In October 2017, President Donald Trump announced that the opioid epidemic is a public health emergency. Earlier the same week, the FDA declared that since 2001, prescription drugs (largely opioids) have been the greatest cause of overdose deaths. In fact, over the past 6 years, there have been more deaths from overdoses than guns, cars, suicides, and murder. How did we get to this point?
The first use of opioids dates back to approximately 3500 BC, when the opium poppy was cultivated in lower Mesopotamia and the Sumerians referred to it as “Hul Gil” or “joy plant”. Its euphoric properties were soon passed on to the Assyrians, Babylonians, and Egyptians. In 1100 BC, it was noted that the “peoples of the sea” on the Island of Cyprus crafted special knives for harvesting opium, and they smoked it before the fall of Troy. Hippocrates, in 460 BC, first noted its usefulness as a narcotic in treating diseases. There are many references to opium in ancient times, when it was used as an anesthetic and even for ritual purposes. The ancient Egyptians, Indians, and Romans used it to treat pain, often during surgical procedures. It was a highly traded commodity for many centuries, and its use spread throughout Europe and Asia.
Opium first arrived in the US in the 1620’s aboard the Mayflower. It was most likely carried in the form of laudanum (an opium/alcohol tincture first created by Paracelsus) and used as a pain killer, anti-diarrheal, and sedative. It was very useful in early frontier times during outbreaks of smallpox, dysentery, and cholera. By the time the American Revolution occurred, the use of opium as a medicine was well-established. In fact, Thomas Jefferson used it in later years to treat chronic diarrhea and ended up growing his own poppies.
During the Civil War in the early 19th Century, morphine was first extracted from opium in its pure form and used as a painkiller. Many soldiers became addicted. In 1830, codeine was isolated by Jean-Pierre Robiquet to replace raw opium for medicinal use. During the early parts of the 19th century, recreational use of opium grew. In 1874, scientists trying to find a less addictive form of morphine created heroin, as well as the rise of heroin addiction. The increased use of these agents led to the ban of opium in 1905. The Pure Food and Drug Act was passed in the following year, requiring medicines to bear labels containing their contents.
During the 1960s and 70s, heroin use again rose, most likely due to Vietnam War soldiers being exposed to it overseas. While previous epidemics appear to have been doctor-driven, this one hit inner cities particularly hard. In fact, in 1970 and 1971, more adolescents in NYC died from heroin than any other cause.
In 2017, more than 90 Americans died every day, on average, due to overdoses involving opioids. Of all patients who receive a prescription for opioid medication for chronic pain, approximately 21% to 29% will misuse them. Furthermore, about 8% to 12% will develop an opioid use disorder. Many experts conclude that prescription abuse is a gateway for heroin use. It has been found that, in fact, 4% to 6% of those who abuse prescription opioids will move on to using heroin. Approximately 80% of those using heroin first misused prescription opioids.
Who Is to Blame for the Opioid Crisis?
Doctors: There are many fingers pointing blame and many being accused of bearing fault. Some say it is doctors who over-prescribe these medications. In 2013, doctors wrote 207 million opioid prescriptions, up from 71 million in 1991. We have all seen stories of pill mill doctors, and many of those are now out of business. Yet, the epidemic continues to sky-rocket. Surely, doctors bear some blame for putting all these drugs on the streets.
Government: Others speculate wrongdoing started in the 1990s, when the federal government enacted the rule of pain as “the fifth viral sign” and stressed that doctors are undertreating pain. During that time, JCAHO mandated that the pain scale be used as the fifth vital sign and be recorded for all patients, whether or not their chief complaint was pain. Hospitals stood to be penalized if they did not meet these requirements. In fact, JCAHO published and sold a book in 2000 as part of required CME that stated “there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” It went as far as to call doctors’ concerns about addiction potential “inaccurate and exaggerated”. Interestingly, this book was sponsored by Purdue Pharma, the creators of oxycodone.
Pharmaceutical companies: Pharmaceutical companies are proclaimed as another cause of our current opioid epidemic. In fact, they are bearing some legal responsibility for their role in the crisis, but is it too little too late? In 2007, Purdue Pharma paid more than $600 million in fines and fees for misleading regulators, patients, and doctors about the risk of addiction with oxycontin. The company, along with three of their top executives, pled guilty to criminal charges for misbranding their product. Many cities and states are now suing pharmaceutical companies and that number continues to rise. States are now issuing new mandates around the prescribing of these medications. However, not much funding is being provided for rehab for those who are already addicted.
