Approximately 10 percent of Americans aged 12 and older report recent illicit drug use, including misuse of prescription medications. While the types of addiction are many, misuse of prescription pain relievers and illegal opioids like heroin and fentanyl are by far the most deadly.
“He curses the spells which chain him down from motion; he would lay down his life if he might but get up and walk; but he is powerless as an infant, and cannot even attempt to rise.”
—Thomas De Quincy, Confessions of an English Opium-Eater (1821)
In every corner of the world, for thousands of years, people have been sipping, snorting, smoking, and topically applying the sap of Papaver somniferum, the opium poppy. In the 19th century, European chemists began isolating the pod’s analgesic compounds, paving the way for the mass production of synthetic opioids.
Over the past two decades, the use of opioids, both synthetic and poppy-based, has blossomed into a full-scale public health crisis. According to the Centers for Disease Control and Prevention (CDC), roughly 1.9 million Americans currently struggle with an opioid use disorder. In 2015, 33,000 Americans died from opioid overdoses. Opioids are now responsible for more deaths in the United States than guns or car accidents.
THE PATH TO AN EPIDEMIC
The most recent National Survey on Drug Use and Health revealed that approximately 10 percent of Americans aged 12 and older report recent illicit drug use, including misuse of prescription medications. Many of those surveyed are addicted to multiple substances. But while the types of addiction are many, misuse of prescription pain relievers and illegal opioids like heroin and fentanyl are by far the most deadly.
Attitudes toward the prescribing of opioids began to change in the late 1980s. As a series of recent investigative reports has revealed, that change stemmed in large part from an aggressive marketing campaign that Stamford, Connecticut–based Purdue Pharma orchestrated for its launch of OxyContin in 1986.
Purdue made several misleading claims about OxyContin, an extended-release formulation of oxycodone, lulling a generation of doctors into a false sense of security about its safety. OxyContin’s supposed competitive advantage over other formulations was its 12-hour schedule, which Purdue insisted would provide patients with “smooth and sustained pain control all day and all night.” Purdue also claimed that OxyContin’s controlled-release design made it safer than immediate-release formulations. Fewer than 1 percent of patients taking OxyContin, Purdue’s sales staff maintained, became addicted.
Physicians, health plans, and even some Purdue staff soon began to suspect that these claims were false. Many patients expecting 12-hour relief instead experienced intense withdrawal symptoms, craving their next doses after only six to eight hours. When physicians tried to help their patients by prescribing OxyContin on more frequent dosage schedules—three or four times per day—Purdue aggressively fought the practice, realizing health plans would stop paying a premium for the new drug. Purdue account managers persuaded physicians to increase dosages of OxyContin, and before long, physicians found themselves prescribing expensive 160mg OxyContin pills instead of more frequent immediate-release formulations. Some patients ended up on 320 or more milligrams per day—more than three times what experts now consider a safe daily dosage.
The consequences were predictable. Rates of addiction and accidental deaths skyrocketed. Patients continued to experience withdrawal, and a steady flow of prescribed opioids into the community led to patterns of diversion and recreational use. As for the oft-mentioned clinical study showing that the rate of addiction from OxyContin was around 1 percent—that never existed.
Perhaps the most pernicious effect of Purdue’s campaign was its success in persuading a generation of doctors to relax their caution about narcotic medications. Purdue’s marketing team pushed the theory of “opiophobia,” which held that concerns about prescribing opioid analgesics, particularly to patients with chronic pain, were exaggerated and unjustified. Purdue further argued that physicians had an ethical obligation to eliminate pain using the strongest tools at their disposal.
Despite the loss of more than 200,000 American lives to opioids since the release of OxyContin in the late 1990s, this legacy of beliefs and attitudes persists in the medical community to this day.
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Patient-satisfaction scores, based in Part on highly subjective Painscale results,
exacerbate the issue by giving doctors an incentive to try to eliminate Pain altogether.
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ONE COMMUNITY’S STRUGGLE WITH OPIOID ADDICTION
Dr. Jessica Bloom has been practicing family medicine in Bellingham, Washington, for more than a decade. Like many family-care physicians, she has been on the front lines of the opioid epidemic since launching her practice, Family Health Associates, with her husband in 2005.
Whatcom County began addressing opioid addiction during the early stages of the epidemic. “Ten years ago, we had a much more serious prescription-opiate issue than we do now,” says Dr. Bloom. “The community came together, creating a task force that identified a handful of significant over-prescribers.”
But though these pill-mill physicians no longer practice in Whatcom County, prescription opioid misuse persists.
