The US opioid crisis
The current US prescription-opioid crisis is one of the most remarkable examples of medicine going wrong. Last year in the USA more people died from an opioid overdose than died from road traffic accidents, and more than the total casualties in the whole of the Vietnam war. The reasons for this are complex. They reflect a perfect storm of good intentions coupled with prescriber ignorance and commercial greed, occurring in a context of growing economic problems in some parts of the country, lack of social support systems, and individual despair, sometimes manifested by pain syndromes, in people who may well have been depressed. A vicious cycle of overprescribing of strong analgesics such as hydrocodone and oxycodone then developed that began the current opioid problem which has now morphed into the massive use of illicit opioids.
At the time, it was generally accepted that the treatment of pain was quite often inadequate so many patients suffered. From the early 2000s the idea that pain was a fifth vital sign [alongside blood pressure, heart rate, breathing rate, consciousness level] was promoted alongside these new analgesics. This led to a large increase in prescribing that made lots of profit for the companies involved. However, there was insufficient education of providers on how to treat pain, and insufficient knowledge about the effects (or lack thereof) of opioids on chronic pain [which most of those given prescription opioids had]. Also, there was limited availability of alternative treatments such as physiotherapy and behavioural therapies, and the risks of the long term exposure to opioids, notably their propensity to cause tolerance (requiring higher doses to achieve a therapeutic affect) and addiction, was not properly communicated. Indeed, the idea was promoted that people in pain didn’t become addicted to opioids; and whilst this was true for acute pain in hospital the concept was extended to chronic pain syndromes. It seems to me plausible that many of these patients were also depressed.
Pharmaceutical companies often encouraged doctors to prescribe and sometimes they were even rewarded for the number of prescriptions written. Some prescribers became so active they gained notoriety as “pill mills.” Prescription drug monitoring programs (PDMPs) were starting to be implemented to prevent doctor shopping, but they were often not “real time” or interoperable across states (so people could travel out of state to get additional scripts). They mostly became a law enforcement tool to identify physicians with very high rates of prescribing.
This explosion of opioid prescriptions meant that there were a lot of these powerful and psychologically pleasurable and rewarding drugs in people's homes. The idea that strong opioids were safe and acceptable pain medications because they had been prescribed for one family member in turn led to use by other family members, some of whom died in accidental overdose, and others of whom became addicted. And the pleasurable aspects of these drugs soon became known so others in families, often the younger generation, turned to them for recreational purposes, often finding ways to get a better “high” e.g. by snorting or injecting. In this way the epidemic grew rapidly and death rates rose alarmingly.
The government response came some years later and was focused on limiting prescribing (see CDC guidelines) and some states and the Federal government began to sue the pharmaceutical companies for compensation. To some extent the move to restrict prescribing compounded the problem for some doctors stopped prescribing , resulting in patients dependent on opioids going into withdrawal. To avoid this many dependent patients started getting opioids from the black market. The figure shows that there was a large rise in heroin deaths beginning in 2010, all of which are from illegal sources as this is not a prescription drug in the USA. As well as supplying heroin, the underground dealers began to supply illicit fentanyls—of which there are many. This led to even more deaths as black-market supplies are very variable in quality and often are mixtures of different drugs. Many of those poisoned by fentanyl were not likely aware of what they were taking.
Some policy approaches to reduce these deaths have now been instigated such as ready access to naloxone for first responders, and many others in the community (including pain patients, their family members; drug users and their friends and family) but others such as safe injecting rooms and fentanyl testing kits have not as yet been authorised.
The pressure on prescribers to reduce the use of strong opioids has led some doctors to be too scared to prescribe, with subsequent under-treatment of some patients in pain. Also, many doctors became fearful of prescribing opioids to pain patients who were opioid dependent in case they were accused of promoting addiction. The US National Academy of Medicine has now stepped in to provide guidelines on good practice in both these clinical areas.
Of course what should have happened in the USA is that there should have been monitoring of the impact of the “fifth vital sign” requirement, particularly as it led to prescribing practice changes using addictive medications. A proper educational programme on pain control for prescribers and patients was also required, and insurers needed to cover non-medication approaches to pain treatment, which may be more costly. The influence of the pharmaceutical industry is profound, and many of the pain advocacy groups received funding from these companies and promoted their messages. Once people have become dependent on prescribed opioids they should not be stopped abruptly, but rather withdrawn slowly or stabilised using established protocols, such as with the safer alternative buprenorphine and/or non-medication treatments for pain.
It is to be hoped that expansion of Medicaid in some US States will allow more individuals in disadvantaged circumstances to access effective treatment for opioid addiction (and pain), though this is being challenged in the courts. Finally, because of the much greater safety ratio of cannabis it was believed that the increased use of medical cannabis would reduce opioid analgesic deaths. However initial promising data to this effect are now being questioned as additional data accumulates.
Excerpted with permission from Drugs Without the Hot Air: Making Sense of Legal and Illegal Drugs by David Nutt (UIT Cambridge, January 2020).