The Real Story Behind the Opioid Epidemic
There seems to be a news story about it almost every day. The statistics are horrifying. Since 1999, the rate of overdose deaths involving opioids—including prescription opioid pain relievers and heroin—nearly quadrupled, and over 165,000 people have died from prescription opioid overdoses. (HHS Bulletin The Opioid Epidemic: By the Numbers). Remember the year, 1999. We are spending 55 billion dollars a year in health and social costs related to prescription opioid abuse each year and $20 billion in emergency department and inpatient care for opioid poisonings. (Source: Pain Med. 2011;12(4):657-67.1 2013;14(10):1534-47.2).
How did this happen?
Three words: The Joint Commission. Yes, that accrediting agency that accredits your hospital.
Back before 1995, physicians were very judicious with their prescribing of opioids. The general opinion then was you should minimize prescribing of opioids and you were strongly discouraged to prescribe them for chronic pain. We were told they didn’t really work for chronic pain because the neural pathways were different between acute and chronic pain. The State Pharmacy Boards were monitoring your opioid use for anything but codeine containing pain medications.
Here are a couple of examples:
It’s 1983. About every 4 months or so, a male patient would come in to see me. He had a diagnosis of Migraine. This is the only thing I saw him for. He had no other active medical problems and, according to him, he generally used over the counter pain meds for most of his migraines. However, occasionally he got a really bad one and had been prescribed a small prescription of Dilaudid (hydromorphone, a pretty strong opioid) for those by a neurologist. He would ask for 10 of these. That meant he used about 2 a month. This didn’t seem like a problem to me, so I would refill this for him.
In early 1984, two people from the Board of Pharmacy visited my office in the middle of my afternoon session. They told me that they expected that I would not prescribe Dilaudid for this patient again. The reason was, the patient had been driving up and down about 200 miles of the Interstate, visiting multiple doctors asking for the same thing, 10 Dilaudid’s. No individual physician thought it was a problem, just like me. He was actually getting several hundred during a four month period. Yes, they were watching and they did something about it.
It’s 1985. I’m in a different state from Example 1. I saw a new male patient; I’d never seen him before. He comes in complaining of a bad cold and a really bad cough. It is keeping him up at night. This happens often when he gets a cold. He just moved here from California and his Primary Care in CA prescribed him Tussionex because it was “the only thing that worked”. I examine him, his exam is consistent with a cold. I prescribe him 200ml of Tussionex, which I had never heard of before that day, but it appeared to be a reasonable anti-tussive in the Physicians Desk Reference (PDR). There was no mention of anything like abuse potential in the PDR. Tussionex is comprised of hydrocodone and chlorpheniramine (an antihistamine) in time-release beads.
The next week, a fellow from the Board of Pharmacy comes in and tells me the patient to whom I had prescribed Tussionex was going around getting prescriptions from multiple physicians. He informed me that Tussionex was very addicting and I shouldn’t be prescribing it at all! Yes, they were watching and they did something about it.
Back then, before 1995, I rarely, if ever, prescribed anything stronger than Tylenol #3. That’s the way I was trained. Stronger opioids were for terminal cancer patients, not the acute pain we saw in the ER and in our offices. We mostly told patients to use aspirin, Tylenol or ibuprofen (which went over the counter in 1983). And, as I mentioned above, opioids were frowned upon for chronic pain. If anyone was on them for any period of time you worked to get them off. In my case, they got the opiates from surgeons after an injury or surgery, not initially from me.
Just to give you an idea about how reluctant we were to prescribe opioids, here’s a story from when I was in training. I was the Senior Resident in training. One of my and my intern’s patients was a fellow who was admitted with abdominal pain to the GI service. He was highly suspected of being a drug abuser and also of selling drugs. He was in the middle of a several day work up when a long holiday weekend “interrupted” his work up. The patient brokered a “weekend pass” from the attending since nothing was going to happen for three days (that’s the way it was back then!). The patient requested Percocet (oxycodone and acetaminophen) for pain control. The attending physician told me to write out a prescription for 30 Percocets. We argued with the attending that the patient was more likely to sell these than take them and we didn’t want to write the prescription for 10 Percocets a day (a lot). I finally told the attending that, if he wanted the patient to have the Percocets, he would have to write the prescription himself, which he did. When the patient came back, he had no leftover Percocets. So he either took 10 a day or he sold them. We always suspected that he sold most of them.
In 1996, The American Pain Society and other pain societies began advocating for the use of opioids for chronic pain and suggested that pain should be the “fifth vital sign”. This notion was based on only one journal letter (one paragraph with minimal details, not peer reviewed, no statistical analysis, no description of the study design, etc.) by one pain specialist without any credible data to support his recommendations (Jane Porter and Hershel Jick, MD, “Addiction Rare In Patients Treated With Narcotics”, NEJM, Vol. 302, No. 2, 1980). The Veteran’s Administration agreed with that approach and declared pain as the fifth vital sign. The Joint Commission picked up on this and in 2000 declared that all accredited hospitals had to adopt pain as the fifth vital sign and generated standards not only to that effect, but that all patients had to be assessed, treated and reassessed and that the medical record had to show decreases in the patient’s pain level reporting. They advocated that adequate pain management was a “patient right”. That’s how strongly The Joint Commission pushed this. Hospitals, including academic hospitals, were afraid of getting a “finding” (a ding) which would affect their accreditation status, so they advocated using whatever medication necessary to make sure patients’ pain scores decreased during their hospital stays. And the patient more than often went home on these medications. The Joint Commission also included that staff needed to be educated about pain and its treatment, which was aligned with the Pain Societies’ new guidelines promoting an increase in the use of opioids for acute pain and opioids for chronic pain. So, physicians in training were now being told to prescribe the more powerful opioids. Vicodin (hydrocodone and acetaminophen) became the drug of choice for most physicians. Since The Joint Commission was accrediting about 4500 of the 5500 hospitals in the US, the impact was incredible. (By comparison, the VA has only 168 hospitals). The Pharmacy Boards were no longer dogging opioid prescribing like it did before 1995 because, well, everyone thought it was the right thing to do.
