It’s not breaking news, but I wanted to highlight the report from the Kaiser Family Foundation regarding per capita drug use in Tennessee.
While Tennessee has the second-highest rate of prescriptions per capita in the United States, the increase of prescription drug use is a national trend that shows no signs of stopping. The Nashville Scene’s Brantley Hargrove notes:
At a rate of 16.9 prescriptions filled per capita, we might as well be named honorary apothecaries and begin running pharmacies out of our bathrooms. The only problem is we need our drugs. Desperately. Because 65.9 percent of us are obese. The national average is 60. The heart disease death rate in Tennessee is 220 per 100,000 of us versus 190 nationally. Ten percent of us have diabetes. Eight percent is the average.
In just 10 years, the number of prescriptions filled in this country has risen nearly 40 percent. Spending on prescriptions is six times what it was in 1990. Are we really that much fatter, that much more sedentary, more diseased than we were in the ’90s? Probably not.
There are several systemic issues at play here that I want to highlight. First, what’s “normal” for Tennessee is not healthy. Nearly two-thirds of Tennesseans are obese. This is the ocean of normalcy that we swim in, so it’s easy to forget the negative health consequences of our lifestyle choices. But are we fatter simply because of how we eat? Is it an issue of genetics? Culture? Public policy? Parenting? Hot summer weather? Long commutes? It’s likely a combination of factors, but that doesn’t mean we can simply throw up our hands and ignore the health risks.
Healthcare providers and prescribing physicians recognize that there is a problem, but they have perverse incentives to ignore the issue. Our disease care industry is a huge cash cow, and treatment of chronic illnesses is highly profitable. Furthermore, the way we practice medicine in a managed care system makes it much easier to write a prescription than to address the underlying emotional, mental, and physical health issues that keep us sick. It takes a minute to write a prescription and an hour not to. The practice of “defensive medicine” to avoid malpractice lawsuits (especially in relation to the treatment of chronic pain complaints) is another issue, but I think the political debate about malpractice reform ignores the core issue. Physicians today are largely technicians who get paid more not to care. Entering into a caring relationship with a patient can be risky and time-consuming. Caring for someone in distress can be emotionally draining, putting caregivers at a high risk for burnout. And many healthcare providers simply lack the skills to empathize without becoming too emotionally involved.
The average medical school student receives just a few hours of education about the treatment of drug abuse and addiction. And while most physicians are aware that drug diversion (doctor shopping, redistribution/resale of prescription drugs by patients, etc.) is a concern, the vast majority of prescribing physicians do not receive adequate training about how to recognize or address drug diversion in their medical practice. Columbia University’s Center on Addiction and Substance Abuse issued a report in 2000 that highlighted the lack of attention given to the issue of substance abuse and addiction by medical professionals. (Download PDF here.) In a hypothetical case presentation where substance abuse was a likely diagnosis, only 6% of physicians surveyed correctly identified substance abuse as a diagnostic issue.
Prescribing physicians are the gatekeepers for prescription drugs, and the unfortunate reality is that doctors fear that asking tough questions about substance use will create an atmosphere of mistrust or lead patients to leave their practice for a “less intrusive” doctor. A competitive healthcare market can create an atmosphere of mistrust among providers, who see fellow providers as competitors instead of collaborative partners. Awareness is the first step, and avoiding professional isolation can prevent burnout, compassion fatigue, and malpractice.