According to a recent study from the Center for Disease Control and Prevention, in 2017 there were 58 opioid prescriptions written for every 100 Americans.(1) With this staggering statistic chances are good that you or someone you know has at least one in their lifetime received a prescription for opioids. A growing number of opioids being prescribed have consequently led to more being available and more individuals misusing them to the point of addiction or even death. A recent study published by US Department of Health and Human Services reports that 11.4 million people have admitted to having misused prescription opioids. The same report also found that almost 66% of drug overdose deaths in 2016 involved opioid use. (2) Over the past decade this has snowballed into a larger and larger problem that is now sweeping our nation and too big to ignore. While most can agree that this is a growing problem disparity comes from deciding who is to blame for it getting so overwhelming and who has the power to make a change to prevent further growth.
In order for us to tackle the issue at hand we must first examine the process to determine who is responsible and who has the influence to halt further development. Some would say patients are to blame for abusing the system and misusing prescriptions while others will argue that irresponsible physicians are at fault for providing such an abundance of prescriptions for opioids. After reading this essay I will give you my thoughts on who is at fault and hopefully your increased knowledge on the topic will allow you to make an informed opinion as well.
Before we go any further it is important to understand what is being referenced when using the term opioids. Opioids are defined as a class of drugs comprised from natural chemicals found in opium poppy plants. They are popular in the medical community because the provide pain relief and help with relaxing the body. The most common prescription opioids on the market include hydrocodone, oxycodone, morphine, codeine and fentanyl.(3)
These prescriptions are given for a variety of reasons but the most common reason is for pain relief. This can be prescribed for acute pain, such as after surgery or injury, or for long term chronic pain such as back pain, osteoarthritis or pain related to cancer and cancer treatments.(4) Along with pain, other uses for opioid prescriptions including treatment for cough as well as diarrhea. Opioids are a popular choice for pain management due to their high effectiveness.
Taking an opioid initiates the release of endorphins which suppress your pain receptors allowing the discomfort to become more manageable.(5) This is perfectly acceptable solution for acute pain as it allows the patient’s body time to recover and deal with the temporary pain. Using opioids to treat chronic pain becomes slightly more problematic. Long term use of opioids causes your body to slowly reduce endorphin production causing the patient to build up a tolerance to the medication and require a higher dosage for the same effect. The “high” of being pain free becomes so desirable that patients become addicted to the medication to continue achieving that feeling. With a wide variety of uses it is easy to see why it is a popular choice with physicians and highly demanded by many patients.
Opioids gain popularity in the 1990s with a campaign headed up by the American Pain Society. They advocated for distinguishing physical pain as an additional vital sign that should be taken into account when evaluating a patient. The argument was that there was an abundance of patients with untreated pain and physicians needed better methods to assess pain levels in order to offer proper treatment options. Answering the call to action was the introduction of OxyContin in 1996.
Purdue Pharma introduced OxyContin as the solution to the untreated pain problems so many were suffering from. It was heavily marketed to physicians and doctor’s offices and quickly exploded in popularity. During its first year of production OxyContin sales totaled $48 million dollars. Just four short years later, after multiple aggressive marketing campaigns, sales in 2000 reached just under $1.1 billion.(6) Countless seminars were held for mass groups of physicians attended to hear about the benefits of prescribing this medication to their patients and the wonderful relief that it would provide them.
In order to better sell their product, Purdue Pharma created a database showing prescribing patterns amongst physicians and what regions were prescribing the most. The information was intended to show physicians how popular OxyContin was becoming to encourage them to have confidence in the product. One of the main features of Purdue Pharma’s marketing campaign was to focus on physicians who would prescribe frequently based on the type of practice they worked in, such as pain clinics. While the database was created to collect data for marketing it was eventually used to highlight which states, counties and physicians had the highest prescribing rates. As a reward for continuing to push their product, Purdue Pharma started providing these offices with incentives to continue prescribing higher and higher quantities.
With growing incentives physicians became more and more comfortable with offering OxyContin, and subsequently other opioids, to their patients for a variety of issues. A major problem that was not originally revealed though was that these medications have the potential to become very addictive. Extended use of these medications leads to patients developing a tolerance of their current dosage causing them to eventually need a higher quantity to achieve the same effect. Over time the body becomes so dependent on the opioids that the individual develops an addiction and suffers from debilitating symptoms if they are without the medication.
With lucrative incentives and lack of education about the medications they were prescribing, it’s easy to see why some feel that medical providers are the most responsible party involved with the opioid crisis. Despite the shortage of knowledge regarding opioid side effects, providers hold accountability to recognize the signs and symptoms that an addiction may be establishing. Physicians have an ethical responsibility to look out for the best interest of their patients without causing further harm. Providers have an obligation to their patients to not only treat them with dignity and respect but to also ensure that they have their best interests at heart when formulating a potential treatment plan. It is easy to build an argument that physicians prescribing high volumes of opioids did not have their patient’s best interest in mind but rather the incentives they had the potential of earning.
