How did the opioid epidemic get so bad?
Doctors are partly to blame, but so is a culture that demands zero pain after medical treatment.
In a recent survey, a third of Americans blamed doctors for our country’s relentless opioid epidemic. I get it. Doctors (myself included) aren’t in a position to defend our prescribing practices — not with Massachusetts losing an estimated 1,173 people to overdoses in 2014, and 1,104 through just the first nine months of last year. While Massachusetts is responding to these deaths with a serious multifaceted approach, including last month’s breakthrough legislation limiting opioid prescriptions, our medical community needs to work hard to bring our culture up to speed with Governor Charlie Baker’s new law.
Overprescribing opioids is something we’ve gotten used to doing. To be fair, the origins of the epidemic aren’t due to the behavior of bad-apple doctors, who are rare. The majority are well-intentioned prescribers caught in a web of entangling interests spun over the past two decades. When the powerful narcotic OxyContin was first made available in the mid-90s, all that doctors heard from sweeping educational campaigns (many driven by pharmaceutical industry marketing) was that they were undertreating pain.
Several reports around the time suggested that opioids could be useful without causing addiction. Then, following new pain-management quality standards implemented in 2001, documenting pain levels (how much does it hurt from 1 to 10?) became a top priority. And in an era of patient satisfaction surveys, hospitals interested in optimizing reimbursement encouraged prescribers to ensure they treated inpatients’ pain appropriately. Meanwhile, the US Food and Drug Administration — asleep at the regulatory wheel — failed to leverage existing law to narrow prescriptions for specific indications, leading to their broad use.
As a result, opioid prescriptions have soared since the 1990s, and so have deaths from the drugs. Unfortunately, most patients killed by opioid addiction initially obtained these medicines either from a doctor’s prescription or from the medicine cabinets of friends or family.
Scrupulous doctors have unknowingly built and fueled the engine running the opioid epidemic: the tremendous stockpiles of drugs in American homes. Since physicians remain at the front lines of this transaction, we also have the capacity to help turn things around. But we’ll need a sea change in our medical culture.
Even today, opioids remain our go-to god for pain relief — and pain is everywhere. It’s the symptom I have been most called on to treat when I speak to inpatients on my rounds. Hardly an hour goes by without my turning to morphine or its stronger cousins to treat everything from kidney stones, gallstone attacks, and even such benign ailments as an ankle sprain or a painful rash. I’ve discharged these patients with dozens of pain pills to take home with them. I did this because untreated pain is unbearable to watch and opioids visibly relieve acute suffering. It’s what most of my teachers and colleagues did, too. It’s what the culture has asked of us.
Unfortunately, too much of our current practice of overprescription rests on the traditions of the past few problematic decades. We’ve been using opioids on autopilot. A growing body of evidence now suggests that even transient bursts of opioids on first exposure can contribute to the development of chronic addiction. A third of patients who receive opioids after spine surgery continue using them a year out, according to one study. And long-term opioid use, which comes with innumerable risks and side effects, arguably has almost zero benefit in treating chronic pain.
I’m ashamed that it took seeing deaths on the news every day in Massachusetts to force me to reconsider how I practice. Now, instead of jumping to opioids, I first try ibuprofen, or its relatives Toradol and intravenous Tylenol. Obviously I’m not alone.
In trials across the country, hospitals are trying new strategies to reduce opioid prescriptions. Peter Smulowitz is the president for the Massachusetts College of Emergency Physicians and associate chief of the emergency department at Beth Israel Deaconess in Plymouth, a town in the hot zone of opioid-related deaths. He’s running a study comparing prescription patterns of providers in the emergency department — if he sees doctors prescribing more opioids than average, Smulowitz’s team reaches out to them. “Providers are often surprised at their behavior, since it’s become their norm,” he says.
Over the first few months of Smulowitz’s study, total prescriptions of opioids in his emergency room dropped almost 25 percent. His ongoing study — among others — is a good start for how doctors can fight the epidemic. Medical and dental schools around the state, such as those at Boston University and Tufts, are now making the prevention and treatment of opioid addiction integral to their curriculums. Baker’s new legislation, alongside new guidelines from the Centers for Disease Control and Prevention, gives doctors a framework to reshape how we prescribe.
Still, we have more work to do. The state’s prescription drug monitoring program, a system doctors can use to track patients at risk for opioid addiction, isn’t used very often by physicians, many of whom find its interface cumbersome, according to a recent study. And while we shouldn’t fear opioids, since they remain appropriate for specific situations, they are too easy to administer broadly in a culture where pain remains unacceptable.
We need to look for new solutions to pain. Massage, meditation, behavioral therapy, placebo studies, and multidisciplinary pain teams need to become a part of routine medical care. Patients can help — by asking their physicians if these options are available. Here’s the biggest challenge: As a society, we need to start accepting that a measure of pain is a normal part of the course of illness.
It took doctors 20 years to help create this epidemic — but if we wake up to changing how we treat pain, we can more quickly contain its toll.
ASSIGNING RESPONSIBILITY FOR OPIOID ABUSE
> 37% of survey respondents say drug users are “mainly responsible”
> 34% say doctors
> 10% say pharmaceutical companies