Even the most well-intentioned physicians, Dr. Bloom observes, find it challenging to prescribe opioids safely, particularly for chronic-pain patients. “The public expects medication to make pain go away completely,” she says. “Reducing pain is not enough. That’s part of the problem.” Patient-satisfaction scores, based in part on highly subjective pain-scale results, exacerbate the issue by giving doctors an incentive to try to eliminate pain altogether.
Meanwhile, limitations on how physicians prescribe certain medications, though intended to ensure safety, can instead drive physicians to write large prescriptions that patients may not need. “If a patient runs out of a prescription on a Saturday or Sunday, when my clinic isn’t open, she has to wait until Monday before I can write another,” says Dr. Bloom. “Sometimes it’s just easier for a physician to write a big prescription and be done with it.”
Most of these outsized prescriptions go partially unused, orphaned to medicine cabinets where adolescents discover and use them for recreational ends. Many kids who misuse prescription opioids become opioid addicts and, unable to sustain their habits through prescriptions, turn to heroin. In 2016, the Whatcom County Medical Examiner reported 23 deaths related to drug use, 18 involving heroin and two involving prescription drugs.
The progression of the addict from prescription opioids to heroin represents a stark reversal from past decades, when heroin was the gateway to opioid abuse. Today most heroin users report that they tried prescription opioids first. One analysis of heroin users found that 75% were introduced to opioids through prescription drugs; of these, most turned to heroin because it was more accessible and less expensive.
Where do we start adjusting prescription practices to head off the epidemic? One answer is emergency rooms, where large prescriptions for OxyContin and Percocet are common and often lead to long-term opioid use. Another is surgeons, who frequently send patients home with large prescriptions to manage post-operative pain.
As Chair of Family Medicine at PeaceHealth St. Joseph Medical Center, Dr. Bloom facilitates regular conversations about post-operative prescribing practices. “We talk about the importance of limiting prescriptions to three days,” she says, “and emphasize that ongoing pain management naturally resides with primary-care physicians.”
Not that doctors need more to worry about—but most of Dr. Bloom’s primary-care colleagues agree that they are in a better position to help patients navigate postoperative pain safely. Regardless of which provider takes the driver’s seat, managing pain, whether acute or chronic, requires striking a delicate balance between comfort, convenience, and patient safety.
“Physicians must walk a fine line,” says Dr. Bloom. “I try to tell people that this isn’t to take their pain away, it’s to reduce it for now. You never want to harm patients by leaving them in pain, but you also don’t want to harm them by inadvertently driving them into the arms of addiction.”
A MEASURED RESPONSE
In 2016, in an unprecedented step, the CDC issued an extensive non-binding guideline on opioid use for chronic pain. Among other things, the CDC guideline stipulates caps on daily dosages for chronic pain, limits on the length of prescriptions for acute pain, and preferential use of immediate-release formulations.
At the state level, departments of health, medical associations, and other groups have begun to ratify the guideline, amending as needed to reflect regional conditions. Almost everyone agrees that a concerted national response has been long overdue; even Purdue has come around to this point of view.
At the same time, experts warn that measures designed to combat the crisis could have unintended effects. People like Jeb Shepard, Associate Director of Policy and Regulatory Affairs for the Washington State Medical Association, argue that, while rampant opioid addiction warrants aggressive action, we need to remain attentive to the needs of patients, including those who have successfully managed their pain for years with opioid medications
“We’re worried about the pendulum swinging from over-treatment to undertreatment,” Shepard says. “If the state decided to put in place blunt pill limits, they’d be very successful in reducing the amount of opioids prescribed. They’d also prevent some patients from accessing clinically appropriate treatments that enhance functioning and quality of life.”
The image of a swinging pendulum comes up often in conversations with public health experts. “People in the pain community fear doctors will stop treating patients who are legitimately in pain,” says Joy Conklin, Vice President of Practice Advocacy for the Oregon Medical Association.
Previous efforts to curb over-prescribing have had a freezing effect, just as experts had warned. So instead of enforcing hardand-fast rules that chill the treatment of chronic pain, states have begun pursuing a multi-pronged approach that simultaneously addresses various facets of the problem. Introducing clinical guidelines and reeducating doctors and patients on the appropriate use of prescription opioids are both part of the equation. Another: putting information in the hands of doctors so they can mitigate risk at the point of care.
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“Research shows that 90% of patients who have a near-fatal overdose and live
will fill a prescription for the same drug that almost killed them.”
