Earlier this week I had the chance to interview author and surgeon Atul Gawande. Our conversation ranged from end-of-life care to his failed rock band — but what stuck with me most was our discussion of the opioid epidemic.
I asked Gawande to weigh in on a question I hadn’t seen him discuss elsewhere: What role did doctors and professional medicine play in the proliferation of opioids?
“We started it,” Gawande told me flatly. He argued that health providers are at the root of the country’s staggering opioid epidemic. He didn’t blame the pharmaceutical companies — although there is good evidence that they played a large role — but instead focused on how views of pain began to shift in the 1990s, with doctors urged to take their patients’ suffering more seriously.
I wrote about this movement a few months ago in a feature for Vox. Gawande went through his medical training in the mid-1990s, at a moment when pain was being dubbed “the fifth vital sign” and pain scales were becoming a standard feature of any doctor office. Gawande said that changed how he practiced medicine.
“I really keyed into the lessons from people like palliative care clinicians who said we have to measure pain, and we have to treat pain,” Gawande says. “But what we had not done was continue to measure what was happening along the way. I had no idea. Basically, I was like more is better, take some.”
Here’s the full exchange:
GAWANDE: We as a profession have caused an epidemic that is bigger than the HIV epidemic. We have more deaths from drug overdoses than occurred at the peak of the HIV/AIDS epidemic in 1995. That’s how big this is. It’s more deaths than in motor vehicle accidents.
The cause in the opioid epidemic starts with getting a prescription of opioids from physicians. We weren’t recognizing — I certainly wasn’t recognizing — the extent to which we were putting people at risk. I think the key thing that has stuck in my mind was that when you go in for an operation, and you give a supply of opioid pills, that if people are on those pills for 7 days they have an 8 percent chance of one year later still being on those narcotic pills.
It is huge. It is startling. I had no idea. Basically, I was like more is better, take some.
KLIFF: And where did you develop that? Was it pharma reps, or somewhere else?
GAWANDE: No, it was really out of the movement that said — and I saw this all the time in my surgical training — that we did not treat pain. That we left people in terrible pain and suffering, and it was a kind of inhumanity that I thought was unacceptable. So I really keyed into the lessons from people like palliative care clinicians who said we have to measure pain, and we have to treat pain. But what we had not done was continue to measure what was happening along the way.
The biggest reason was that we weren’t recognizing this issue. [An editorial I wrote] said a few things. Number one: There were things we could do and still weren’t doing at the height of the epidemic. There were some people who did some basic research who showed that after thyroid surgery, or breast cancer surgery, that 10 pills covered the need of more than 80 percent of patients. And you’d still have a third of them have leftover pills. So we should be prescribing way less than we often give out, and we should have the research that shows what that need really is.
Second, we have to teach people that the goal is not zero pain — the goal is that you have enough pain that there will be an ache but you can do the things you want to do. You can sleep, you can eat, you can go shopping.
Third, tell people these are addictive and weighing that against your choices. Fourth, teach them how to dispose of these things. The biggest thing is that the leftovers get stolen and then go on the black market that way.
KLIFF: It sounds like you attribute a lot of this to professional medicine.
GAWANDE: We started it. We started it.
You can listen to my entire discussion with Atul on the latest episode of The Weeds, which was taped Wednesday night live at Sixth and I Synagogue in Washington, D.C. You’ll also hear Gawande talk about how his practice of medicine has changed since he published Being Mortal, a book focused on end-of-life care, in 2014 and which country’s health care system he admires the most.