I recently came across a couple of news bits that suggested that the Joint Commission was largely responsible for the opioid epidemic. I don’t remember the exact source and wasn’t sure if it was real news or not, but it struck me as odd that an accreditation organization would be implicated as a cause of the current opioid crisis. So I looked into it, keeping what I’ve learned from Freakonomics in mind, as always. I was surprised by what I found.

I remember as a resident hearing the nurses at the hospital speaking with dread about upcoming JCAHO (as the Joint Commission was known back then, standing for Joint Commission on Accreditation of Healthcare Organizations) evaluations. All I knew was that the JCAHO was coming to evaluate the hospital and that it was very important. I’m long out of residency and have only done outpatient medicine since then, so I’ve never had to deal with the Joint Commission in my professional life. I’ll admit that I know nothing about them except for what I can find on internet searches.

I’ll leave it up to anyone interested in a detailed explanation of what the Joint Commission is to look them up on Wikipedia. The short summary is that it is a nonprofit organization that sets standards and accredits hospitals and medical centers. It’s too much to try to explain how and why the Joint Commission has become such a player in healthcare; just understand that it is as close to an ultimate authority when it comes to hospital ranking/reputation as there is. Hospital administrators live and die by what the Joint Commission reports about their hospitals. So in today’s healthcare landscape, when a hospital is told by the Joint Commission to do something, it does it jumping with both feet and without looking.

CNN reported that in 2001, the Joint Commission decided to make pain treatment a priority (http://www.cnn.com/2016/05/12/health/opioid-addiction-history/). The Joint Commission wields such power that any hospitals that failed to meet the Joint Commission’s standard in pain management would be given “requirements on improvement” and be expected to follow them in order to remain accredited. In theory this concept of oversight works well, as long as what the overseeing body believes needs to be done is in fact correct and without negative consequence. The good effects propagate throughout the system quickly, and everything gets better (think of how infection rates improve with increased hand washing. A hospital accreditation organization might mandate that hand sanitizer dispensers be available in every patient room, bathroom, nursing station, cafeteria, etc, and placards reminding staff to wash their hands be placed in prominent locations in order to pass certification).

Unfortunately, these groups are not infallible. Bad decisions get made or are made due to inappropriate influence from entities who would benefit from the overseeing group’s decision. Imagine if Company X paid off an accreditation organization so that not just ANY hand sanitizer but only X brand hand sanitizer would be required for accreditation. If a hospital had been using Z brand sanitizer (which is perfectly equivalent to X brand, just sold by a different company), they would fail accreditation. They have to buy X brand sanitizer and Company X would reap the financial rewards. As silly as this may sound, this has happened ( https://www.forbes.com/sites/michaelmillenson/2015/03/08/the-fate-of-the-md-in-the-12-million-patient-safety-scandal/#1e2accfc5f21 ). If any negative consequences of the recommendations (read “requirements”) exist, they will spread just as quickly. This happens with operating system updates ( https://www.myce.com/news/another-flawed-windows-7-update-prevents-users-from-logging-in-crashes-all-outlook-versions-77781/ ), so it should be no surprise that it happens with something even more complex like healthcare.

Simplistically, the “blame the Joint Commission theory” says that the Joint Commission decreed that hospitals manage pain aggressively, so hospitals got their doctors to do so, efficiently and quickly. And this has resulted in the increased use of opioids and subsequent addiction epidemic.

Unfortunately, this theory does make sense. I am not assigning the blame for the opioid crisis to the Joint Commission entirely, but I believe they were a part of this crisis, and that they know it. I found it telling that Joint Commission released a statement on pain management in 2016 regarding their pain standards (https://www.jointcommission.org/joint_commission_statement_on_pain_management/). They make a point to say that their “standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.” They say that their standards simply require that:

• the hospital educate practitioners in the assessment and management of pain
• the hospital respect the patient’s right to pain management
• the hospital assess and manage the patient’s pain
• The hospital either treats the patient’s pain or refers the patient for treatment. Note: Treatment strategies for pain may include pharmacologic and nonpharmacologic approaches. Strategies should reflect a patient-centered approach and consider the patient’s current presentation, the health care providers’ clinical judgment, and the risks and benefits associated with the strategies, including potential risk of dependency, addiction, and abuse

Allow me to translate: “We mandated that hospitals make pain recognition and treatment a requirement for Joint Commission accreditation, but we didn’t tell them to prescribe opioids so we’re not to blame.” Sorry, but that seems disingenuous. Especially when the CNN article above points out that:

…the Joint Commission printed a book in 2000 for purchase by doctors as part of required continuing education seminars. The book cited studies that claimed “there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” It also called doctors’ concerns about addiction side effects “inaccurate and exaggerated”.

 That’s enough for me. In the end, doctors are the ones who over prescribed opioids, but the Joint Commission doesn’t want to admit to their enabling role. I’m disappointed that the Joint Commission didn’t accept their part in all of this, but I guess that’s a little too much to expect.