It was the year 2000, I was chair of anesthesia at the University of Iowa, practicing pain medicine and the Editor-in-Chief of the journal, Regional Anesthesia and Pain Medicine. A subpoena arrived from a state prosecutor in Florida inviting me to a grand jury proceeding on a physician prescribing large quantities of Oxycontin® and mixtures of other drugs; patients were dying. After consulting with our hospital’s attorney, I honored the subpoena, and helped establish what is the professional practice of pain medicine for the court.
Many volumes of police and autopsy reports crossed my desk. They were studied and left a deep impression on me. My “postgraduate work” in how pill mill practices work needed no more data! I got it. The deaths were almost always mixed-drug overdoses. Rarely was a single drug found in the deceased; rather alcohol, oxycodone, lorazepam and other drugs all showed up, creating a deadly pharmacologic mess. Two hundred dollars without an exam; the pill mill “cocktail” was easy to obtain. It was transactional. Big pharma databases tracked where Oxycontin® was being prescribed in detail and profits grew well past expectations with marketing focused on the drug’s safety and ease of use. The physician received a 63-year sentence for his crimes.
It was before and during this time that a regulator, the Joint Commission, was promoting the treatment of pain as the fifth vital sign, and when combined with case studies from 1980s-1990s suggesting opioid misuse (addiction) was uncommon with medically directed opioid prescriptions, opioid prescription volumes grew across patient populations. The focus on patient satisfaction as an effective marketing technique for health systems and as an accreditation tool for regulators, also encouraged more opioid prescriptions.
At this time, pain medicine as a specialty – using interventions and medications - was also growing and establishing a niche by promoting concept that all pain could be treated; especially when opioids were safely used by these newly trained experts.
In parallel, society was experiencing the spread of postmodernism; existential meaning was increasingly difficult to understand, and we had prescription opioids circulating in high volumes. The opioid epidemic respected no boundaries amongst diverse geographic, ethnic, income, education, and religious demographics. The suburbs, as well as inner city and rural areas participated. My respected, ethical and talented physician colleagues practicing pain medicine navigated the epidemic well, and yet the blame for the problem was hung on them.
At the end of the day, I believe that three-H’s (humans, hoodlums, and healthcare) ultimately conspired to produce and maintain the epidemic. Too many opioids in societal circulation, regulators focusing on metrics they knew little about, criminally greedy physicians establishing pill mills, and attractive profits for big pharma and healthcare organizations all contributed. It is an ugly story, yet, sadly, not that complex.