The Opioid Epidemic: How did we get here and where are we going?

Most of you have been personally affected or know someone who has been personally affected by the opioid epidemic in the United States. Virtually every week, we see a news report about the impact of opioid abuse, addiction, and misuse in this country. As a pain management expert, I deal with this issue every day at work. The amount of misinformation and apathy I have witnessed continues to shock me. I would like this article to serve as both an educational piece and a reference for suggestions on how to understand and cope with our epidemic. As I see it, there were four important factors in the development of our current opioid crisis. All of these emerged within a short period of time in the late 1990s.

The first was an article published in a journal by a physician who reported excellent relief of chronic pain in a small group of patients managed with opioids. He recommended that opioids be utilized more regularly for the management of chronic, non-cancer pain. During the same time, Purdue pharmaceuticals released and fraudulently marketed OxyContin as a safe and effective treatment for chronic pain. Their marketing strategy was incredibly successful and resulted in millions of milligrams of oxycodone entering the U.S. market. Furthermore, the concept of pain as the fifth vital sign was introduced around this time. This resulted in very aggressive treatment of pain to improve patient satisfaction and quality measurement scores. Finally, several years later, inexpensive, black tar heroin began to flood the country from Mexico. This provided inexpensive and easy access to opioids for those who began their addiction with prescription medications but could no longer obtain them due to cost and limited supply.

During the period from 1999-2013, the number of opioid prescriptions dispensed in the United States increased 400% while the incidence of chronic pain actually rose! During most of that period, there was little to no high-quality evidence that

recommended against the use of opioid medications for chronic pain. However, by 2007, data had been published that suggested strongly that opioids were not effective in the treatment of chronic non-cancer pain. Unfortunately, it took almost 10 years before the majority of the medical community took notice.

In 2016, the CDC released their opioid guidelines. These guidelines were based upon hundreds of studies and millions of patients. In summary, they said that opioids were typically much more risky than beneficial for the treatment of chronic non-cancer pain. They also recommended limiting the dose of opioids as there is good evidence that harm from opioids is often dose-related. Almost overnight, the pendulum begun to swing back towards limiting opioids. To this day, I am shocked and disheartened that the data had been available for almost 10 years for health care providers to read, yet it took a national organization to release guidelines before substantive change occurred.

The release of these guidelines resulted in dramatically different responses from health care providers. Some ignored them, some embraced them without rational concern for their patients, and some, like those The Montana Center, applauded them for being consistent with what we had done for many years.

From a population-based perspective, the guidelines are very good. They have resulted in a limitation in the number of opioids prescribed in the United States and have coincided with a reduction in overdose deaths due to prescription opioids. Unfortunately, the thoughtless application of these guidelines as rules have occasionally resulted in cruel discontinuation of opioid therapy. Thousands of patients have been hurt and many suicides have occurred as a result.

So what can we do?

We can limit the prescription of opioids for acute (new onset or short-term) pain. Multiple studies and initiatives have shown that patient satisfaction and pain scores are not significantly changed by using dramatically fewer opioids after injuries or surgeries.

We can educate ALL people receiving opioid prescriptions. This education should include information about avoiding the use of alcohol and other sedatives with opioids, taking the medications exactly as directed, keeping the medications in a safe or hidden place, and properly disposing of the medications once they are no longer needed. The education should also include information about long-term use. Evidence shows that continuous opioid use beyond five days exponentially increases the risk of long-term use. More importantly, it shows that long-term use is not effective for the vast majority of patients.

We can educate those who have been on opioids for quite some time that although their body has likely become chemically dependent upon the opioids, it is unlikely that the opioids are increasing their overall quality of life. All patients should be notified that there are a significant number of risks associated with long-term opioid use including:

• Reduced hormone levels and function
• Infections
• Pain (resulting from an increased sensitivity in the nervous system to painful stimuli)
• Cardiovascular disease
• Broken bones
• Decreased sleep quality
• Accidental overdose
• Addiction

We can educate those suffering from chronic pain about the multitude of other safe and effective treatments. The Montana Center for wellness and pain management is among the most comprehensive interdisciplinary pain management centers in the U.S.. Every patient who takes opioids on a regular basis owes it to themselves to learn more about the options. There is no better place in this part of the United States to learn about those options than right here!

We can educate our patients about the variety of services available to treat opioid addiction. Though we are in need of more addiction specialist in our Valley, there are excellent medication assisted and non-medication addiction programs available. The Montana Center for Wellness & Pain Management and Pathways Treatment Center are good places to start for more information.

By Camden Kneeland, MD, anesthesiologist at KRH