The current opioid crisis has been brewing for nearly three decades. The reasons are numerous, unclear and wrought with the best of intentions. For example, in 2001, the Joint Commission rolled out its “Pain Management Standards”, which gave birth to the idea that pain was under-diagnosed and under-treated. In 1999, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, requiring a pain intensity rating (0 to 10) at all clinical encounters, as a result, pain became the “fifth vital sign.” Endorsed by the Institute of Medicine (IOM), this became standard practice in all primary care in the U.S. The result was surprising. Patients reported increased pain and compassionate doctors trained in symptom management, did exactly that—prescribed pain medication at record numbers. Studying the outcome of this practice among veterans, Mularski and colleagues (2017) reported that “routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management”. Yet, because of this change, more medications were prescribed by practitioners who lacked experience in pain management or addiction medicine.
Additionally, the publication of a short letter to the editor in a major medical journal declared that opioids, when given under good clinical supervision were both safe and effective. OxyContin was FDA approved by the dawn of the new millennium and touted as a safe, long acting opioid with few side effects and a low addiction potential. As a result, opioids were no longer reserved for treatment of acute nociceptive pain or terminal pain conditions, but were becoming increasingly used in treating many pain syndromes in spite of the lack of peer reviewed, high quality evidence regarding their safety and efficacy.
Because of the Joint Commission’s standard in regards to pain, providers are evaluated and given a score that affected their overall quality as a medical institution. Without a high rating from the Joint Commission, hospitals suffer tremendous consequences, particularly in their recruitment of physicians, new managed care contracts, and perceived quality by their community. As a result, if a patient’s self-rated pain score was higher than normal, pain relieving medication including opioids were prescribed, as a way of showing compliance with Joint Commission standards. More opioid use leads to tolerance, physical dependence, and in some cases, addiction. With thousands more opioid users, the percentage alone drove up the prevalence of opioid misuse, abuse and addiction. Soon the pill mills flourished leading to a misperception that most doctors were clueless and addicting their patients. To further complicate matters, a recent NIH funded study revealed that nearly one third of the U.S. population suffers from chronic pain, of which, less that 10% ever misuse or become addicted to their medications.
When the pill mills were finally shut down and the worst of the worst doctors were put away, the epidemic did not go away. In many ways, it became much worse as counterfeit pills appeared on the street, lacking indications of milligrams or dosage on the pills that made for the pharmaceutical versions “safer” to use. Quickly, opioid users switched to cheap Mexican heroin that was illicit and often cut with all sorts of other dangerous drugs, including homemade fentanyl—thus increasing the mortality rate dramatically. These deaths were not the chronic pain patients, they were mostly drug seeking addicts and dealers. So, the illicit use of opioids and consequent mortality today is primarily due to unregulated sources of opioids and not from unscrupulous or clueless physicians. Quite the opposite. Physicians are leaning toward under treatment of pain, for fear of reprisal. Yet, 100,000,000 legitimate chronic pain patients need answers.
The current opioid epidemic is the deadliest drug crisis in American history. Overdoses, fueled by opioids, are the leading cause of death for Americans under 50 years old—killing roughly 64,000 people last year (2017) more than gun violence or car accidents.
Reigning in the opioid crisis will require the collaborative engagement of health care providers, hospitals, the pharmaceutical industry, and policy makers—and perhaps most important, parents. At the same time, the chronic pain crisis is real and opioids offer the only way to improved self-efficacy and quality of life for most. New non- or less addictive therapeutics are desperately needed to replace opioid medication for those who need it.
Rummans TA, et al. How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis. Mayo Clin Proc. 2018;93(3):344-350