Iatrogenics is my new favorite five dollar-word. I like five-dollar words, because telling an ER nurse the patient is “obtunded” or pounding “normotensive status” into an electronic healthcare report makes me feel a little less like a hayseed ambulance driver and more like Curt Doolittle. Put simply, iatrogenics is “harm produced by the healer”. It could be relatively innocuous, like my driver hitting a bump in our antique meat-wagon as I attempt to start an IV, causing me to miss the vein and cut loose a string of colorful profanities related to the quality of suspension systems in 16 year old ambulances. You end up with an unnecessary hole in your arm, I have to dig out another needle, and for the rest of the day my partner will be listening to me wax poetic about why slapping a patient compartment on top of a worn-out pick-up chassis is not the right way to build EMS units.
Or, iatrogenics can be much more costly, as is the case of Vioxx, a prescription NSAID pain reliever. While killing patients with heart-attacks will definitely reduce their 9 of 10 pain level to a 0, most of the public balked at this human cost and the drug was finally pulled from the market after roughly 60,000 people died.
What I want to discuss is a much more dangerous class of drugs which have inflicted a staggering iatrogenic death toll on the American population, to a degree which should cause everyone to be skeptical of the underlying philosophies of our healthcare system. Primum non nocere is the first component of the Hippocractic Oath for a reason: Medicine should not be needlessly doing harm, otherwise it isn’t truly medicine anymore.
Opiates are not a new phenomena in clinical practice, nor is their horrific cost on individuals, families and societies in general. In 1803 morphine was isolated by German pharmacist Friedrich Wilhelm Adam Serturner, setting a trend for opiate innovation in this part of the world that would include the first commercial marketing of heroin in 1897 after Felix Hoffman re-synthesized the drug under direction of his supervisor, and finally culminating in 1959 with the Belgian discovery of Fentynal by Paul Janssen. “Heroin” itself is actually taken from the German word “heroisch”, meaning “heroic”, a descriptor I definitely wouldn’t associate with the typical overdose patient laying unresponsive on a stretcher. Unsurprisingly, Serturner’s first experiments with morphine resulted in near lethal overdoses for himself and the family pets, setting another historical trend that continues into the present.
It was the popularization of the hypodermic needle in the mid 1800s that set the stage for massive levels of medical interventionism using opiates. Because of the gruesome injuries and widespread dysentery endemic to the War For Southern Independence, the pain relieving and anti-diarrheal properties of morphine combined with the effective delivery system of the fancy new hypodermic syringe made it a first line treatment in battlefield medicine. Getting high on morphine before a surgeon goes after your leg with a rusty saw was completely understandable given the circumstances, but pioneering IV opiates in wartime would create a legacy of addiction for decades after the conflict.
A physician in the period who was remarkably prescient in his observations about iatrogenics noted that, “Opium … is also liable to great abuse, and if we estimate its uses and abuses, it is quite possible that the injuries of the one would quite outdo the benefits of the other.”
Those are the words of someone actually weighing the costs and benefits of a medical intervention instead of naively assuming there are no risks at all to treatment. Unfortunately his words went unheeded and by the end of the century the country would see the widespread abuse of morphine, heroin and patent medicines containing large amounts of opiates. These drugs were popularized as a cure-all for “feminine complaints” and the gastrointestinal upsets common to a period before sanitation but also 100 years before Mexicans would defecate all over lettuce and strawberries. Middle and upper class white woman were hit hardest by addiction, a gender specific outcome that seems to be repeating itself again in the present day with the overprescription of benzodiazepines.
In fact, our modern concept of “addiction” owes itself to clinical literature from this period describing opiate dependence. Even “iatragenic morphine addiction” as a specific entity was openly discussed in the medical community of the late 1800s. Then, as now, one of the “cures” prescribed for opiate addiction was another opiate, in this case, heroin. After many lives lost and much political wrangling, the US government would eventually pass the Harrison Narcotics Tax Act and the availability of opiates would swiftly decline in lock-step with a growing Prohibition movement that took a dim view of all psychoactive substances.
