Though the opioid epidemic was declared a public health emergency by the U.S. government in 2017, the development of the crisis spans the past two decades. The first wave began in 1991 when a sharp rise in opioid-related deaths followed the increase in opioid prescriptions.
Opioids are a type of drug that can be produced naturally from opium poppy plants, but are often chemically synthesized in a laboratory. Prescription opioids — including oxycodone, hydrocodone and morphine — are used to treat moderate to severe pain. By activating opioid receptors on nerve cells, opioids block pain messages sent from the body to the brain, thereby mimicking the effects of naturally occurring pain-relieving chemicals called endorphins. The euphoric effects of opioids often lead to misuse.
Opioid tolerance occurs when long-term exposure to opioids reduces your body’s natural production of endorphins. This tolerance induces dependence, causing patients to require larger and more frequent doses to produce the same pain-relieving and euphoric effects while averting symptoms of drug withdrawal.
In the early 1990s, opioid overprescription was largely due to the pharmaceutical industry’s guarantee that the risk of addiction to prescription opioids was very low, thus setting the course for the steady increase in the opioid dispensing rate by prescribers. This rate reached an all time peak in 2012 at 81.3 prescriptions per 100 persons, according to CDC data.
The Joint Commision (TJC), in a 2000 publication of the standards for pain management, encouraged the use of opioids to treat chronic pain states other than those associated with cancer, treating pain as the fifth vital sign. As a result, physicians were obligated to deliver adequate pain control, in fear that if the TJC benchmarks were not met, they would not receive federal healthcare funds and their practice would be deemed inhumane.
Opioids soon grew to become the primary approach toward chronic non-cancer pain treatment in the U.S.
In his evaluation of the opioid epidemic in The Journal of the Missouri State Medical Association, Dr. Ronald Hirsch, vice president of the Regulations and Education Group at R1 Physician Advisory Services, said that though most physicians are well meaning, they often prescribe “30 or 60 pills when five or 20 would have been adequate.”
A study performed by the VA Center for Clinical Management Research in Michigan investigated rates of opioid use and overdose among veterans and found that those prescribed higher doses of opiates were more likely to overdose than those prescribed lower doses for chronic pain, revealing that the threshold for safe dosing might be much lower than previously thought.
“We need to step back and reconsider whether giving these medications for long periods of time is the best treatment course for all patients with chronic pain,” said Dr. Amy Bohnert, the principal investigator of this study and an assistant professor at the University of Michigan Department of Psychiatry. “And we need to draw a clearer line between controlling pain and setting people up to overdose.”
It is this line regarding the quality of life that healthcare providers grapple with, because of their fear of inadvertently harming chronic pain patients with life-threatening diagnoses by denying them prescription opioids, who in response might resort to black market drugs like heroin or synthetic fentanyl.
“There are lots of patients who are under-medicated because of the restrictions and the pain that they have is not addressed,” said Cory Patrick Hartley, a nurse practitioner specializing in wound care at San Ramon Regional Medical Center. “They know they’re going to die and they could die very comfortably. There’s this balance between ‘I gave you the right kind of pain medication in the smallest enough dose so that you’re able to function and enjoy what time you have left versus just being in the fetal position in tears half the day.’”
In response to the epidemic, TJC regulations were changed to take a stricter approach towards monitoring opioid prescribing patterns. The 2017 standards “focus on appropriate and effective management of pain, including the recommended inclusion of psychosocial risk factors that may affect self-reporting in any pain assessment; set realistic goals when developing treatment plans with patients; emphasize impairment of physical function during pain assessment; emphasize diligent monitoring of opioid prescribing patterns; and promote use of non-pharmacologic pain treatments.”
However, the aggressive government efforts to curb the overdose rate have come with unintended consequences. The CDC’s revised “Guideline for Prescribing Opioids for Chronic Pain,” which urges physicians to limit opioid doses for new patients to daily doses of 50 morphine milligram equivalents (MME), has met serious backlash after its misapplication by healthcare providers. Taking the guideline as a harsh mandate, physicians have abruptly reduced opioid prescription, even in cases where they believe a patient is benefitting from and taking their medication appropriately.
“There is no doubt the government has to take action to counter the overdose crisis,” said Laura Mills, a health researcher at Human Rights Watch. “But it should make sure that chronic pain patients don’t end up being collateral damage.”
Rather than combating the epidemic through the sudden elimination of opioid medication, organizations such as the Department of Health and Human Services, the Food and Drug Administration and the Centers for Medicare & Medicaid Services suggest a more holistic proposal with an emphasis on prevention, not just treatment, to ensure that chronic pain patients don’t experience a diminished quality of life due to opioid deprivation.
“A multimodal approach will help to overcome this problem,” said Dr. Vaishali Ahire, an internal medicine physician at Sutter Health Memorial Medical Center in Modesto, California. Ahire emphasizes the importance of a pain team in addition to the primary care provider when conducting initial assessments.
“First of all, what’s causing the pain? As a clinician, you have to decide, is it some trauma or underlying infection? You have to treat that cause so you can cut down the total dose of opioids,” she said.
According to Ahire, in addition to patient interviews, a thorough initial assessment involves reviewing electronic medical records, especially since many patients see multiple primary care providers.
However, change is not limited to in-patient settings. Research suggests that prescribing behaviors are cemented during medical school. In a 2017 study conducted by the National Bureau of Economic Research, medical school ranking was found to be negatively correlated with physician opioid prescribing, potentially reflecting discrepancies in training about appropriate opioid prescribing.
Medical schools across the U.S. have begun to integrate courses covering pain-related incidents and substance use disorders. Improvement strategies seem to encompass multifaceted interventions, implementing “departmental grand rounds, service meetings with data review and one-on-one meetings with prescribers,” according to the AMA Journal of Ethics.
Researchers insist that combating the opioid epidemic does not mean eradicating the progress made in understanding and treating pain, but rather involves making strides in physician education and the use of non-opioid treatment options.