Patients: Healthcare providers are frequently frustrated by patients who come seeking prescriptions for opioids when they are not in fact indicated. Confounding the fact that we are facing an opioid addiction crisis, chronic pain continues to be a very real problem. The IOM concluded that there are 116 million Americans suffering pain lasting for weeks to months at a cost of $560 billion to $635 billion per year. Patients using these medications for non-medicinal purposes make it more difficult for patients suffering real pain to get appropriate medication to treat those conditions.
Dealers: Dealers are not just selling drugs they picked up off of the streets. They now sell a whole host of prescription medications that were obtained “legally” in some fashion from healthcare providers.
Insurance companies: When we examine the causes of this epidemic, third party insurance companies bear some of the burden of blame. Often, non-medicinal treatments for the management for pain, such as massage, acupuncture, chiropractics, etc. are not covered, and patients need to foot the entire cost for potentially chronic conditions. Additionally, some non-opioid medications, such as Lidoderm patches, are similarly denied coverage frequently.
According to a poll of healthcare providers conducted by Platform Q Health, 46.1% of clinician respondents chose increased development and access to effective, non-addictive pain medications as having the most positive, long-acting impact on the opioid epidemic. Clearly, just saying “no is no” is not an option. We need better tools in our war with addiction. Leaving patients to suffer in pain is not good medicine and not why most people chose our field. We want to alleviate pain, but we do not want to fuel the opioid crisis in the process.
Opium addiction has been around for thousands of years. Today, we are facing a crisis in which there are enough prescriptions for opioids being written that every American adult could possess their own bottle. The death rate from overdoses involving opioids continues to sky-rocket despite the rising awareness of how dangerous these drugs can be.
What needs to be done to ease this crisis?
- Easy access to recovery services. As a doctor, I struggle to locate rehabilitation services for my patents, even when they come seeking help. Often, there are waiting lists to be treated, and an overdose can happen with just one episode of drug abuse. Delayed access puts lives at risk. Insurance companies often do not cover these services, and they can be quite costly. If the state and federal governments want to continue to create initiatives and agendas to target the opioid epidemic, they also need to put funds into these programs and actually help victims recover. Political rhetoric without actual access to services will not help any of these patients, and this will only fuel the flames of crisis.
- Education for teens is needed. Heroin in teenagers is rapidly rising in many states. Many experts conclude that prescription opioids serve as a gateway to IV heroin use. One of the major problems we face with prescription drug abuse is the assumption of many people that because opioids are prescriptions written by doctors, they are safe. We need to end this assumption, especially in younger patients who may be more gullible.
- Pharmaceutical companies need to take responsibility for their role in misleading healthcare providers and the general public regarding opioid medications. These companies are facing increasing and costly lawsuits for their role in fostering this epidemic. But rather than doling out funds for legal penalties, perhaps they can fund educational campaigns getting the truth out and developing alternative, non-addicting medications. It may not be as financially compelling as a $1,000 per month cholesterol medication, but the time has come to call them to take responsibility for their actions, either voluntarily or by legal force.
- Sanctioning of pill mill doctors needs to be strict. These doctors make it hard for the rest of us. Doling out opioid prescriptions can be a profitable business, and some doctors are not immune to the allure. But, as doctors, they bear the most responsibility in public safety, and ramifications need to be swift and severe.
- Increased doctor education needs to address the epidemic. As doctors, we all learned how to treat pain. And we all were targeted by a patient looking for a prescription of opioids for illicit use at one time or another. We were not taught so much how to tell the difference or the consequences of letting out a prescription that is not intended for the use the patient requests. We need more education into this crisis.
- Better insurance coverage for non-medicinal therapies. Some of these therapies may not be evidence-based, but patients get much relief from their pain using them. Many people criticized pain as the “fifth vital sign” as being too subjective. But shouldn’t the treatment then be based on subjective findings as well?
- New non-addicting pain medications. Treating pain has never been harder. It is always a balancing act when a patient complains of pain. Stricter guidelines for prescribing opioids have been rolled out by many states, but, they neglect the lack of many alternatives. As it stands, doctors are under scrutiny for under-treating pain while at the same time being criticized for flaming the epidemic by writing too many prescriptions for scheduled pain medications. We need new tools to treat pain. That is the only way this equation can be balanced.
Time for Action
While the opioid crisis continues to flourish, the ones being lost are the patients. They are left fighting for treatment of their pain or for help with their addiction to pain medications. Making blanket statements that we need to end this crisis neglects these patients. Yes, we all need to become more responsible in our role in this epidemic, but we also need to help these patients. When politicians acknowledge the crisis without actually devoting any funds to helping those caught in the ugly grasp of this public health catastrophe, it does nothing to help these suffering human beings. Hollow words will not halt the raging fire that is devouring lives. It is time for action, by all parties.