in any of the JCAHO material about the serious problems of large percentages of patients getting hooked on narcotics.  No mention is made of the easy leakage of prescription drugs onto the street by large numbers of supposedly good patients.  No mention is made by the harm of narcotic addiction on society or how 25% of heroin addicts get started on prescription narcotics.  No mention is made of the vast body of research proving that narcotics are poor pain relievers.

JCAHO is being highly irresponsible by hiding behind "consensus statements" from the irresponsible American Pain Society.  JCAHO is definitely part of the problem, not the answer.  Neither JCAHO mention the fact that 80% of all cancer and terminally ill patients spend their last week of life without the more powerful NSAID pain relievers.  There has never been a study in the history of medicine showing that adding an NSAID to narcotics failed in increase pain relief.  The problem with inadequate pain relief in America has nothing to do with inadequate doses of opiates and everything to do without pursuing pain control with non-opioids.