Health care professionals share a common and lofty goal: to minimize their patients’ pain. But what if we’re hurting more people than we’re helping? That may be the sad reality of the opioid epidemic, one driven in part by doctors’ desire to do good.
The use and abuse of prescription opioids like hydrocodone and oxycodone is currently among the most significant health crises today. While Americans account for only 5 percent of the world’s population, we consume approximately 80 percent of the world’s prescription opioids. Overdoses from prescription opioids are the major driver of the 15-year increase in opioid overdose deaths. Overall, prescription opioids are now killing more people each year — 22,000 by last count in 2015 — than die from homicide.
Why is the problem of prescription opioids unique to the United States?
Several historic events led us to this juncture. In the 1990s, multiple professional societies argued that physicians weren’t doing enough to treat people in pain and needed to improve pain management. This advocacy was based on the notion that the current levels of disability related to pain was unacceptable. Based on the educational efforts of major US health systems and leading professional societies, pain came to be thought of, and treated like, a vital sign.
In 2001, hospitals were prompted to create pain management standards, including the process of recording patients’ perceptions of their pain in a way that made it easier to assess and treat pain. The results of this social advocacy and regulatory behavior led to a skyrocketing number of prescriptions for opioids. But troubling data emerged from the Centers for Disease Control and Prevention: Despite this increase, there was little to no improvement in Americans’ pain.
This poor correlation between increasing opioid prescribing and health benefits is sadly and starkly contrasted with the tight correlation between increasing opioid prescribing and rising health care expenditures, opioid abuse, overdose, addiction, diversion, and death.
While the early advocates for the liberal prescription of opioids are no longer vocal, there continue to be insidious incentives to prescribe opioids. For instance, physician reimbursement is now closely linked to patient satisfaction surveys. There is deep concern in the medical community that overprescribing may be occurring as a function of the desire to optimize patient satisfaction.
How do we start to make things better?
First, we need to identify individuals who are at high risk for opioid use. Our new research on opioid prescribing found that Americans with mental health disorders such as depression and anxiety, a group that represent 16 percent of U.S. adults, receive more than half of all opioid medications distributed in the U.S. The high use of opioids among this population is particularly concerning because mental illness is also a prominent risk factor for overdose, abuse, and long-term use.
Second, we need to develop and put in place health policies and practice guidelines — totally free of influence by the drug industry — that aim to reduce physicians’ dependency on opioids for treating pain. This may involve building infrastructure to routinely offer alternative therapies such as cognitive behavioral therapy, acupuncture, physical therapy, and access to mental health experts.
Third, we need to carefully vet policies regarding financial reimbursement for outcomes such as patient satisfaction to anticipate any indirect effects on opioid prescribing.
Finally, we need to quickly put in place regulatory policies to identify fraudulent prescribing practices and improve access to drug addiction treatment.
Pain rarely kills, though we know of people in chronic pain who feel like it is killing them. But pain pills are actually killing astonishing numbers of vulnerable Americans. If we don’t resolve this opioid problem, thousands more will needlessly die.
Brian D. Sites, M.D., is an anesthesiologist at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. Matthew A. Davis, Ph.D., is an assistant professor at the University of Michigan School of Nursing and the Institute for Healthcare Policy and Innovation.