The triangle of blame for the opioid epidemic

Prescription opioid abuse is one of the United States’ greatest public health challenges. Approximately 97.5 million Americans consume opioids annually, and around 90 people die every day from opioid overuse. The last time in recent history a health care crisis garnered this much public attention was following the release of the 1964 “Surgeon General’s Report on Smoking and Health” correlating smoking to heart disease and cancer. Today, we hear stories like a coroner reporting — for the second time this year — that he has run out of storage space for bodies due to rising opioid overdose deaths. Such stories are shocking to American families and health care professionals. As students interested in medicine and health care issues, we want to delve into the factors that have influenced the opioid crisis and understand the trajectory of this epidemic.

Opioids include a family of drugs that mimic our natural neurotransmitters and block pain perception in our central nervous system. Physicians commonly prescribe these drugs to patients experiencing postoperative pain, acute or chronic pain and cancer-related pain. But over the last decade, the clinical efficacy of these drugs have been challenged, and attitudes towards opioid therapy have shifted dramatically.

Prolonged opioid administration has led to patients building physical dependency. When consumers chose to abruptly discontinue opioid usage, they experienced severe withdrawal syndrome, characterized by diarrhea, nausea, vomiting, hypertension, and seizures. Ironically, some studies have demonstrated that opioid use can also increase pain sensitivity, a condition called opioid-induced hyperalgesia, ultimately leading to patients seeking even higher dosages or changing opioids. A CNBC report last year showed us that America consumes
80 percent of the global opioid supply and that there has been a 2.8 fold increase in number of opioid-associated death between 2002 and 2015. This accounts for a hefty medical expense of 72.5 billion dollars associated with opioid consumption. The aforementioned data makes us question the stringency of opioid prescriptions and necessitates further analyses of what we believe are the three most important players revolving the opioid crisis: physicians, pharmaceutical companies, and insurance companies.

The huge variability in pain perception among the general population makes it understandably difficult to judge when opioid prescriptions are unnecessary. As aspiring physicians ourselves, we value patient-centered care, one where the patient’s satisfaction is highly prioritized. However, we believe that physicians can, perhaps inadvertently, over-prescribe opioids. Although most of the cases warrant legitimate use of opioids, physicians could turn to non-medicative mediums of pain remediation such as physical therapy. It is possible that a different, more detailed pain-rating system could allow physicians to assess the magnitude of pain and reserve opioids for only the most severe cases.

While the addictive potentials of opioids are clear, there is still the question of how we arrived at this crisis. Some argue that it began in 1999, when the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, which has now made pain as important as the other four vital signs (heart rate, blood pressure, respiratory rate, temperature). Thus, medical physicians are now assessing pain in their patients and aggressively treating it for greater patient satisfaction. The most common argument against classifying pain as the fifth vital sign has been that self-reported pain is inherently subjective and can be modulated by several factors. The complexity now lies in the fact that clinicians must respect a patient’s self-reporting of pain.

Nonetheless, we believe that the crisis began further upstream with the pharmaceutical companies who have the ear of the health providers. Certain opioid manufacturers, such as Purdue Pharma, opportunistically capitalized on the issue of pain relief with aggressive advertisement of narcotics. They targeted health professionals with little experience, falsely promoting their time-release design of OxyContin as less addictive than other medications. The ramifications of these deceptive tactics were devastating, because the FDA stepped in and introduced a reformulated version of OxyContin into the market, which although reduced abuse, was linked to increased heroin usage. We are cognizant of the misleading campaigns employed by pharmaceutical companies such as Purdue Pharma and believe that lucid and honest reporting, combined with more stringent oversight by the FDA, will allow for greater understanding of the addiction potential of new drugs.

Although physicians and pharmaceutical companies are directly involved in the circulation of prescription opioids, the crisis has also been fueled by insurance companies. By placing drugs like morphine in low-cost brackets, insurance companies have made prescription opioids affordable and accessible. Recently, however, some insurance companies have made efforts to curb the over of pain medication by
not providing coverage for certain opioids. While this could be seen as a step in the right direction, it raises the question of whether this is an equitable decision for those in legitimate need of opioid painkillers. We imagine that rather than taking drastic measures like removing certain pain medications for coverage, a stronger synergy between physicians and insurance companies would be a logical move in combating the epidemic. Many insurance companies have implemented novel measures to track patients that are considered to be at “high risk,” those who are prescribed high doses of opioids. By maintaining close contact with the physicians of these patients, insurance companies can effectively monitor opioid users and prevent opioid overuse.

Since opioids are such a vital element of modern medicine, we cannot expect the ban of opioid usage to be a pragmatic solution. With pain being a crucial component of many conditions, it is difficult to discern legitimate usage of opioids from overuse of these drugs. We are convinced that proper collaboration between the three factors is crucial in controlling the usage of opioids. Both physicians and and pharmaceutical companies can also educate patients on the risks associated with consuming opioids. Furthermore, monitoring programs can be promising in tracking opioid users in risk of drug overdose. Although the opioid crisis is only recently receiving the much-needed attention it deserves, we are hopeful that, with the right measures, our health care system will be successful in tackling this epidemic.

Sangrag Ganguli and Uche Ezeh are graduate students.

Image credit: Shutterstock.com

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