When death is a side effect

    27 September 2014


    ‘Is there any other point to which you would wish to draw my attention?’

    ‘To the curious incident of the dog in the night-time.’
    ‘The dog did nothing in the night-time.’
    ‘That was the curious incident,’ remarked Sherlock Holmes.
    Arthur Conan-Doyle, Silver Blaze


    One might suppose that the deaths in the United States of nearly 17,000 people in 2011 alone from overdose of a group of drugs prescribed without any evidence of their efficacy would have caused a major scandal and given rise to the mother of all class actions against both doctors and pharmaceutical companies. But one would be mistaken. The deaths of more than 100,000 Americans from these drugs since the year 2000 has so far evoked little more than hand-wringing by the CDC (the Center for Disease Control) and a few editorials in medical journals.

    The drugs in question are opioids, strong pain-killers, oxycodone and hydromorphone among them. They have been increasingly prescribed for patients with chronic pain, though — as Dr Kissin of Harvard says in a paper in the Journal of Pain Research — ‘There is no high-quality evidence on the efficacy of long-term opioid treatment of chronic non-malignant pain.’ What is certain, though, is that they have significant side effects in 80 per cent of cases in which they are prescribed; and that nearly 1 per cent of those prescribed them will die of an overdose of them, admittedly usually while also taking other drugs, especially tranquillisers such as diazepam. The frequency with which the fatal combination of strong painkillers and tranquillisers is prescribed might almost suggest a death wish by doctors — for their patients.

    How has this situation arisen? It is not age-old, as the bleeding of patients for every condition under the sun once was; it started in the 1990s. Perhaps the most creditable reason was that there was a reaction against the puritanical attitude of doctors towards pain relief.  I remember the days when heroin and morphine were withheld from dying patients for fear that they would become addicted, as if it were better that they should die in agony. But the pendulum of fashion has swung too far the other way, as the pendulum of fashion often does.

    For example, the guidance on prescribing of opioids to patients with chronic, non-cancer pain issued by the American and British Pain Societies, in 2009 and 2010 respectively, does not mention the drug-induced hecatomb. The American guidance asks the question: ‘What are the effects of opioid prescribing policies on clinical outcomes?’ and fails altogether to mention death as one of them.

    The manufacturers of the drugs in question advertise them widely in medical journals, and perhaps it is not surprising that the deaths from overdose of over 100,000 people from their products do not feature prominently in their propaganda. (I hesitate to mention that three of the seven authors of the British Pain Society’s guidelines have connections to the principal British manufacturer of these products, for this in itself proves nothing: but it might have been tactful of the society to have found other authors.)

    Patients with chronic pain are a heterogeneous group for whom total relief is seldom possible. But there are less dangerous drugs than opioids that provide some relief, as well as psychological techniques to assist those patients. But specialised pain clinics persist in prescribing opioids; and I have myself observed patients on their way to such a clinic, clearly neither disabled or in severe pain until within striking distance, who emerge with their prescriptions for these drugs.

    The transformation of the patient into customer, who seeks not so much advice from the doctor but what he wants from him, no doubt plays its part. A good doctor becomes one who does what his patients want, which in most cases is probably a good thing and creates no conflict, since most people are reasonably sensible; but there are some people who do not want what is good for them, who indeed want the opposite, and will not tolerate being told so.

    In the age of social (or antisocial) media, this is particularly important. Patients’ reviews of doctors can reach large audiences. A doctor can easily become known for non-compliance with his patients’ wishes and all sorts of trouble can be made for him as a result. An American doctor wrote to me recently to tell me how he had been suspended from practice, and his practice ruined, by a couple of patients disgruntled in this way. For more than one reason, then, it is easier for doctors to prescribe than not. The drugs may help some; the patient and doctor alike feel that something is being done; and it avoids trouble of the kind I have described. To adapt slightly an old medical saying of the 19th century, the consultation was a success, but the patient died.