I never thought I’d ever consider disregarding my oath. She is a strong, charismatic, caring, successful, disciplined, and reflected woman. As her significant other, I am subjected to a degree of observer bias; nevertheless, her life’s accomplishments and her friends and acquaintances would validate these characteristics all the same. She looks nothing like a typical pill-seeking patient in clinic, if you were ever to imagine one – or do I even know what they look like outside of clinic hours, I wonder. Do they have physicians as significant others or family members, or are they even health care professionals themselves, with extensive knowledge of the pharmacodynamics causing this relentless craving? Can it be that I never thought about having to disregard my oath because I don’t love my patients as much as I love my wife? When she asked me what “oxycodone” was after returning from CVS with a full bottle of prescription medicine, the hair on the back of my neck stood up. Here she was, curiously squinting at the label on the all-too-common orange pill bottle. It was freshly filled, with 14 inconspicuous small, white, oval pills. I had been involved in a research initiative uncovering the opioid epidemic from numerous angles, to better understand and battle the toll it had been taking on too many American lives. The words “oh, it’s just a pill for your pain” tasted sour on the tip of my tongue. All I could think of were the staggering numbers I knew by rote, 125 deaths per day, roughly 45,000 deaths per year, while digging into my memory to retrieve the morphine milligram equivalent of oxycodone and which receptors it has the greatest affinity towards. While she was not a patient at high risk for opioid misuse at a glance, how many friends and families would have genuinely believed that about their dearly departed? Besides, how many victims had a partner or trusted companion who would have been able to gauge their risk of opioid addiction? Too many times, this controlled substance illuminated a winding and treacherous path towards addiction, filling the lives of countless “prescription-abiding patients” with dread, to warrant seeking the answer to this question. So many lives, in fact, that it has been classified as an epidemic for close to two decades now. “It is a pill that targets your pain, while also being the root cause of the death of more than 230,000 people within the last twenty years”, was my scripted enunciation. “What?” Why should I take this then?” she implored. For her, the answer was quite clear, but it still conflicted me. For a well-educated woman from a developed country, constantly being inundated with information, her health literacy shouldn’t have failed her on this topic. More particularly, there must have been multiple checkpoints along her recent path through the medical system, to hammer down every single detail about opioid pain medication, starting with her preoperative consultation on how they would fix her ankle fracture. Where did she fall through the hole that American physicians, clinicians, and interventionists have been trying to patch for years? While she knew all of the common street drugs and the all-too vivid aftermath that was ingrained into our societal attitudes towards them, this small inconspicuous pill would not spark a visceral response, as she read the name and instructions neatly printed on the label. On the contrary, every pack of cigarettes in her European home country, readily available and exposed to everyone paying for their items at their local gas station, each boasted a variety of repulsive images associated with the very product they contain. Never would she have asked these questions before smoking a cigarette. Yet, this small, orange pill bottle containing arguably the most addictive prescription drug, was handed over freely by a legitimate, certified, and licensed specialist on the orders of another well-meaning, caring, and experienced specialist. An indifferent convenience store clerk did not simply pass it out on the orders of your inveterate craving to pollute your lungs with a nicotine and carcinogen-filled smoke-cocktail. Clearly, one out of the two world’s deadliest substances still carried the “blessing” of a physician and the pristine disguise behind a meticulously branded name on a white label, while the other started to lose these privileges roughly 70 years ago. My brain is still struggling to comprehend the battle for the status quo a physician faces each day; one who must, by default, be cognizant of the lurking dangers of an opioid prescription, while also helping the patient on their swiftest way to recovery, led by the very same guidelines. But what happens when the patient slips on the road to recovery and out from underneath the physician’s caring cloak towards substance abuse? Whether the patient’s role changes at that very threshold is a different story. While it certainly is a part of this somewhat self-perpetuated epidemic, the struggle to keep a status quo has ancient roots and every physician has — if not knowingly so — sworn to abide by them when uttering the anecdotal resemblance of the Hippocratic Oath: “I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.” But what if we dare to question the application of this ancient commitment on this particular matter? Should we have already done so, or can we afford to wait until the death toll reaches an unspeakable capita? Should opioids for postoperative pain even be permitted to dance on this slippery spectrum between adequate analgesia and addiction? I wish the answer were that simple. Maybe now is the time to ask more questions. Maybe now is the time to revisit history and learn from our gruesome marketing affiliation with the world’s deadliest consumer product up until the 1950s. Maybe, just now is the time to hold all stakeholders accountable for labeling a drug that is destroying more lives than the number of people it kills. Source