— Ian Corbridge, Policy Director for Patient Safety, Washington State Hospital Association
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The point is not to penalize doctors for breaking rules, but to give them the information they need to ensure patient safety. To that end, most states have rolled out prescription drug monitoring programs, or PDMPs, that help doctors evaluate their prescribing practices while identifying patients at high risk of abusing opioid medications.
“Research shows that 90% of patients who have a near-fatal overdose and live will fill a prescription for the same drug that almost killed them,” says Ian Corbridge, Policy Director for Patient Safety at the Washington State Hospital Association. “That’s largely because providers aren’t aware these events happened.”
Ongoing performance improvement and education are equally important. In 2018, prescribers in Washington will begin to receive reports indicating how their prescribing practices compare to those of their peers. “Our goal is to identify and provide feedback and education around prescribing guidelines to outliers so they can update their clinical practice,” says Shepard.
ACCESS TO TREATMENT
Health experts are also acutely aware of the need to improve the accessibility of effective addiction treatment. Medication-assisted treatment (MAT), using such medicines as buprenorphine, methadone, and extended-release naltrexone in combination with counseling and behavioral therapy, has been shown to reduce opioid use, opioid-related overdose deaths, and infectious-disease transmission.
The availability of MAT programs varies considerably. “Oregon is among the states with the least access to addiction treatment,” says Conklin. “If you’re outside urban areas, treatment resources are even more scarce.” And it’s not just Oregon. Rural areas in most states, often the hardest-hit by the opioid crisis, struggle with inadequate access to MAT resources. The problem of accessibility extends to non-opioid therapies for chronic pain as well. Safer alternatives for chronicpain management, like physical therapy, acupuncture, and cognitive-behavioral therapy, are often unavailable or not covered by patients’ insurance plans. “It’s unfair to ask providers to use other strategies for chronic-pain management if the health system doesn’t enable that,” says Corbridge.
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“We need doctors who acknowledge their fears, but manage to
roll up their sleeves and learn how to care for these patients.”
— Dr. Michael Schiesser, Internal Medicine, Addiction Specialist, EverGreen Healthcare
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THE WAY FORWARD
Dr. Michael Schiesser, an internist who specializes in addiction, believes primary-care physicians should be prepared to engage patients who present with highrisk medication regimens. When a pain clinic closes, too often the wider medical community lacks the skills necessary to manage the patients orphaned by that closure, many of whom could benefit by transitioning to more conservative pain-management approaches. Fear of regulatory action often discourages physicians from obtaining the skills they need to treat these patients.
“No doctor wants to be scrutinized for their prescribing practices, whether it’s a civil or regulatory claim, charge, or investigation,” says Dr. Schiesser. Still, he says, managing pain medications is within the scope of primary care. “We need doctors who acknowledge their fears, but manage to roll up their sleeves and learn how to care for these patients.”
Many patients were first prescribed large doses of opioids years ago, when the medical community widely endorsed their long-term use, and most have never developed addictions. Ignoring these patients or aggressively tapering their opioid regimens introduces significant risks.
“The most recent sea change in opinion about the role of opioids in treating chronic pain has the potential to cause a lot of patient harm,” says Dr. Schiesser. “The adverse effects a patient may experience while tapering from a high opioid dose to little or no opioids are not trivial.”
When working with new patients who have experienced prolonged opioid exposure, doctors should carefully consider the benefits and risks of lowering dosages to comply with prescribing guidelines. Ultimately the benefits may not outweigh the downside for the patient, even if it makes the doctor feel protected from scrutiny.
Doctors must also be able to distinguish between addiction and dependence. Not all patients who have received long-term opioid treatment for chronic pain are addicts. “Most patients with prolonged exposure to pain medications develop central nervous system adaptations that cause withdrawal symptoms when they don’t take those medications,” says Dr. Schiesser. Those withdrawal symptoms establish dependence, but the behavioral changes that accompany addiction are often absent.
Physicians who regularly use prescription drug monitoring databases, engage patients in weighing the risks, and thoroughly document clinical decisions in patients’ medical records have nothing to fear. Each patient presents a unique set of circumstances, and in some cases continuing the use of opioid medications may be reasonable.
“Physicians on the front lines need the acquired skills and training to engage opioid patients and facilitate good decisionmaking,” says Dr. Schiesser. “We want to help these patients achieve the healthiest long-term outcome possible.”
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Learn more about the latest recommendations on opioid prescribing.
Download these guidelines from the Centers for Disease Control and Prevention: https://bit.ly/2GATD0o
For additional regional information, visit your state’s Department of Health.