Over the past two decades opioid use in the US skyrocketed creating widespread misuse, addiction, and overdose, leading us to a modern day opioid crisis. At its peak overdose deaths in the US exceed that of car crashes and the majority of these deaths are due to opioids. 2018 data showed that in the US 128 people died daily after opioid overdose. Let's go back in time and explore some of the events that got us here.
In 1980 a Letter to the Editor written by Jane Porter and Hershel Jick was published in the well respected New England Journal of Medicine entitled “Addiction rare in patient treated with narcotics.” It was loose science at best with a misleading conclusion that opioids are essentially non-addictive. Drug representatives began using this letter as proof that it was safe to now prescribe opioids for a variety of circumstances.
Another article published in Pain in 1986 by PK Portenoy concluded that use of long-term opiates was safe for chronic, non-cancer pain. The study had a whopping total of 38 patients! 38 patients is nowhere near the number needed to make such claims, nonetheless this paper was extensively cited as proof that opioids were safe.
As the patent for MS Contin ran out, OxyContin arrived in 1996 and was vigorously promoted as less likely to be addictive than other opioids because of its “extended release” variant, later proven to be quite the opposite. Drug reps went nuts promoting OxyContin aggressively with advertising, sales benchmark bonuses, and free coupons. The infamous Prudue Pharma spent $200 million dollars promoting Oxycontin in 2001 alone, stating risk of addiction as being <1%. The Porter and Jick letter as well as the Portenoy study were in heavy rotation during this time.
Enter pain, the 5th vital sign. Vitals signs (blood pressure, pulse, respiratory rate, temperature) are measured objectively. Pain is subjective as reported by the patient and cannot be measured, thus it really has no place on the Mount Rushmore of vital signs. JHACO (Joint Commission on the Accreditation of Healthcare Organizations) began promoting pain as a 5th vital sign in the 90’s with the belief that health care professionals were not adequately treating pain. This continued to gain traction and is universally used throughout the US today. So based on the subjective account of pain levels usually on a 1-10 scale there was a push to get those high, subjectively reported, numbers down, most often with opioids. Opioid makers gave millions of dollars promoting this campaign and within the first decade of its introduction opioid overdose deaths increased 4 fold, opioid prescriptions increased 7 fold.
The US, by far, has the largest amount of opioids in the world despite having a relatively small percentage of the worlds population. As our opioid prescription practices increased along with the subsequent rise in overdose deaths the “Pill Mills” proliferated rapidly. Glorified pain clinics began popping up throughout the US, willingly writing large doses of opioids for long periods of time for any “justifiable” pain complaint. These clinics usually did not accept insurance, preferred patients pay cash, and were highly profitable. Over time these clinics were shut down and other legit clinics were affected by new regulations. We reached our peak opioid prescription total in 2011, after regulations began this number has steadily decreased.
So now we have a large population addicted to opioids and the access door was promptly shut. With no access people were forced to turn to the streets due to lack of prescription opioids. The street value of prescription opioids was very high and heroin was cheap so we start to see a rise in heroin overdose deaths. It was reported in 2011 that 4 out of 5 heroin users stared with prescription opioids.
Over the last 5 years fentanyl has been increasingly added to or replacing heroin all together, why, simple economics. They costs the same to make but the street value of fentanyl is roughly 6x higher. So dealers began adding small amounts of fentanyl to diluted heroin to make it hit harder up front. Fentanyl has 100x the potency of Morphine so even small additions of this drug can be enough to push a user over the edge. Fentanyl can also be easily put in pill form and labeled as Norco, Vicodin, or Lortab for those that shy away from intravenous administration.
As we continue to climb out of this crisis approximately 30,000 Americans still die yearly due to opiates. Fentanyl will continue to rise and prescription regulation will only partially address the problem. People suffering from addiction to opioids will continue to get their opioids somewhere and pills containing high potency opioids will cause more overdoses. Treatment options will continue to be limited as methadone/Suboxone clinics as well as rehab facilities continue to struggle. Big pharmaceutical companies such as Purdue Pharma will be slapped on the wrist but others will continue to find loopholes and creative strategies to promote and sell their drugs. As awareness grows about the true dangers of opioids and misinformation is quickly disproven, people will begin to discover better ways to get relief from pain.
Opioids do have a place in medicine for acute pain and some chronic pain conditions but for most things there are very effective, nonaddictive alternatives with no side effect profiles. Plant-based medicine, physical therapy, yoga, acupuncture, meditation, and a myriad of other modalities are readily available and have proven to be highly effective in the treatment of pain.
In future posts we will break down pain and do a deep dive into a myriad of non-opioid treatment modalities. We encourage your feedback and want to hear about your experiences with pain and what methods you use to mitigate that pain.
Laning Andrews, M.D.