<table><tr><th>From:</th><th>Ed &lt;</th></tr><tr><td>Sent:</td><td>Friday, January 18, 2013 1A6 AM</td></tr><tr><td>To:</td><td>Epstein, Jeff</td></tr><tr><td>Subject:</td><td>Susana Duncan blog on opiate epidemic</td></tr></table>

Hi Jeff

Thanks for a great meeting. If you need any help to find a geisha =o train a robot, I have just the person in Tokyo. Below is Susana =uncan blog on how doctors, responding to the incentives in health =ystem, accelerate the opiate epidemic.

BELOW

Is Managed Care Pushing Addiction

By Dr.Susana Duncan

America's new addiction, which I wrote about in June in the Huffington =ost, is the epidemic of opiate pain killers, which, aptly named, last =ear resulted in over 16,000 overdose deaths. This is not the =tereotyped drug problem that can be solved by Miami Vice style drug =usts of traffickers and periodic round-up of street-addicts and =ushers. In this epidemic, the traffickers are our respected =harmaceutical companies acting entirely within the law seeking only to =ring legitimate pain relief to sufferers; the addicts are, for the =ost part, upstanding citizens seeking a medical solution to their =ain, and the "pushers" are, with few exceptions, dedicated doctors =ttempting to alleviate the suffering of their patients. So how can the =nteraction of decent people, pursuing well intentioned and legitimate =nds, result in a truly disastrous narcotics epidemic?

The answer, as counter-intuitive as it may seems, is that in large part =he epidemic is an unanticipated consequence of "managed are"; which =wept the country in the 1980's to contain rising medical costs. Almost every week, I have received more calls from new patients =earching for a pain specialist willing to take on the prescribing of =heir drug. In each case the reason given for the need for a new doctor =as their previous doctor's retiring or otherwise no longer being =vailable for the task. In each case a brief interview revealed the =ature of the injury or physical problem to be either minor or at best =artially diagnosed. Further, there is a turn of phrase, an urgency, a =orn thin quality to their stories, which informs the practiced =istener that driving the call is addiction. The previous prescriber =ad created a demon and had withdrawn.

As I reflect on why this wave of opiate addiction is so rapidly gaining =old in America, I realize that the answer lies in the new realities of =ow doctors must practice to earn their livelihood. Listening to Bill =linton, the only campaign speaker to try to get across the mechanics =f Obamacare, I learned for the first time where the funding ($617 =illion) for the proposed expansion of medical insurance coverage was =o come from: Hospitals, private insurers and doctors. A proposed 27% cut in Medicare payments to physicians, already so low =s to drive many physicians to refuse to see Medicare patients, is part =f the agreed legislation. It is not clear that private medical =ractice as we know it will survive at all under these cuts. In the =ast five years physicians have annually fought off a pending far =mailer cut, as the austere economics of managed care compels them to =ompromise and see increasing numbers of patients each hour. This =equisite for what government administrators might call =93efficiency", cuts deeply into a commodity precious to diagnosis =nd patient care, especially precious in pain management; adequate time =or listening, for which, under =ut-costs managed at all care, cost there system. is no Back commensurate and neck problems, =eimbursement. vague complaints Pain has =f its limb own pain special, can unfortunate be challenging place at the in this best new of times and may take long =nd repeated visits, interviewing and examining to fathom and correctly =reat. It takes not so much diligence as time to apply skill in getting =o the bottom of some of these complaints. And time is what is rationed =nder this new system. In this time-is-at-a-premium climate one =nderstands how for a harried physician, prescribing a pain killer =ecomes an expedient substitute for a lengthy diagnostic encounter. =ndeed, in the last decade, the use of opiates in general practice pain =anagement has become increasingly the norm. The sad truth is that =nder economic exigency prescribing in all fields, whether it be drugs =r expensive laboratory or imaging testing, is dramatically escalating; =oo

often replacing appropriate, in-depth office encounters between =hysician and patient, such that a precious gem of spoken information, =hich might provide the key, is never heard. This pattern is only =rowing: Enough pain killers were prescribed in 2010 to medicate every =merican adult around-the-clock for a month. If one examines the whole story of opiate use more closely, one finds =hat (here too) there is another hidden and costly outcome: these =rescription drugs can readily reach those for whom they were never =ntended. A bottle of half finished opiates lying somewhere at home can =empt a teenager, and these drugs have the power to addict within three =ays of use. Further, less well intentioned callers at doctors' offices =ave learned to mimic pain, to see multiple doctors with the same =tory, and then sell the prescribed drugs for handsome profits. Looking ahead one sees that in a system where symptoms are treated, but =he source of pain remains, a growing number of patients will become =hronic pain sufferers. And as long as managed care continues to =anifest as =piate-based "efficiencies" pills become in medical faster practices; acting and doctors' more powerful, =emuneration the =nevitable for office visits outcome progressively tragically is is even whittled greater down, opiate and addiction in =merica.

BLOG AT http://drsusananaduncan.blogspot.com/

## Best regards

<u>Ed Epstein</u>

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