Fields of opium poppies in bloom are lovely. But opiates, derived from the flower, have been both a boon and a bane to multitudes through many centuries. Derivatives, such as morphine, codeine, hydrocodone, oxycodone, and fentanyl, are excellent pain relievers but also highly addictive. Morphine was purified in the 1800s and was used during the Civil War to ease the pain of wounds. Many soldiers became addicted to the drug.
Opium became recreational in the 1800s. The opium trade was so important that the British navy was sent to China in 1839 to prevent that country from eliminating the trade.
More opiate-derived compounds were developed over the next century. Heroin, methadone, oxycodone work well for pain relief, but all are addictive. Many physicians recognized the addictive potential, becoming hesitant to use the drugs. Patients complained that they were not given sufficient pain relief.
In 1996, the American Pain Society, a multi-disciplinary group of research scientists, doctors, dentists, and pharmacists, introduced the “Pain as the 5th Vital Sign” program. The pain was to be treated and relieved. Medicare and Medicaid supported the program, along with medical societies and pharmaceutical companies.
In 2002, CMS (Medicare and Medicaid) introduced a program asking patients how they rated their hospitals and doctors. A company called Press-Ganey had been building a hospital survey business. The Press-Ganey surveys and the HCAHPS surveys later preferred by CMS included a question that asked whether the patient thought the doctor did everything possible to relieve the pain.
Several studies, such as the one by Adams et al. in the American Journal of Public Health in 2016, have postulated that the combination of numerical pain scores (1-10) and the introduction of patient satisfaction surveys has fueled the opiate addiction epidemic in America. Their findings suggest not only survey unreliable because of low numbers, but doctors who give out pain meds get good ratings. Doctors who don’t get bad reviews and less pay.
CMS withdrew support for the 5th Vital Sign program along with the AMA, the AAFP, and others. After a decade of being encouraged to prescribe narcotics, doctors are under pressure to avoid prescribing them, caught in a bind between patients and the governmental regulatory agencies.