Dr. David A. Kessler was interviewed by Jim Axelrod of CBS News about the opioid crisis. Specifically, Axelrod asked Kessler about the increased use of opioids over the past twenty years, and how we might get the opioid epidemic “back in the bottle.”

Always controversial, since the days between 1990 and 1997 when he served as the Commissioner of the FDA, Kessler calls the handling of opioids “one of the greatest mistakes of modern medicine.”

He blames the opioid epidemic on his former agency, the FDA; pharmaceutical companies; and physicians. “They didn’t see these drugs for what they truly are,” Kessler asserts.

The genesis of the epidemic, as Kessler sees it, is the American Pain Society‘s campaign in the late 1990s to classify pain as the “fifth vital sign” that doctors should monitor along with blood pressure, temperature, heartbeat and breathing. The Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative in 1999 to require a pain intensity rating (of 0 to 10) at all clinical encounters.

Here’s where I respectfully disagree with Dr. Kessler: assessing pain as a 5th vital sign was not the reason for the opioid crisis.

Pain is Drastically Under-Treated

It is important to recognize pain as a major factor that affects the quality of life for tens of millions of Americans. In fact, pain is drastically under-treated, and the voices of patients with pain are not being heard.

The problem is that physicians have never been adequately trained to assess and treat pain. Asking patients how much they hurt does not mandate prescribing opioids. To even suggest otherwise demonstrates the lack of understanding about what led to the opioid crisis.

Suggesting that the problem rests with doctors who ask patients to quantify their pain demonstrates the failure of our medical education system, and the need for more pain education in medical schools and residency programs.

Pain affects more people than heart disease, cancer and diabetes combined.

It is the number one public health problem. Chronic pain is a problem without a solution. We cannot solve the opioid crisis without first addressing the unmet need of hundreds of millions of Americans in chronic pain.

Dr. Kessler should have used this opportunity to acknowledge the findings of the Institute of Health: that the country needs a cultural transformation regarding pain that should begin in medical schools, with priorities on more effective ways to address pain.

Not All Physicians are Irresponsible In Prescribing Opioids

Also, while it is true that some doctors have not been responsible in prescribing opioids, it is unfair to paint all physicians with the same brush. Most physicians have been very responsible and concerned about the suffering of people in pain and the potential harm that opioids can cause.

These physicians have been squeezed between high expectations from their patients and the desire to do no harm — the proverbial rock and hard place. However, physicians do not have the tools necessary to meet the needs of their patients.

Dr. Kessler fails to mention the entity most responsible for the opioid problem may be the payers (that is, the insurance companies). Physicians are not only inadequately trained to assess and treat pain, but there are very few treatment alternatives to opioids. Those treatment options that do exist are rarely covered by payers.

The opioid crisis is not just about opioids. It is about a flawed healthcare system that includes payers, physicians, and pharmaceuticals. Patient outcomes are not aligned with reimbursement. Our healthcare system pays providers for procedures or visits without regard as to how those procedures or visits affect the patients’ overall well being.

Financial incentives for providers are not based upon better care but, rather, upon more care. We waste enormous amounts because we can, and we get paid for it.

The discordance between patients’ outcomes and reimbursement for their healthcare has contributed to the crisis. Short office visits and minimal reimbursement to treat very complicated chronic illnesses has fueled the crisis. Dr. Kessler should have cited this as a factor and called for a change that would align outcomes with reimbursement. The healthier the patients, the more the providers who treated them should earn.

Dr. Kessler seems to think that the problem is largely that opioids are overprescribed, yet he does not recognize that the demand for overprescribing is at the root of the problem.

Why do so many people want to overuse opioids? This is where it gets complicated.

There are many reasons for the demand for opioids, and severe unrelenting pain is among them. Does Dr. Kessler suggest that people in pain not be treated? I doubt he believes this, but what are the alternatives? He doesn’t provide any during the CBS News interview.

Opioid abuse and addiction are a disease triggered by exposure, but opioids are not the cause of the disease. Failure to recognize the fact that addiction is a disease and that the country has treated people with opioid addiction as criminals rather than with compassion has contributed to the number of deaths attributed to opioids alone.

People with the disease of opioid abuse and addiction, many of whom are not prescribed opioids, have no safe place to seek care. This leads to a disenfranchisement of people most in need of care. Here, too, the legal system has contributed to the opioid crisis.

It is easy to cast stones. Honest appraisal of the current opioid crisis cannot overlook the lack of pain education, prejudices towards people in pain, lack of payers’ willingness to cover alternative therapies, inadequate NIH funding to find alternatives to opioids, and criminalization of addiction as factors that have contributed to our crisis.

Pharma, physicians, CDC, FDA, Congress, medical schools, law enforcement, and payers have each contributed to the crisis but, sadly, everyone is pointing fingers rather than collectively tackling the root causes to the problem.

This is not just an opioids crisis. It is fundamentally a failure to address humanity’s primal enemy: pain.

Purchase my book The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us (available on Amazon) or read a free excerpt here.

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Copyright 2016, Lynn Webster, MD