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    Why is there an opioid crisis?

    Charles J Lockwood, MD, MHCMUnlike Hurricane Irma, the opioid crisis took me unawares. I first began noticing more cases of heroin abuse among pregnant women when I moved to New Haven from NYC in 2002. But when I arrived in Columbus, Ohio, in 2011 the sheer number of addicted pregnant patients attending the Ohio State high-risk clinic was staggering. Nor was the problem limited to Ohio.

    From 1999 through 2011, overdose deaths from prescribed opioids tripled nationally, and while these numbers remained relatively constant over the next 4 years, the number of overdose deaths from illicit narcotics—mostly heroin and fentanyl—tripled.1 Thus, by 2015, more than 2.5 million Americans had an opioid use disorder (OUD) from either prescription medications (77%) or illicit drugs (23%)1 and 90 Americans died of an opioid overdose every day.1,2 Drug overdoses, primarily from opioids, have now overtaken motor vehicle accidents as the leading cause of unintentional injury deaths in this Nation. It was also no accident that I found there to be an opioid epidemic in Ohio. By the time I arrived there, it had become the nidus of a national opioid epidemic.

    How did this happen? Why now? Why Ohio? In his meticulously researched book, Dreamland, author Sam Quinones starts and ends in Portsmouth, Ohio, to answer these questions.3 But his findings have far broader application for American medicine and society as a whole.

    An iatrogenic crisis

    Quinones makes the case that, like the road to hell, the road to the opioid crisis was paved with good intentions. For decades, it was argued that American medicine had been overly conservative in use of narcotics for end-of-life care. In the early 1980s a number of palliative care pioneers began a vocal campaign to address under-treatment of cancer pain, particularly among terminal patients.

    A few years later advocates appeared arguing for increased opioid treatment for patients with chronic pain. Many cited data published in a letter to the editor in The New England Journal of Medicine by Dr. Hershel Jick and his graduate student, Jane Porter, reporting that of almost 12,000 inpatients treated with generally short courses of various opioids, only 4 became addicted.4 This datum came from a large hospital database, was not applicable to chronic pain, but was subject to selection bias since there were no links to other relevant outpatient data. However, despite its lack of methodological rigor, that 1-paragraph letter was cited by pain treatment advocates as justification for expanded opioid use for many forms of non-cancer chronic pain.

    Adding fuel to the fire was the 1986 Portenoy and Foley report that of 38 patients maintained on various opioids for non-cancer pain, in some cases for up to 7 years, only 2 developed an OUD, and both had a history of drug abuse.5 Dr. Portenoy soon became a leading voice for aggressive treatment of pain and inclusion of opioids in the management of non-cancer chronic pain.3 Increasing attention was focused on the physical, psychiatric, social and economic burden of chronic pain that annually affected 11.2% to 43% of American adults.1

    This drumbeat grew louder and the mere presence of pain soon became anathema. Ultimately, both the Veterans Administration and Joint Commission pushed to make pain assessment a “fifth vital sign.” Soon, pain relief became an obsession with hospitals and physicians seeking to improve their patient satisfaction scores. As a consequence of this “pain revolution” opioid prescriptions exploded, peaking at 206 million in 2011.1 Helping to fuel this fire were busy primary care physicians who were bearing the burden of seeing these often-complex patients while being driven to churn patients by the introduction of managed care. So-called “pill mills” also proliferated, particularly in Ohio and the “Rust Belt,” many with unscrupulous owners offering little more than a prescription pad. The ultimate irony of this iatrogenic crisis is that there never was real evidence of the long-term efficacy of opioids for chronic pain because tolerance occurs so quickly, but there was abundant evidence of harms including OUD, fractures, myocardial infarction, and sexual dysfunction.6

    Marketing of OxyContin

    In 1996, early on in the “pain revolution,” Purdue Pharma marketed its sustained-release opioid, OxyContin. Quinones contends that the company was legitimately convinced that its sustained-release formulation and attendant stable blood levels would greatly reduce the peaks and troughs of narcotic levels that fuel addiction.3   This tenuous theory formed the basis for an extraordinary marketing campaign that highlighted some of the worst abuses of physician office “detailing” and conflicts of interest in continuing medical education (CME) programs that occurred before implementation of the 2002 PhRMA Code on Interactions with Healthcare Professionals. Purdue funded pain conferences at resorts, employed a bevy of paid speakers, flooded doctors’ offices with gift-bearing salesmen, and funded so-called patient support groups.7 Sales personnel were even trained to quote the Porter and Jick “study.”

    Not surprisingly, OxyContin prescriptions soared from 670,000 in 1997 to 6.2 million in 2002.3 Between 2000 and 2010, oxycodone sales increased 287.3% and oxycodone accounted for the largest volume of opioids sold in the United States, with prescriptions accelerating further after 2005.8 As sales soared, so did the bonuses of Purdue salesmen and opioid overdose deaths, since OxyContin’s abuse potential proved as high as other opioids.1,3 This combination of increasingly lenient opioid prescribing practices and mass marketing of this potent opioid certainly accelerated the crisis, but there were other factors as well.

    NEXT: Hillbilly Elegy meets the OxyContin economy

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...


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