The Opioid Epidemic: A Complex Monster

As an addiction treatment professional, people often ask me two questions: First, how do I think the current opioid epidemic is different from previous periods of increased drug abuse? And, more important, when is it going to get better? My response to both is always cautious, and usually delivered after a long pause: “It’s completely different; it’s much worse,” and “I don’t know.”

It always troubles me to deliver such a somber declaration, but the reality and statistics of the situation support my viewpoint. The current prescription drug abuse and opioid epidemic is responsible for considerably more deaths than previous epidemics, with mortality rates currently four to five times higher than rates during the “black tar” heroin epidemic in the mid-1970s, and more than three times what they were during the peak years of the crack cocaine epidemic of the 1990s.

I have yet to see significant improvement in any of the metrics attached to this plague, be it death rates or any other important statistic. It is not that there is an absence of people working hard to turn the tide; I can tell you firsthand that a lot of efforts are in progress by a lot of intelligent, dedicated individuals. The answer to the difficulty in combating this epidemic lies in the complexity of the monster itself.

What Caused the Opioid Epidemic?

There are three basic components that have gotten us into this quagmire. Each is substantial and complicated it its own right. The medical, social and economic drivers of this epidemic are as fascinating as they are terrifying. I am going to briefly summarize each one, but if you want a more detailed storyline, check out Dreamland: The True Tale of America’s Opiate Epidemic, by Sam Quinones. Each of these issues — medical, social and economic — could be its own blog or book chapter, but by nature this blog post is a practice in brevity.

First, the medical establishment has drastically changed its view of pain and the treatment of pain with powerful medications. For decades, the medical profession considered only the suffering of cancer and post-operative patients severe enough to be dosed with heavy-duty opioids. But in the 1980s, doctors began arguing in medical journals that all forms of chronic pain should be treated more aggressively. Congress declared the first decade of the new century to be the “decade of pain control and research.” Makers of narcotic painkillers, like Purdue Pharma, downplayed the risk of addiction and devised slick promotional campaigns for the drugs. The pain medication OxyContin, an oxycodone opioid, was one of the most dramatic examples of this, as demonstrated by the fact that in 2002, doctors were prescribing 10 times more OxyContin than they had in 1997.

Seeing Pain Differently

The Opioid Epidemic: A Complex MonsterThere has also been a fundamental change in the way pain is perceived in our society, by both doctors and patients. Pain is no longer understood as something that had to be endured; it could be easily and quickly treated with pills. “By the 1990s, it became unacceptable for patients to be in pain,” says Carl Sullivan, MD, an addiction specialist.

In addition there was the “Pain is the 5th vital sign” campaign seen in new pain management standards put forth by many healthcare entities. These positions were based on flawed science and blatant misinformation and accompanied by dangerous assumptions that opioids are highly effective and safe and devoid of adverse events when prescribed by physicians.

Furthermore, many hospital doctors’ pay and promotions are now tied to patient satisfaction scores. These can be sunk by bitter patients who feel their providers don’t dispense painkillers readily enough. The result is that unreasonable pressure is placed on conscientious physicians who can have a hard time differentiating between a desperate patient who is genuinely suffering and a manipulative one who’s seeking out drugs to fuel their dependence or addiction.

Lastly, there is the economics of it all. Shortly after Purdue Pharma introduced OxyContin in 1996, the company spent large amounts of money directly marketing to patients, physicians and pharmacists. Purdue bolstered its sales force and compiled databases of doctors who were likely to prescribe the drug. Its sales representatives received millions in bonuses for persuading doctors to write scripts. Just as the medical establishment and government entities were recognizing the inundation of both appropriate and inappropriate opioids to the public, the drug cartels in Mexico recognized the growing opiate abuse issue in the U.S. and took advantage of this by mowing down fields of marijuana in 2000 and planting poppy extensively.

As more “pill mills” were shut down and the supply of prescription opioids declined, the cartels and dealers made significant changes in their own marketing and distribution of heroin. They targeted suburban populations where prescription opiates were already a problem, used extensive untraceable cell phone networks and delivery services and employed chemists to make heroin both cheaper and more addictive (e.g., adding fentanyl).

But there is hope. Through the utilization of comprehensive, evidence-based medical care and in conjunction with psychosocial support, people are getting treatment that can save their lives and rebuild our communities. Check out my next blog for an uplifting discussion about combating this scourge on our society. Expert Blogger

About the author

Shawn A. Ryan, MD, MBA, is an assistant professor, department of emergency medicine, at the University of Cincinnati, and chair of quality and patient safety at Jewish Hospital-Mercy Health Partners. Dr. Ryan graduated from the University of Kentucky College of Medicine and obtained his MBA at the University of Cincinnati College of Business while simultaneously completing his emergency medicine residency there. His dual degrees provided background for Dr. Ryan to lead the quality department at Jewish Hospital as well as many other initiatives for Mercy Health, including the prescription drug abuse epidemic and post-acute care collaboration. Dr. Ryan is currently practicing addiction medicine at Brightview Treatment Center in Cincinnati, is published on this issue and has spoken nationally at conferences in regards to opiate abuse.  He also serves on many regional, state and national committees addressing this complicated subject.