Sunday, December 21
Part 6, Shoot Yourself in the Foot health care: Death as an effective pain remedy
"It usually began with a back sprain."
This situation is horribly complex don't you dare laugh Pundita it's not a bit funny. But from a long distance there is something funny -- not about the specifics but how democratic governments typically react to an outcry from the public that can be politically ruinous. The elected legislative body -- in this case, the U.S. Congress -- after being told by voters to "do something" right away, turns to the federal bureaucracy and says "do something right away." Then the frantic hunt launches for a government agency, any agency, that has a little budget and manpower to spare and can be hurled into doing something this minute.
That's how the Secret Service, which is supposed to guard the U.S. President and other high-ranking government officials, got roped into helping the FBI chase down pyramid scheme scammers. The flimflam artists proliferated like rabbits after 9/11, when the FBI got roped into fighting terrorism, leaving the agency few resources to go after pyramid schemes. The upshot was that many Americans were being conned out of their life's savings, with the attendant hue and cry from the public to do something.
At least from what I saw of the Secret Service efforts, which were depicted in CNBC's documentary series Greed: Scams, Scoundrels, and Suckers, the Service did a surprisingly good job at cooperating with the FBI and helped bring many pyramid schemers to justice, which is harder than it sounds.
The government's duct tape approach to problem solving didn't work out as well when the U.S. Drug Enforcement Agency (DEA) was roped into doing something right away about misuse of opioid prescription painkillers. By the start of this decade the misuse was killing a surprising number of Americans. Perhaps not the "epidemic" as it was characterized in the press but the most alarming part is that many of the people who die in this way aren't knowingly abusing the drugs they're prescribed.
As an ER physician in Seattle noted to Dr Sanjay Gupta (CNN's Chief Medical Correspondent) for Gupta's 2012 CNN documentary, Deadly Dose: Let's End the Prescription Drug Death Epidemic, " often it starts with a person being prescribed an opioid for severe pain due to a back sprain. But because opiates depress the lung and heart functions, if taken with alcohol, which is also a depressant, death can easily result -- particularly if a person inadvertently takes a pill too soon after the previous dose.
Take a pill, have a couple beers a few hours later, go to sleep and not wake up. It can happen. But hurling the DEA into dealing with the problem just because it involves drugs was like sequestering a logger to perform an emergency appendectomy. You cut down trees, right? So you should have no problem cutting out appendix.
The DEA typically deals with violent criminal drug cartels. When it turned its scorched-earth methods to legitimately prescribed opiates, by gum it quickly got a handle on the worst of the problem. And if I recall, put some of the illegal operators and counterfeit opioid pill manufacturers out of business
But in the process the agency so greatly terrified respectable pharmacies, physicians, and law-abiding pill takers that for a time the prescribing of opiate painkillers ground to a virtual halt. Doctors who prescribed opiates and drug stores that filled the prescriptions were frightened that the DEA would descend on them in full body armor with automatic weapons drawn. And patients trying to get their legitimate prescriptions filled were treated by their local pharmacy like drug addicts or illegal pill dealers.
The upshot was that everyone involved in the muddle -- doctors, pharmacists, legal opiate manufacturers, pain-ridden patients. etc. -- pointed fingers of blame at everyone else.
All this greatly upset another U.S. agency, the Food and Drug Administration. Hey the FDA also had "drug" in its name. So why was the DEA chosen to handle the opioid overdose problem? (Maybe because the FDA never tires of complaining that it's grossly understaffed and under budgeted?)
There's much more to the story, which as I noted is complex. If you're a sucker for jigsaw puzzles you can read a yeoman attempt by Reuters in 2012 to clearly explain all parts of the issue. If you combine that report with the 2012 CNN transcript that discusses Dr Gupta's very dramatic and emotional documentary, you'll have a fairly clear picture.
What that picture is today, I don't know; I haven't followed up. But it was in the course of my reading Radley Balko's 2012 discussion of the Reuters report, which while praising it cherry-picked a little too much for my taste, that I stumbled across a situation which is in some ways worse than the prescription opioid misuse, and which is colloquially known as drug bundling.
The bundling was mentioned by a reader in the comment section on Balko's blog, more as a question to other readers about the practice than a comment. The sum total of the replies, and their implications, dropped my jaw.
I didn't come across the discussion at Balko's blog until the other day. Until then I'd never known about drug bundling. This is despite the fact that I stared straight at an indication of bundling on the label of a prescription opioid I'd briefly taken same years ago for a bout of severe pain. I just hadn't paid any attention to the verbiage on the prescription bottle label, didn't bother to read the warnings included with the bottle, and wouldn't have made anything out of it, if I had.
And while I check the headlines at Google News at least three times a day, and until July 2013 kept close track of news on national TV stations, I'd never come across mention of bundling. So to the extent it's been publicized in the USA I think only certain segments of the American population, such as physicians and the patients who routinely take painkillers, have paid attention.
This ignorance works out to societies shooting themselves in the foot in the name of compassion. It seems one of the few comparable situations is the ongoing practice in several developing countries of injecting medications and vaccines with disease-contaminated hypodermic syringes. On the one hand the injections are saving lives, on the other the jabs are killing people or making them sick for life.
But the bundling is mostly directed to pain management. And right now it seems the only way to stop the severe medical consequences of bundling is by warning the public not to accept at least certain types of bundled medication prescriptions. And then informed individuals, on a case by case basis, refusing bundled medication.
Granted, this can be hard when a person is in severe pain. One just wants the pain too stop by any means necessary. I've been in that situation once; if I ever went through it again I'd take any painkiller I'm handed by an ER nurse and without demanding to know the ingredients.
And for emergency or short-term purposes, unless the person has a prior medical condition that could be affected I can't see great or lasting harm -- although whether bundling for painkiller pills is necessary is another question.
There is an element to this story that reminds me of sugar, which over time was added to more and more processed foods even when the recipe doesn't call for it. I mean, who adds sugar to mayonnaise and ketchup? But it seems that it's the routine, ongoing use of bundled prescription painkillers that becomes increasingly harmful to the pill taker's health. The effect seems to be cumulative.
Without further introduction here are the relevant responses to the reader's query at Balko's blog, by comment number. They're certainly not a definitive analysis, and a caveat is that Balko's readers tend to be in the libertarian camp, which looks askance at government efforts to do just about anything, But the information and links provided by the commenters are enough to sound a clear warning and prompt further inquiries:
#4 | C. S. P. Schofield | June 18th, 2012 at 3:27 pm
I have read the assertion that many of the overdoses associated with prescription pain meds are, in fact, kidney failure due to the DEA mandated inclusion of Acetominophen(sp?). While this sounds like the kind of bone-headed idiocy I expect from the government, the assertion was made in a comment on a Blog, and without reference. Does anybody here know anything about this? Is there any basis for it, or am I drifting into Area 51 territory?