The Evolving Opioid Crisis: Prescription Opioids, To Heroin, To Fentanyl
Author: Mark Gold, MD
Brief History of The Evolving Opioid Crisis
Prescriptions for chronic non-cancer pain rose by 300% and became a major source of available opioids over the past two decades. While many physicians who write prescriptions for high blood pressure, cholesterol, type 2 diabetes know that many patients do not take their medication, few patients ever comply with physician guidance or prescriptions in the treatment of medical or psychiatric disease. When it comes to pain and opioids, patients not only have taken the medication as directed but also took more and asked for refills. The shift in pain prescription practice norms was fueled by an acceptance of low-quality evidence that opioids are a relatively benign remedy for managing chronic pain. The risk benefit analysis failed. Since 1999, overdose deaths due to opioid medication rose consistently and outpaced annual heroin deaths. Heroin overdose deaths remained relatively low from 1999 until 2010, where a three-fold increase occurred and continued until 2015. These preventable deaths persisted during this time, but surveys revealed a disproportionate rise in deaths attributable to fentanyl/analogs (72.2%) and heroin (20.6%) compared with prescription opioids at only 2.6%.
Cost and convenience incentivized away from pills toward heroin/fentanyl, soon after implementation of policies to crack down on prescription opioids, thus the dramatic influx of high-potency, low-priced heroin/fentanyl analogs. The over-manufacturing and sale of opioids in the US, and late response by the national drug abuse experts and medical community forced federal and state governments to generate policies to limit access to prescription opioids, augment treatment services and prevent overdose deaths. As a result, persons with legitimate chronic pain are being dismissed from practices who are afraid of government or under treated for their pain. Yet the evidence is clear, most pain patients don’t abuse their medication and do not become addicts.
Why Does This Matter?
Regrettably, both national and medical policies consigned lower priority status to universal prevention, screening, and intervention for all substances and for mental health status, as polypharmacy and psychiatric comorbidity are common. The assumption is that taking opioids is a risk and the risks have been minimized and the benefits exaggerated. An integrated medical and behavioral treatment system, under the supervision of a physician and substance abuse specialist, would foster comprehensive services, provide expedient access to prescription medicines, and bring care into alignment with current medical standards of care. The current system of medication only substitution and opioid overdose reversal is inadequate.