For more detailed information about this see the JAMA supplement written by David W. Baker, MD, MPH from February 23, 2017.
Of course, none of this was lost on the Pharmaceutical Industry. They immediately began aggressively marketing their opioid drugs. Since The Joint Commission had mandated training and education in their standards, the Pharmaceutical companies started offering free education session to “help” the hospitals fulfill the standards. One opioid manufacturing drug company provided all-expense-paid “speaker training conferences” where they “trained” 5000 practitioners, then provided 20,000 “pain education programs” to hospitals trying to avoid a “finding” or loss of accreditation by The Joint Commission. The drug company revenue increased from $48,000,000 in annual sales of their drug to $1.1 billion. And this is only one example of this. The usual Pharma opportunistic behavior with total disregard to patient impact. I can hear them saying, “I don’t write the prescriptions. The doctor does. We just create the supply.”
All of this shifted the culture. But it started with the American Pain Society, the VA system and The Joint Commission (who had the largest influence by far).
I had to take a hiatus from seeing patients between 1996 and 2003. When I got back into practice in 2003, I was seeing same day appointments and I couldn’t believe how many patients were on Vicodin and Percocet! Especially Vicodin. I don’t think I ever prescribed Vicodin before 2003. Physicians now had a very low threshold for prescribing opioids. Understandable, since that was how they were trained. It was (maybe still is) so bad that, I know physicians who were prescribing Vicodin for coughs! (Remember Tussionex has hydrocodone in it, it is a cough suppressant). You can imagine what happened to those!
Here’s a personal example. I had a minor orthopedic surgical procedure. It was under general anesthesia in an outpatient surgery center. My wife took me home, then went to the pharmacy to fill the prescription the surgeon had written for me. It was 40 Percocets! I took one. I destroyed the other 39. There are studies showing that people use only about 10% of the opioids prescribed for them by surgeons. (“Prescription Opioid Analgesics Commonly Unused After Surgery”; Mark C. Bicket, MD, et al; JAMA Surgery Published online August 2, 2017)They frequently get 40-60 tablets and use only 4-6 tablets. Gee, what happens to the other 34-54 tablets? In the JAMASurgery systematic review, only 9% of patients disposed of their opioids according to FDA recommended disposal methods.
As the opioid epidemic evolved there was more and more concern that The Joint Commission (TJC) stance was leading to an over reliance on opioids and over prescribing by physicians. TJC started to back off on the strength and emphasis of its pain standards and eliminated them in 2009. Unfortunately, the damage was already done.
Now the trend is reversing again but not as fast and thorough enough yet. The recent recommendations in the US tend to still be medication based, not including alternatives to medication, or recommending not prescribing opioids at all (It’s hard to get addicted if you never get an opioid). People did relatively well before 1996 when we were discouraged from using opioids. Why not return to that? The Scottish recommendations/guidelines for pain control , for example, are predominantly non-medication based. Maybe the US efforts are more medication based because of the Pharmaceutical industry influence in the US, which is much stronger than other countries.
I took a chronic pain elective in 1981 while in training. That program was run by an internist. The main goal of the program was to eliminate opioids if they were being prescribed, and use non-medication interventions (like guided imagery, relaxation exercises, etc) instead of medications. He was specific with patients about the fact that the program would not eliminate their pain but make it manageable and they would live a normal life. I took a lot of notes and photocopied a lot of protocols and articles while in that program and used his techniques in my practice.
Since the opioid epidemic reaction by regulators (meaning, for example, I have to take an all day pain management course every three years to maintain my medical license) I have attended two mandatory pain management seminars. In both, 100% of the teaching is related to using medications. These seminars were led by a University medical school group of “pain specialists”. They never talked about the non-medication interventions I was taught and that are in the Scottish pain treatment guidelines. I actually spoke to them about this after the seminars and their answer was, there wasn’t anyone available to do the non-medication interventions, and they weren’t interested in building them at the University. I also emphasized that managing chronic pain is a PCP issue. Unfortunately, the PCPs nowadays have no idea nor do they have the support systems to do this so patients get referred to pain specialists who are mostly anesthesiologists who want to give everyone injections.
Anytime I described the way chronic pain should be managed, it fell on deaf ears. It is time and labor intensive for practitioners, but, it works. I Have many stories about how successful it is.
To my delight (but probably not of interest to others) an article came out on May 18, 2017 advocating for exactly what I’d been taught 30 years ago! (Primary Care of PatientsWith Chronic Pain, Jill Schneiderhan,MD, et al, JAMA, May 18, 2017). If we could swing the management of chronic pain as described in this article and stop prescribing opioids stronger than Tylenol #3, we’d actually be doing something that benefits the patients.
Anyway, if any of my loved ones died of an overdose that started with prescription drugs prescribed by a practitioner, even if the overdose drug was a different drug like heroin, I would sue The Joint Commission. My opinion is, they were negligent in adopting the standards they did; they were the major impetus to the current opioid epidemic. They did not do their due diligence relative to the strength of the literature/data or the consequences of their position and their standards, and their standards were ultimately the major influence on physician opioid prescribing behavior.