The Opioid Epidemic - How did this happen?

History Repeats Itself

It is said that if you don’t know your history, you are doomed to repeat it.  Our current opioid epidemic is history repeating itself. We have had two prior opioid epidemics in US history, during the late 1800’s, fueled by overprescribing and overuse of opiates and during the late 1960’s enabled by the easy access to opium during the Vietnam war.  Unfortunately, today’s burgeoning epidemic is threatening to become the deadliest episode in the country’s abusive relationship with opioids. The scale and breadth of the present wave of opioid abuse and premature overdose deaths is unprecedented.

The saga of this epidemic includes a perfect storm of bad science, big pharma profit motives, and good intentions.  First the bad science. In a 1986 study published in the journal “Pain”, Dr. Russell Portenoy reported that only two of 38 patients treated with narcotics for pain became addicted (1).  This implied that in the setting of chronic pain that opioids are not addictive.  Dr. Portenoy, who was being compensated by pharmaceutical companies stated that “there is a growing literature showing that these drugs can be used for a long time, with few side effects and that addiction and abuse are not a problem.”  Motivated by these findings, doctors who once thought long-term use of narcotic painkillers was unsafe began to prescribe them in greater numbers. Unfortunately, the study was flawed and not representative. There was a false conclusion that somehow pain reduced the risk of physical dependence and addiction.  The reality is that pain, physical or mental, only deepens the hook that creates and sustains opioid addiction.

The second component then took effect when the pharmaceutical companies realized the profit potential of increasing the use of the opioid wonder drugs for the enormous pool of patients in pain.  With 11% of the US population having some issue with chronic pain, there was a large and profitable market for opioids. This new literature gave them license to cast a blind eye to the well know addiction potential.  The pharmaceutical industry promoted greater use of the narcotic medications it sold. They spent millions on marketing and sales and funded American Academy of Pain Management and American Pain Society events. Pain clinics expanded, some funded by grants by companies that produced the narcotic painkillers they dispensed.  In 1996, Purdue Pharma created Oxycontin and then unleashed one of the most sadly effective marketing campaigns in history. Oxycontin's sole active ingredient is oxycodone, a chemical cousin of heroin that is twice as powerful as morphine. The door had been opened to make the case that concerns about opioid addiction were exaggerated in the setting of pain.  The Purdue Pharma marketing campaign blew the hinges off the door. The company funded research and paid doctors to make the case that opioids were safe and the most effective option for pain management. It worked.

The third component, good intentions, kicked in at the end of the 1990's.  Medical societies and accreditation agencies began to consider pain control as an essential element of a quality practice.  The American Pain Society termed pain as the "fifth vital sign" which should be routinely measured and treated. However, unlike blood pressure, pulse, temperature, and respirations, pain could not be objectively measured.  If someone said their pain was at a level of 10 of 10, then there was an obligation to treat. Guidelines recommended the use of opioids as standard pain treatment practice. With the increasing peer and industry pressure, physicians expressed concern that by withholding opioid drugs, that they could be undertreating pain as you could undertreat high blood pressure.  Quality metrics that included measures of pain management increased the pressure to be aggressive with pain treatment. During this time there was also increasing time pressures with the need to treat more patients to achieve the same reimbursement. Chronic pain is a difficult and time-consuming condition to treat effectively. Opioids were an easy panacea and they saved time.  The prescribing of opioids exploded. So did deaths. The chart below shows the direct correlation between opioid sales and opioid deaths. Never before has the treatment of a non-fatal condition lead to so many deaths. This is in addition to the problem of creating a massive pool of persons struggling with addiction and it’s attendant ravaging ripple effects tearing through families and communities.

Where are we today?

The explosion in addiction and premature mortality that overprescribing ignited has rocked the fabric of our society.  The increase in drug overdoses, driven by the increase in opioid overdoses that began in 1999, has continued to climb. In 2016, over 64,000 people died of drug overdose, a new record.  And we don’t know if this is the peak. The impact of the premature deaths is of such significance that the average life expectancy in the United States has decreased. This is in addition to the socioeconomic ripple effects of addiction.  The reason this epidemic is so impactful is simply the numbers. Because so many people across all walks of society have chronic pain issues, the pain to opioid use to addiction pathway drives a dramatically higher number of people than would ever occur for addicts that begin with street drugs.  But once addicted, street drugs become a cheaper and more potent alternative. This is why you can’t just “cut the pills off” because you still have people in pain with dependence or addiction that need to be effectively treated. If they turn to street drugs and IV drug use, the problem for themselves, their families and society is compounded.  The combined economic impact of the opioid epidemic (health care, labor, and criminal justice costs) was estimated at $92 billion in 2016 (an increase of 67% over a decade ago).  We are seeing the complications of Intravenous Drug Use (IVDU) multiply. From 2002 - 2012, dramatic increases occurred in IVDU related conditions including endocarditis (1.5-fold), osteomyelitis (2.2-fold), septic arthritis (2.7 fold), and epidural abscess (2.6-fold).  Opioid use also has contributed to an estimated tripling of hepatitis C infections between 2010 and 2015. The ripple effect even extends to causing the HIV outbreaks.  Women are particularly at risk.  They are more likely to have chronic pain, be prescribed prescription pain relievers,  be given higher doses, and use them for longer time periods than men. Women may become dependent on prescription pain relievers more quickly than men and they are dying of drug overdoses at a 4x the rate of men.  This dynamic is having an impact on families. In a Florida study, a one-standard-deviation increase in the statewide opioid prescription rate was associated with over 2,000 additional Florida children being removed due to parental neglect(2). The resulting fiscal cost is roughly $40 million, which does not include the psychological and physical effects and health care costs for affected children.

So this epidemic is unlike any other we have seen due to the scope, complexity, and economics. There is no silver bullet, however, we can learn from the past. We have quelled other epidemics, including opioid epidemics, through awareness, education, concerted efforts across society and appropriate funding and resources.  Those efforts are occurring and let’s hope that, in 2017, we will finally see the drug overdose death rate decrease and begin to turn the tide on this devastating epidemic.

References

1. Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 1986;25(2):171–86.

2. Quast T, Storch EA, Yampolskaya S. Opioid Prescription Rates And Child Removals: Evidence From Florida. Health Aff 2018;37(1):134–9.