Review: A Doctor Changes His Mind About Opioid Prescriptions

In Greed to Do Good, a former CDC physician calls the agency's war on opioids a disaster.

When the Centers for Disease Control and Prevention (CDC) urged doctors to cut back on opioid prescriptions in 2016, Charles LeBaron thought the advice made sense. LeBaron, a physician who was a CDC medical epidemiologist for nearly three decades, believed doctors had been too loose with pain medication, contributing to a dramatic increase in opioid-related deaths. In this context, he thought, it was perfectly reasonable to recommend greater restraint.

As LeBaron relates in his book Greed to Do Good, he had a change of heart a couple of years later, when he suffered agonizing pain as a result of staphylococcal meningitis. The pain was so bad that he contemplated suicide when it seemed he might not be able to obtain the oxycodone he needed to relieve his torment.

Now LeBaron intimately understood how patients desperate for pain relief could start to look like addicts desperate for a fix, driven to switch doctors, hoard pills, and move from one pharmacy to another. He also understood the downside of discouraging doctors from prescribing opioids. While curtailing prescriptions might prevent some nonmedical use, it also hurt bona fide patients.

The CDC's notionally optional advice resulted in widespread restrictions imposed by legislators, regulators, insurers, pharmacies, and medical providers. The human costs included abrupt medication "tapering," appalling undertreatment, patient abandonment, suicide, and a surge in drug deaths as nonmedical users replaced reliably dosed pharmaceuticals with iffy black market products.

The CDC's main error, LeBaron argues, was treating the opioid "epidemic" the way it had long treated communicable diseases: by trying to stop transmission of the "pathogen" at "the most accessible point." That mentality, he says, obscured the point that the "pathogen" in this case was a boon to patients like him, who needed it to make their suffering bearable.

Comments

[Zeb]

Well, at least they solved the opioid problem once and for all. Can't make an omelette without breaking a few eggs.

[Zeb]

More seriously, what gets me about this is how easily pushed around doctors are with stuff like this (though I can't really blame them too much when the DEA is breathing down their necks). First there was the push for better pain treatment, and opioids probably were being somewhat overprescribed. But now it's swung way too far in the opposite direction and everyone gets treated like a junkie.

[MWAocdoc]

It's worse than that. In some jurisdictions you can lose your license to practice and be prosecuted for over-prescribing opiates for pain patients; and lose your license to practice and be prosecuted for FAILING to adequately prescribe opiates for pain patients.

[MWAocdoc]

"... he had a change of heart a couple of years later, when he suffered agonizing pain as a result of staphylococcal meningitis."

Of course! It's not about his studying the issue scientifically using epidemiological and statistical tools to make a more informed decision. It's about his personal narrative and his feeling that the CDC had made a mistake based on incomplete scientific evidence. The CDC launched the war on drugs because it was given the power to do so, with or without any scientific evidence or logical imperative. The CDC declared an emergency and attacked the most vulnerable people as scapegoats. As the body count rises, instead of going back and taking another look, they doubled down and started attacking doctors.

[Rick James]

In Greed to Do Good, a former CDC physician calls the agency's war on opioids a disaster.

My jar of nickels for every 'former' official that realized everything he did while an actual official is full. So I can't fit anymore in there.

[MWAocdoc]

Amen, brother!

[Zeb]

Pro-tip: change them in for dimes.
And you seem to have omitted some important words there.

[AT]

The pain was so bad that he contemplated suicide when it seemed he might not be able to obtain the oxycodone he needed to relieve his torment.

Ahh, so a change of mind that was based in careful research and in-depth study. Yes, we should re-evaluate the entirety of medicine based on the fact that some guy got some very rare diagnosis and it was hurty.

Also, let's talk about his diagnosis. Aside from its rarity (though it probably came from the very common MRSA), it's also something that needs in-patient treatment. If you're being treated for this, you're unequivocally in a hospital where your pain management is being actively monitored. I won't deny the need for them during the acute stages - but when you're ready for discharge, you should be well past the point of needing opioids for pain management. And even in the outlying cases, it would be short-term at best.

I'm going to go out on a limb and speculate that Dr. Doctor here became an addict at some point. And that by presenting a self-told tale of his pain, he's really just rationalizing addiction.

The $64K question is: did he become addicted while in-patient. And if so, how and why?

Maybe, just maybe, those are the REAL questions we should be asking.

While curtailing prescriptions might prevent some nonmedical use, it also hurt bona fide patients.

Bona fide patients will work hand-in-hand with pain management specialists. The problem is that one doesn't want to work with the other, because that's a hassle. They just want a scrip and to self-medicate as they see fit. After all, who wants to sit in a hospital and be continuously monitored for pain management? Popping pills like they're coming out of a Pez Dispenser is much less work.

suicide, and a surge in drug deaths as nonmedical users replaced reliably dosed pharmaceuticals with iffy black market products.

Why'd you say suicide twice?

[KiwiDude]

Well you speculated that he became an addict, why don’t you just speculate the answers to your $64k questions?

[AT]

The point was to question whether we should be giving as much in-patient opioids as we do. And whether our doing so creates the addictions that we should be focused on preventing.

Not to put too fine a point on it, but when did we become pussies about pain management? When did we decide that three grammes of Soma was preferable to biting down on this leather wrap. We don't even TRULY know how pain management works. Like, when an anesthesiologist puts you under, he doesn't know that this drug does this thing to this nerve receptor or that neurotransmitter - just that you won't feel a thing and won't remember anything when you wake up, and he knows how to control the dosage so as not to kill you or react with any other drugs that may be needed. The ACTUAL biological science of pain management is still a mystery. (Wonder again at the marvel of God's Creation - a nervous system that we still only barely grasp the fringes of understanding!)

And yet, we'll pump ourselves full of drugs to feel good - good to such a degree that our baseline for "good" changes - and then contemplate how/why drug abuse occurs.

Now, I'm not saying I'm against pain management. Yea, if my leg is split in two and sticking out of my thigh, give me something to take the edge off. But how often do we ask whether we're treating genuine pain or merely discomfort. (Also, let's throw in a little theology and ask whether pain is something we're meant to suffer: "To the woman He said, 'I will intensify the pangs of your childbearing; in pain you shall bring forth children.'" Makes one wonder about God's stance on epidurals, no?) And indeed, pain management allows us to perform complex surgeries that we'd never be able to do if the patient were to die of shock right there on the table as they cut into him.

But you'll notice that's not what anyone is ever talking about on the subject. We all just take it as a granted that because we can, we should. And I think that's a premise worth disputing. Not when you're being cut on or your bone is sticking out of your leg (or even when you're delivering a baby). But when we're not talking about pain. Just discomfort.

That's what makes this particular guy's story so questionable. The cause of his pain was something that would have been monitored and controlled in hospital. By all rights, he shouldn't have needed any pain management after discharge. It's just not that kind of malady.

So why did he? And what caused that?