Thread by @LeorSapir

This week four years ago, the American Pain Society, a professional medical association, closed down due to concerns that it had collaborated with Purdue Pharma, maker of OxyContin, and helped fuel the devastating opioid epidemic. 🧵

In 1995, the president of APS, Dr. James Campbell, made the case for using pain as a fifth vital sign alongside pulse, blood pressure, core temperature, and respiration.

There were good arguments for this new approach, but also serious risks. For instance, unlike the other four vital signs, pain is largely subjective; its diagnosis relies heavily on patient self-report.

In 1996, APS released a statement claiming that opioids are safe and effective and that the addiction rate is very low.

Opioid advocates said studies showed that addiction is negligible among those without a prior history of drug addiction.

Three studies (in NEJM, Headache, and Pain) were cited over and over in the initial years of the opioid epidemic. None of these actually showed what those who cited them claimed, but the idea laundering made this irrelevant. The narrative was out there, and the science "settled."

Those who saw the risks in what was happening and spoke out were accused of lacking compassion for pain sufferers. Pain treatment advocates coined the term "opiophobia" to describe the irrational fears of skeptics.

Arguments for scaling up the use of opioids were based on studies on a narrowly defined cohort: cancer patients. It was assumed, without good evidence, that the same risk/benefit calculus applies to other conditions and patient groups as well.

In 2001, the FDA adopted a rule requiring doctors to undergo training if they wanted to prescribe a new addition-treatment drug called buprenorphine. Pain experts insisted that there should be equal or greater training for prescribing addictive drugs like OxyContin.

The American Medical Association vehemently opposed such a rule, however, arguing that it would inconvenience doctors. Later, during the Obama years, the AMA once again thwarted regulatory efforts to rein in opioid prescription.

It is simply wrong to think that Big Pharma is alone responsible for perverse outcomes in American healthcare, and that professional medical associations stand watch valiantly over the best interests of patients.

Perverse outcomes are very often the result of a confluence of financial motives (Purdue), institutional incentives (AMA), and ideological shifts (pain-relief as imperative) in medicine and in the broader culture. Sometimes one factor is more important, sometimes another other.

(This thread draws on research from Barry Meier's book, Pain Killer)