Comment by nickpsecurity | Hacker News Reader

Comment by nickpsecurity | Hacker News Reader

This is a great letter. I do want to pause on this, though, about doctors prescribing opiates:

"The epidemic would have been avoidable if doctors as a whole had adopted a more critical and thoughtful approach"

He could be totally right about causes of that problem in that time. Currently, though, drug companies offer all kinds of financial incentives anyone that will increase drugs use in ways ranging from BS studies to incorrect info in textbooks to actual prescriptions. I've also read they give free samples.

Examples I found in quick DuckDuckGo:

https://www.bostonglobe.com/opinion/2016/04/11/medical-resea...

https://www.nytimes.com/2004/06/27/us/medical-marketing-trea...

http://content.time.com/time/health/article/0,8599,1883449,0...

This stuff could've been going on a long time. Maybe back when the push to use addictive drugs started. Or maybe that was just bad science like author says with the current push involving massive amounts of corruption. I say don't forget what's going on in any current debate about drugs, though.

No, we didn't get free opioid samples. I can't imagine many docs got paid, either (I certainly got neither, nor would I have accepted them). What we actually got was a tsunami of alleged literature that said we should be doing more about non-malignant pain and that addiction was a minor risk. And, well, most of us bought it. Of course, look at who turned out to be behind it.

Yep. The fifth vital sign and all that.

respectfully, what remotely well-trained doctor _didn't_ realize that part about an opiate being only a minor addiction risk was obviously bullshit?

The doctors were getting shown a whole host of studies which all said that there was only a minor addiction risk. You need to be able to put trust into what the studies are showing.

I'm shocked to the point of disbelief on this as well, this does not pass the smell test for me. Anybody, especially doctors, should have been well aware of the risks, this was not a surprise to anybody with as much as a toe in the public health sector.

The book Dreamland[1] chronicles a lot of this history... but a belief in science means that if scientific studies challenge some of your preexisting beliefs, you accept that evidence.

[1] https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...

There was also a push to have pain as a fifth vital sign:

https://www.medpagetoday.com/publichealthpolicy/publichealth...

> In 2001, the Joint Commission rolled out its Pain Management Standards, which helped grow the idea of pain as a "fifth vital sign." It required healthcare providers to ask every patient about their pain, given the perception at the time was that pain was undertreated.

My parents have complained about this; my mom's an RN, who's been everything from a home health nurse to an ICU nurse to a clinic nurse in a podiatrist's office, and my dad's a CRNA, and they talk about people who are likely drug-seeking and people who just don't like any discomfort, even stuff that, if you felt like that on a normal day, wouldn't cause you to take anything for it if you were a normal person.

So you have a mandate to Take Pain Really, Really Seriously. You have someone in a clinic, or on a table, groaning about how it hurts even though there's nothing, objectively, wrong with them. What do you do?

> You have someone in a clinic, or on a table, groaning about how it hurts even though there's nothing, objectively, wrong with them. What do you do?

In practice, living the years I have with my wife, the answer seems to usually be "assume that you, as a doctor, have much more knowledge about your patient's experience and that because no test you know how to do dings 'yep, a problem', that the patient in fact _does not_ have a problem, that their claims of being in enough pain to want to die at least a few times a week are made-up, that they've lived this long with their 'must be just in their head' problem that surely it's not so bad and they can keep doing so".

From a purely probabilistic standpoint, they might be right.

From my wife's perspective, they are torturing her, hopefully not to death.

What _do_ you do?

I had a post viral illness this year after glandular fever. The post viral illness is related to chronic fatigue and if it hadn't resolved I would have been diagnosed with chronic fatigue. I had every test the doctors could think of and I was seeing specialists, yet every test said I was a bill of health. It's incredibly frustrating to have medical practitioners not believe you when the illness is ruining your life.

For most aspiring doctors, it's also worth contemplating the physicians assistant and nurse practitioner routes: https://jakeseliger.com/2012/10/20/why-you-should-become-a-n.... The number of actual doctors who lament not knowing about, or understand, these routes is notable.

There also was a very strong emphasis on pain treatment as part of standard-of-care.

When pain management is legislated, it becomes a lot easier for doctors to accept it as necessary.

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