“Every positive value has its price in negative terms … the genius of Einstein leads to Hiroshima.” — Pablo Picasso (1881-1973)

by U.S. Medicine

October 11, 2016
Editor-In-Chief, Chester "Trip" Buckenmaier III, MD,  COL (ret.), MC, USA

Editor-In-Chief,
Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

One of the interesting aspects of writing this federal medicine column is friends, colleagues and readers who follow U.S. Medicine editorials feed me interesting unsolicited ideas for writing topics. Often these suggestions in and of themselves will not create an editorial, but seemingly disparate tidbits of information will congeal in my increasingly-crowded mind and form into an interesting correlation worthy of comment. Such was the case with a recent article sent to me by my Uniformed Services University supervisor, retired Lt. Gen. Eric Schoomaker, MD, “The Rise of the Predator Empire: Tracing the History of U.S. Drones.”1

Apparently, after only three decades of civilian drone development, the Federal Aviation Administration (FAA) and commercial drone industry have settled on the “rules of the air” for the use of small (<55 lbs) commercial, recreational and scientific drones. With predictions of hundreds of thousands of these drones winging their way into our daily lives from private investigations, law enforcement, environmental monitoring and even Amazon deliveries,2 the potential for unanticipated negative outcomes seems high.

Are we really prepared for the consequences of all this computer/radio-controlled machinery buzzing just over our heads? 

Beyond the fascinating story of drone development in the U.S. military, what snagged me was Dr. Schoomaker’s comment about this article in his email to me concerning the rapid development of civilian drone technology. He stated, “We may be getting our prescription opioids delivered by mail order drones for treating chronic pain before dependably getting acupuncture.” This insightful prediction really caused me pause (perhaps that’s why he is a general). I am presently reading “Dreamland: The True Tale of America’s Opioid Epidemic,”3 which I highly recommend for a historical perspective of how American medicine got itself and the rest of the country into the current prescription opioid and heroin crisis.

In “Dreamland,” author Sam Quinones outlines the unintended consequences of Purdue Pharma’s marketing campaign for OxyContin (oxycodone HCL), a powerful medication for pain introduced during the 1990s. The motivations for the development of this analgesic medication were pure, since effective acute and chronic pain management is a primary function of medical practice. Relief of pain is a value few medical providers would contest. Furthermore, the relief of pain by oxycodone was undeniable. The medication, like all medications in the opioid class, is peerless for the rapid reduction or elimination of pain. Sadly, as sagely predicted by Pablo Picasso, the medical profession’s value of an easy answer for pain management in the genius of modifications to the morphine molecule has led to the consequence of a national addiction epidemic to prescription medications. Unintentional death by prescription medication overdose, usually opioids, has surpassed motor vehicle accident death in many states. How did we get here!

My sense is that we, as a species, tend to rush forward with any technologic advance that we perceive has value with little time or inclination to consider the negative aspects of said technology. Americans in particular prefer technological solutions to complex problems. In medicine, this ethos leads to a preference for “doing things” to patients through procedures or a pill, as opposed to more holistic, time-consuming approaches that place greater responsibility on patients for their own health. 

American history is rife with examples of our general preference for technology. Some I have provided here, while others I imagine would not be too difficult for readers of this column to conceive. Continuing with the drone example, while I am fascinated at the rapid development of civilian drone technology and delighted with the idea of my purchase being whisked to my doorstep by a flying automaton, I still have this nagging feeling that 55 pounds of unmanned flying machinery hurling through the air with thousands of other small devices is bound not to end well. I recognize that any technical innovation necessarily includes risks, and, when something has an obvious commercial value, such as drone technology, it tends to be done right.

I imagine when the developers of OxyContin set out to develop a very-effective medication for pain, I doubt they were planning on starting a national opioid abuse epidemic. I believe they were beguiled by the positive value of their product and allowed themselves to become blinded to the real consequences of this technology to patients or the unscrupulous uses for profit some individuals would develop for the drug. For physicians struggling with difficult pain patients, having few alternatives for pain management, I imagine the introduction of OxyContin seemed extremely valuable. The idea of pain being a disease process was in its infancy at the time.

Chronic pain patients can be some of the most-challenging patients to manage, and nothing moves a patient faster out of the clinic than a prescription. Good pain management is difficult, time-consuming and involves a variety of diverse specialty skill sets to be done well. Unfortunately, integrative medicine in support of good pain management tends to be low-tech and lacks obvious commercial value. In a culture that presently values patient throughput—a pill for every ill, and easy, protocol-driven treatment plans—our overdependence on opioid prescriptions and technical procedures is perhaps understandable.

The negative consequences of this approach is certainly no longer a mystery. A significant part of my work life lately has been consumed by ongoing efforts in federal medicine to respond to the CDC Guideline for Prescribing Opioids for Chronic Pain and the Presidential Memorandum—Addressing Prescription Drug Abuse and Heroin Use. Both documents were produced to address the unintended consequences of opioid predominant approaches to pain management in this country.

Federal medicine can and must do better in educating patients and providers about safe opioid use and best pain practices. We must change what we value and evaluate more critically new technologies that at first glance seem miraculous but become less captivating when subjected to the thoughtful exploration for unintended consequences.

The federal medicine system is unique in its ability to respond as a nationwide system to the opioid crisis and serve as a model for the country. We can benefit from the genius of new analgesic formulations and pain technologies, if we open our minds and our system to the complexity of managing pain and the complementary need for more holistic, nonpharmacologic treatment approaches, such as integrative pain medicine. We have no time to waste, for it would be truly tragic if we started delivering opioids to our patients by drone before we have established routine access to integrative pain management practices, like acupuncture, massage, etc., for pain.    

 

1Ian G. R. Shaw, (2014), “The Rise of the Predator Empire: Tracing the History of U.S. Drones”, Understanding Empire, https://understandingempire.wordpress.com/2-0-a-brief-history-of-u-s-drones/

2https://www.amazon.com/b?node=803772001. Accessed 12 September 2016.

3Quinones, Sam. “Dreamland: The true tale of America’s opiate epidemic.” Health Affairs, 34 (2015): 9.


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