To sum up, over a century ago, chemically modified opiates were widely popularized as a miracle cure by naive doctors and greedy pharmaceutical companies, eventually resulting in widespread addiction problems in which the “cure” was more of the disease. It would take a sea-change in public policy and something akin to a religious crusade to stop the epidemic, but the seeds were planted and opiate addiction would remain a background problem for the rest of American history.
Fast forward to the present day, and yet again, synthetic, chemically modified opiates were touted by the modern patent medicine industry as a safe cure-all for chronic pain. The swindle performed by Purdue Pharma is well-known to everyone, but the real question concerns how the medical community could repeat the same exact historical mistake only with a significantly enhanced death toll. Close to 50 people per day overdose in the United States on prescription opiates with no abatement of the epidemic in sight, a sobering fact that should underline just how bad this crisis really is.
The iatrogenic cost of “treating” people with opioid medications is so fucking high it actually reduced the overall average life expectancy in the United States.
That is an unacceptable outcome of medical interventionism. Worse, this hasn’t provoked any sort of conversation or critique of the healthcare system itself. A system which repeats the same deadly errors with greater impact on each successive reiteration is badly in need of a little medicine itself.
Two questions come to my mind regarding these kinds of outcomes:
First of all, why are doctors so strongly motivated to intervene with a medication to “treat” pain to begin with? There are specific reasons for this, such as the adoption of subjective pain scales as an important criteria to monitor. It is true that the campaign for pain as a “fifth vital sign” began with one overzealous doctor trying to alleviate the misery of his patients, but ultimately he came to see the consequences of nodding chickens come home to roost and lamented his own position as leading general of the nationwide opiate epidemic. The greater epistemological question has to do with an overly permissive attitude towards medical interventions themselves. The prevailing culture is that if a patient presents with a complaint, this complaint must be treated with some sort of intervention, whether it be surgical or a medication, if, for no other reason, so that the physician can say they “did something”. It’s entirely possible large numbers of patients present with complaints that do not require treatment, or with symptoms that cannot be successfully rectified with any of the items currently residing within a physician’s toolkit, but this hasn’t stopped them from grabbing the large framing hammer and treating every problem as a nail. Blue collar workers with chronic pain related to repetitive motion injuries from swinging actual hammers all day were prescribed synthetic heroin instead of a trip to the physical therapist because of a system of protocols and HCAHPS performance metrics that favored reckless abuse of chemical options, meaning much of this is policy driven, but I also think an attitude that assumes interventionism is partially to blame.
Secondly, even accepting the philosophically dubious interventionist model of healthcare that renders every patient encounter down to a flowchart scripted mandatory response, the person writing the prescription should be doing their fucking homework before dispensing a drug stronger than heroin to a patient with an ingrown toenail. (Yes I have seen this happen firsthand while working in the ER) This is equivalent to being asleep at the wheel while driving the activity bus for the local church. If you’re going to pharmacologically intervene in someone else’s life, you’d damn well better know exactly what the effects of the drug are before reaching for that prescription pad. If you don’t know, why are you dispensing the medication? The idea that doctors, a group of people ostensibly trained on pharmacology, pathophysiology and human anatomy couldn’t figure out that just maybe Opanas aren’t the right answer for dental pain should raise serious questions about their authority to practice medicine in the first place. Obviously years of the best medical education didn’t serve to safeguard the overall patient population from bad treatments since doctors aren’t really evaluating the efficacy of their own interventions.
To me, part of the approach to fixing this mess would involve actually setting a reasonable bar for intervention in which the interventionist shows the costs and benefits have properly been accounted for. The burden of proof should fall on the clinician to demonstrate that the procedure or medication will help more than it will hurt, instead of robotically consulting the Current Year’s flowchart and hiding behind a dubious “standard of care“.
These sorts of conversations are the ones we aren’t having though, and I fear we’ll be doomed to use this broken model of healthcare until the soothing nuclear fire blows me off the chainlink fence.