Medical providers strive to treat patients with compassionate care though and that involves addressing issues brought forth by the patient. As previously mentioned, there was a lack of pain assessment tools available to accurately quantify the level of pain a patient was experiencing. Without these tools, it made it very easy for patients to lie about their level of discomfort and request more opioid prescriptions to manage their pain. Falsifying symptoms to receive more prescriptions shows that blame could be accurately placed on the patient population for how the opioid problem got out of hand.
Another tactic used by patients is to use the medications in ways other than prescribed by physicians. Some patients are guilty of convincing their provider to write the prescription and then passing it along to someone other than who it was intended for. They either sell the prescription or fill the prescription and sell the medication on the street for a profit. There are also patients who use the medication other than how it was prescribed.
A larger amount of opioids come in pill for which is easy to be misused by patients. A common way patients misuse these is by crushing the pills and snorting them instead of taking them orally as intended. Snorting crushed pills allows the mucus membranes in the sinuses to quickly absorb the medication and let it to get into the bloodstream very quickly and reach the brain almost instantly. By doing this the user will experience an immediate high and feel the effects of the medication much faster. If taken orally as intended, it takes longer to be digested and enters the bloodstream after being absorbed via the intestines before it reaches the brain.(7) This is the safest way to take pill form opioids as it spreads out the process of the body absorbing the medication and providing relief for what the prescription was intended to treat.
Contributing factors from physicians and patients led to the opioid crisis becoming an overwhelming problem that could no longer be ignored. Over the past several years the government has taken steps to prevent further growth. Prescription drug monitoring programs (PDMPs) are amongst one of the best state-level tools which impedes opioid abuse at the pharmacy and raises awareness with physician’s offices. PDMPs are a database maintained by the government which monitors and tracks controlled substance prescriptions through pharmacies and physician’s offices. They allow for pharmacies to be alerted if the patient is attempting to fill a prescription sooner than approved or if they have recently filled a similar prescription from an additional provider. (8)
This database is also accessible to physician’s offices. This allows providers to ensure a patient is not receiving controlled substance prescriptions from other providers. It also allows medical providers to see a patient’s prescribing history which allows them to make better informed decisions about treatment plans for their patients. While the concept has been around for many years, PDMPs have grown increasing popular within the last ten to fifteen years. In 2005 only 5 states had laws which mandated that a query of the database be performed before distributing controlled substance prescriptions. Today over 40 states have a mandatory query law and 49 states have access to review the database. (9)
The state of Florida took another step towards combating the opioid abuse problem by passing a new law in July of this year. Governor Rick Scott signed the HB 21 bill which implemented further restrictions on physicians providing controlled substance prescriptions. Prescriptions are now required to state whether it is for acute or chronic pain. If the prescription falls into the acute category, a limit of a 3-7 day supply has been put into place.(10) This restriction is intended to deter potential addictions from starting and force patient’s to be reevaluated by a medical professional if the pain is still not manageable after the prescription runs out. The law also requires physicians to run an inquiry from the PDMP before supplying a prescription for controlled substance as well.
In addition to new laws put into place, increased awareness related to the issue has stunted additional growth of the opioid epidemic. Further education allows for patients to make better informed decisions on treatment plans. It also allows physicians to better evaluate if opioids are really the best option for their patient. Physicians have also been better informed of warning signs to look for while their patients are using opioid prescriptions to potentially notice or evade a developing dependence to the medication.
While both medical providers and patients played key roles in the opioid crisis, my belief is that pharmaceutical companies carry the burden of initiating the problem. Lack of education to providers led them to falsely believing that this was a suitable option for their patients with little to no side effects. That was not the case and with additional education those providers could have made better informed decisions for treating their patients. These pharmaceutical companies also contributed to the influx of opioids being prescribed because they were offering lucrative monetary incentives to medical offices and individual providers based on the amount they were prescribing. A treatment decision for a patient should never be made based on if the physician is going to make a profit. The interest of the patient should be considered and the treatment choice should be chosen according to what the most suitable option is for the patient. If these companies would have had a better interest in patient care instead of making a profit, the opioid epidemic could have been completely prevented.
The power to make a difference and reverse the opioid crisis lies with all of the groups involved. A change requires physicians to be more cognizant of their patient’s prescription history and susceptibility to forming an addiction before choosing to treat their patient with opioids. Due to their strength opioids should only be used in severe instances when other alternatives have already been exhausted. Patients also need to be held accountable for using the medication correctly. They should be informed of all potential side effects and work with their physician to made an educated decision before using opioids. Patients also need to be truthful and honest with their physician if they feel they are becoming too dependent on the medication so adjustments can be made before the addiction becomes overwhelming. If both patients and physicians can learn to work together and communicate efficiently I think that the opioid problem could be eradicated and in turn create a safer society for all.