VOLUME 30, ISSUE 2

Prior to the 1980s, opioids were rarely utilized for pain in the outpatient setting. Up to that time, these medications were reserved almost entirely for palliative care and oncology patients. A definitive shift in opioid prescribing began when a small group of pain practitioners came to the mistaken conclusion that opioids could be safely used in the chronic pain population with minimal risk of addiction. Unfortunately, there was little to no evidence to support their flawed opinion. It is now estimated that up to 25% of patients treated with opioids are at risk of opioid misuse or addiction. Nonetheless, physicians were drawn to the hope of minimizing suffering in their chronic pain patients. Concurrently, many medical governing bodies bought into the necessity of addressing patients’ pain. In the late 1990s, Veterans Administration hospitals launched an initiative in which pain was to be considered the “fifth vital sign.” Providers practicing in those facilities were required to record a pain score at all clinical encounters and document a treatment plan for pain. Soon thereafter, Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services mandated that hospitals focus on monitoring and treating patients’ pain as well using patient satisfaction scores. These scores were now tied to hospital accreditation and reimbursement for services. Concurrently, the Federation of state medical boards was urging individual State Boards to punish physicians for inadequately treating pain. Many State Boards capitulated, as was the case in Oregon where a physician was disciplined for failure to prescribe adequate pain medication for his patients in 1999. Clearly, physicians were being pressured to treat pain and, all too often, that pressure resulted in the over prescribing opioids. In stark contrast, in 2015, a physician in California became the first doctor to be convicted of second degree murder for over prescribing pain medications.

Pressure to treat pain has continued in recent years in the form of patient satisfaction surveys and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, with the satisfaction of patients with their care directly affecting payment to both hospitals and physicians. Driven by a sincere desire to minimize suffering, external pressure from governing institutions and aggressive marketing from pharmaceutical companies, the medical community began prescribing an immense number of opioids. Today, opioids are the most frequently prescribed drug class. Opioid prescribing peaked in 2012 when over 259 million opioids were prescribed. As access to opioids has increased, so have both opioid misuse and addiction. Emergency rooms in our nation now treat more than 1,000 people daily for opioid abuse and overdose. It is estimated that the number of people with a substance abuse disorder exceeds the number of people with cancer in our nation. Over 64,000 people died from drug overdoses in 2016 with more than 75% of those deaths attributed to opioids. That number represents more lives than were lost in the Vietnam, Iraq and Afghanistan wars combined. It comes as no surprise that Dr. Jerome Adams, the new Surgeon General, has identified the opioid crisis as his top priority.

Although recent restrictions and guidelines have led to a reduction in opioid prescribing, they have also had some unintended consequences. Many physicians now refuse to prescribe opioids altogether, due both to the immense time needed to meet all of the mandatory requirements necessary to do so, as well as the fear of possible prosecution in the event of poor patient outcomes. This has led to long wait times to be seen by those physicians who remain willing to prescribe opioids. Additionally, the decrease in access to prescription opioids has also had the inadvertent effect of driving many patients who are addicted to prescription opioids towards heroin when they are no longer able to obtain pain medication from their physician. A recent United Nations Drug Report found that 914,000 adults used Heroin in 2014. . That represents a 145% increase since 2007.

Clearly, the opioid epidemic is real and profound. While recent efforts have resulted in a decline in opioid prescribing, future efforts must focus on identifying and appropriately treating those patients who are suffering from opioid addiction. Otherwise, we may find that the opioid crisis has only shifted from the physicians’ office to the street.