The opioid crisis has been designated a national health emergency. To understand how we got to where we are today, it might be helpful to briefly review the history of how pain management in America evolved over recent decades. Prior to the 1990s, prescribing opioids for non-cancer pain was largely frowned upon. Around the early 1990s, the medical community started being inundated with messages that pain was under-treated. Funding from the pharmaceutical industry helped the American Pain Society (APS) to become ever more active, promoting more liberal treatment of pain. Simultaneously, aggressive marketing from pharmaceutical companies, led by Purdue Pharma, the makers of OxyContin, claimed that risks of addiction with opioid therapy for pain were low.
The pressure for physicians to manage pain more aggressively peaked by the early 2000s, with physicians feeling threatened with censure from licensing boards and lawsuits. The Oregon State Medical Board disciplined a physician in 1999 for under-treating pain, while another physician in California was successfully sued in 2001 for $1.5 million for inadequately treating pain. Responding to lobbying by the APS, the Joint Commission on Healthcare Organizations (JCAHO), the organization that accredits hospitals, required pain to be assessed as a 5th Vital Sign in 2001. Hospitals failing to adequately address pain jeopardized their accreditation, putting payment from Insurance Companies at risk. Purdue Pharma’s footprint is again visible through its support of the APS because JCAHO granted Purdue exclusive rights to distribute educational videos to promote compliance with the new pain standards.
The resulting explosive growth in opioid prescriptions gave birth to today’s opioid crisis. In November 2011, the Centers for Disease Control and Prevention (CDC) revealed clear correlations between opioid prescriptions, rates of admissions for addictions treatment and opioid overdose mortality rates. Recognition of the rising opioid crisis triggered efforts to curtail the opioid epidemic. These programs largely focused on limiting opioid prescriptions. Many states passed legislation governing the prescribing of opioids including rules regulating dosing of opioid medications. The CDC issued guidelines for opioid prescribing in 2016.
Prescribers experienced whiplash, swinging from fear of lawsuits for under-prescribing in the 2000s to fear of extreme penalties for over-prescribing in the 2010s. Doctors feared losing their licenses for prescribing and even being found guilty of murder for fatal opioid overdoses related to prescribing habits. Where I practice in central Indiana, many medical practices have taken the stance that they will no longer prescribe any opioids. Entire hospital systems have instructed all employed prescribers to stop chronic opioid prescribing and refer patients to pain management, which often have 6-month waiting lists.
As a result of pressures to reduce and limit opioid prescribing, prescriptions have declined substantially. The state of West Virginia led the nation in per capita opioid prescriptions during the years 2010 to 2012, when opioid prescriptions peaked nationwide (see Figure 1). West Virginia’s efforts succeeded in dropping opioid prescriptions by 42% from 2012 to 2017, more than any other state in the union. Yet, despite phenomenal success at cutting opioid prescriptions, West Virginia couldn’t shake its status as the state with the highest opioid mortality rate. West Virginia remains first in opioid deaths despite plummeting opioid sales because it now leads the nation in fatal overdoses from synthetic opioids, such as fentanyl. The case of West Virginia shows unequivocally that curtailing access to opioid prescriptions alone did not and will not bring the opioid epidemic under control.
The CDC describes the opioid crisis arriving in 3 phases (see Figure 2). Phase 1 began with prescription opioids, Phase 2 involved heroin, and in Phase 3, fentanyl and its analogs. The fall in opioid sales beginning in 2012 coincides with the rise of heroin in Phase 2, suggesting the strong possibility that aggressive reductions in availability of legal opioids fueled the transition to illicit opioids.
The shift from prescription opioids to heroin might be attributed to drug addicts seeking newer sources of opioids. An alternate explanation involves pain patients turning to illicit sources out of desperation when harsh regulations scared physicians out of prescribing. Either way, drastic reduction in availability of prescription opioids has not been good for society, pain patients, prescribers or even drug addicts. The only party really benefiting have been the drug cartels.
The plight of pain patients suddenly losing access to pain medications can be severe. The FDA acknowledges that patients suddenly deprived of pain medications can endure much physiological and psychological distress, even the possibility of resorting to suicide. For those who cannot entertain suicide, the less drastic route to illegal opioids becomes an option. As one opinion article in Tennessee put it, the only options for pain patients deprived of their medications are to “turn to illegal drugs, suffer or suicide”. This narrative matches my personal professional experience. It is likely that enthusiasm to tame the opioid crisis by curbing access to opioids has been paradoxically feeding it.
Clearly, we must not return to excessive opioid prescriptions. However, I believe efforts to combat the current opioid crisis must address pain patients’ needs. We must not sacrifice pain patients as pawns in our zeal to battle the opioid epidemic; depriving pain patients of medications is unethical, inhumane, and also clearly ineffective. Rather than intimidating physicians into abandoning opioid prescriptions, we need to teach them the skills to prescribe responsibly, screen effectively for problematic use, manage abuse and addiction when they are found, and refer difficult patients. These things can be done.
The model proposed above is actually the same model utilized for almost every common disease. Before the obesity epidemic produced a secondary epidemic of diabetes, family doctors did not always screen for diabetes, didn’t manage diabetes well, and often didn’t feel comfortable prescribing insulin. Nowadays, primary care providers routinely screen for diabetes, are much better equipped to manage diabetes, feel comfortable managing insulin, and tend to refer only difficult cases. The difference is that diabetes is treated as a disease but opioid addiction, even though recognized as a disease by addiction doctors, is approached as criminal activity. We return to the central message of this website that addiction must be managed as a disease.