An estimated 20 million people in the United States meet the criteria for substance use disorder. In 2015 alone, the opioid epidemic cost an estimated $504 billion in health care, criminal justice, and lost productivity.1
The current opioid crisis is the third one observed in the United States.2 This latest trend is, however, the result of unusual factors and has had some unique effects. Knee-jerk reactions to restrictions on opioid prescriptions have resulted in an increase in the narco-trafficking of heroin and fentanyl, and as the consumption of opioids shifted from oral intake to injections, hepatitis B and C and HIV infections have increased.2
Opioid Use Disorders: A Historical Perspective
Opioid misuse in America dates back to the Civil War and the passage of the Pure Food and Drug Act (1906).2 Opioid use blossomed with the invention of hypodermic syringes and the inclusion of unregulated opioids in medications.2 With the passage of the Harrison Narcotics Tax Act in 1914 and later rulings, the perception of opioid misuse changed.2 Opioid addiction was no longer viewed as a treatable disease, and individuals with opioid use disorders (OUD) were perceived as responsible for their condition and as lacking moral fiber.2 The Supreme Court supported this view until 1962, when it ruled that addiction was a disease.2
The second opioid use crisis hit the United States from 1960 to 1975.2 Heroin spread from major cities to the countryside and was linked with disenchantment associated with the Vietnam War.2 In the late 1960s, medication-based treatment for OUD using methadone gained acceptance, but the rapid and poorly monitored expansion of this effort created a highly regulated system of methadone clinics.2 The passing of Federal Regulation 37 F.R. 26 806 led to tight controlled access to medication for clinics and patients, mandated drug screening, and supplemental counseling and required stringent reporting practices.2 This regulation resulted in a system of clinics that were disconnected from the rest of the healthcare system and further stigmatized medication-based treatment for OUD.2 More importantly, the regulation paved the way for a return to abstinence-based approaches as the more socially acceptable form of treatment for OUD.2
Today’s Opioid Crisis
· Over the past 25 years, clinicians have prescribed opioids for fear pain may be undertreated.2 Additional factors are thought to play a role in the current OUD crisis, including a shift in the American health system toward “patient-centered” medical care.
· The paucity of studies examining the effectiveness of opioids for treating chronic musculoskeletal, neurologic, and autoimmune pain.
· False claims by pharmaceutical companies regarding the potential for abuse and duration of effect of extended-release formulations of opioids and the use of incentives by these companies to promote sales and secure endorsements from prominent physicians using retainers and speaker’s fees.
· The need by clinicians to limit the time allotted to each patient, which has resulted in prescribing opioids appearing as a simpler option for pain management compared with the adoption of behavioral approaches.
· The use of standardized patient satisfaction surveys may have incentivized providers to address their patients’ requests for “pain killers.”
· The unwillingness by a majority of payors to reimburse alternative medications or therapies and that employers rarely permit sufficient paid time off to allow for physical recovery.
· The stigmas associated with the use of drugs, despite evidence indicating the genetic and neurobiological bases of addiction.
· The promotion of abstinence as the prime goal of OUD treatment, as OUD, much like hypertension or diabetes, is a condition that can be managed but rarely cured, as opioid misuse has been shown to alter neural pathways.
Attempts to limit supply by getting tough on large-volume prescribers or wholesalers whose practices have been deemed criminal or suspect have been unsuccessful. “The unintended effect [of limiting supply] has opened many communities to narco-trafficking. New markets for heroin have emerged to take the place of ‘pill mills’ and other sources for diverted pharmaceuticals,” explained the article’s authors. “We believe that the new, cartel-supplied black markets for heroin/fentanyl have produced more dire consequences than if misuse of pharmaceuticals had continued.”1
Researchers note that despite a documented doubling of opioid analgesic use from 2000 to 2010, they cannot find evidence that prescribing opioids for chronic pain is the principal driver of rising addiction rates in adults.2 OUD develops in only a small percentage of adults who are prescribed opioids for acute pain.2 In a large study of 640,000 opioid-naive patients in which chronic opioid use was examined one year after surgery for 11 surgical conditions, the prevalence was found to range from 0.12% for cesarean section deliveries to 1.4% for total knee replacement surgeries.2 In another study in which chronic opioid use was examined in approximately 18 million people with acute pain who had not undergone surgery and had never taken opioids, only 0.14% of those who were prescribed opioids were found to still use the medications a year later.2