As opioids have become more readily available, we’ve seen a correspondingly steady rise in opioid abuse and overdose deaths.

The dark side of opioids: How these addictive drugs have led to abuse and death

As opioids have become more readily available, we’ve seen a correspondingly steady rise in opioid abuse and overdose deaths. What next?
August 16, 2016

By now, you’ve probably heard about the opioid crisis in America: Opioid abuse is a major problem that kills an American every 19 minutes. For every death, there are 10 people admitted to the hospital for substance abuse treatment, and 1000 people visit emergency rooms every day after misusing prescription opioids. One study found that 24 percent of high school students have abused prescription medications, and prescription drugs are now responsible for more overdose deaths than all “street” drugs (such as cocaine, heroin and methamphetamine) combined.

But how did we get from drugs that were used to relieve unimaginable pain to those same drugs being such a major problem? And where do we go from here?

“The opioid epidemic may be doctor-driven,” said Christopher J. Burnett, MD, an assistant professor of anesthesiology at the Texas A&M College of Medicine and anesthesiologist at Baylor Scott & White Health. “Doctors want to relieve their patients’ pain, and pain is one of the most common reasons people visit a physician’s office. Regardless of the etiology, pain is a very real experience for us all and can span a broad spectrum in both its quality and intensity.”

However, it has only been in the last 30 years that the default method of treating pain was to prescribe an opioid.

Until the mid-1980s, opioids were reserved for the treatment of cancer pain and for palliative, end-of-life care. (They still have this largely uncontroversial purpose: Recent Centers for Disease Control and Prevention (CDC) guidelines suggesting limits for opioid prescribing specifically don’t apply to these situations.) However,  beginning in the mid-1980s, a small group of pain-care specialists led by Russell Portenoy advocated for long-term use of opioids for patients with chronic, non-malignant pain. At the same time, major pharmaceutical companies increased the number of available products and aggressively marketed opioids, including the new OxyContin.

READ MORE: Curbing opioid abuse

This led to a boom in opioid prescribing in the 1990s, culminating in a 1999 campaign to see “pain as fifth vital sign.” Regulatory organizations, including the Texas Medical Board, may, even now, punish physicians for not adequately treating patients’ pain.

Opioids are now the most frequently prescribed drug class in the United States. In 2012 alone, there were 259 million prescriptions written for painkillers in our nation, up from 76 million in 1991. That is enough pain pills for every man, woman and child to receive one pill every four hours around the clock for three consecutive weeks, and twice as many painkiller prescriptions per person than in Canada.

Today, physicians are torn between two competing forces: the pressure to adequately treat pain, while at the same time being told to be careful with one of the best weapons against pain.

One of the provisions of the Affordable Care Act includes 1.5 billion dollars of funding in Medicare payments to hospitals based on criteria that include patient satisfaction scores. Many of the questions being asked of patients relate specifically to pain control during hospitalization or during a clinical encounter. (Did the hospital staff do everything to help you with your pain?; Was your pain controlled?) “Increased demand for optimal pain control, coupled with an abundance of visits to physicians for pain, has resulted in a drastic shift in prescribing habits among physicians,” said Burnett, who is also the director of the Temple Pain Clinic. “More than 48 percent of doctors overprescribed narcotics in 2014 because of patient satisfaction survey pressure.”

This need to earn high patient satisfaction scores conflicts with the CDC guidelines that suggest serious curtailing of long-term use of opioids to control pain that isn’t the result of cancer. Physicians know that addiction to prescription opioids can often lead to heroin use and even death, but at the same time, it can be difficult to resist the urge to write a prescription to stop someone’s pain. “What we do poorly as providers is communicate about problems,” Burnett said. “Physicians must follow responsible prescribing practices and communicate with pharmacists and with each other.”

Such communication might help identify professional drug seekers—street dealers that sell prescription medications. “Drug seekers are not the addicts,” Burnett said. “They are not desperate. They are patient, deliberate and methodical and are looking for a reputable physician and pharmacy that can provide them with a sustainable supply of drugs.” It can be difficult for providers to know the difference between a drug seeker and a patient in genuine pain. Often, the drug seeker will not ask for opioids immediately but instead seek to build a trusting relationship with a physician.

One tactic employed by drug seekers is to essentially commit insurance fraud as well as illegal prescription distribution. They locate people desperate for money who have health insurance and pay them for the use of their ID cards and use those prescription cards, along with a fake driver’s license, to obtain prescription opioids.

“Potential profit for prescription drug sellers is high, and the risk for obtaining them is low,” Burnett said. “Physicians, especially those of us who specialize in treating pain, need to be vigilant for this kind of drug-seeking behavior, while still providing our patients the best possible care. It’s a constant balancing act between using these powerful drugs to alleviate pain and trying to prevent devastating drug addiction that has affected so many families.”

— Christina Sumners

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