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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?

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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.

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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.

  • The notion that legislators on both the state & Federal levels think that they can micromanage the opioid pain treatment problems better than most doctors & their patients reminds me of how the legislators also want to micromanage women’s reproductive choices, rather than letting women & their doctors have the final say without interference!!

  • Pain rarely kills? So if it only kills a few people, who suffer to death, that’s OK? What gave you the right to sit in judgement over what medication others take? You know more than our doctors now? Who are you to make such reckless proclamations, clearly you are doing NO INDEPENDENT RESEARCH to see the whole issue. Your peice was “opinion?” At last a fact. A poorly considered opinion IMHO.

    Here are more facts for you. Please take the time to read this as people are suffering and dying due to the type of hogwash you wrote here.

    Roughly 11 million Americans live with extreme chronic pain. Those people were able to use opioids to manage their pain , many did so for years without problems. Not everyone who takes opioids gets addicted. For many opioids provide quality of life, allowing CPPs to have any life instead of being crippled by pain.

    Then hysteria broke out, promoted by articles like yours. Now CPPs are just told to suffer, while you “assure” us that we probably wont die from the pain.
    Really?

    Pain so overwhelming that it interferes with sleep, concentration, memory and physical function. It damages the body in a host of ways, most stress related like high blood pressure and ulcers. It rewires the nervous system in ways that make pain worse and more widespread. The constant hammering of pain signals to the brain cause brain damage, loss of gray matter and dementia. You can google all this information very easily.

    Chronic pain MUST be managed for the well being of chronic pain survivors. Now due to this hysterical response to drug abuse, the chronic pain patient has been thrown under the bus. Many have been forced to taper their doses, or are denied any opioids, even though many patients took opioids for years without problems or signs of addiction. How can that be right?

    This was not done for their well being but to suit the demands of the “high holy ones” dictating this from within our own government, based on JUNK SCIENCE.
    Please look into the creation of the CDC guidelines that are devastating the lives of chronic pain patients. Look into how PROP, a rabid and well funded anti-opioid lobbying group, dictated these guidelines and pushed their agenda onto the entire nation. These fanatics are killing people in their bassackward attempt to fight addiction by denying pain management to chronic pain patients. Don’t help them do that.

    How would you like to live with endless pain and be denied the meds you know ease that pain, because others abuse the meds you need? Do you know there is a crisis in healthcare for CPPs now due to all this? Do you know people are dying, some killing themselves, due to this hysteria? Do you even care?

    Cronic pain kills too. Our lives matter as much as anyone else’s, or should. Please do another article on the problems faced by CPPs in the age of opioid hysteria. There is the real epidemic. At the very least, stop fanning the flames of hysteria.

  • I have a myriad of health conditions that wreaks havoc on my body. I am in chronic 24/7 pain. My pain is legitimate and has been proven with MRI’s, x-rays, etc. I have been through almost every non opiate medication there is and none helped. What they did do was give me horrible side effects. I have been on opiates now for years. It is the only thing that gives me enough relief where I can at least function somewhat. Without it, and yes, I have gone without it, I can barely get out of bed. I have a child to care for so I have to be able to function. Never once have I overdosed and never once have I abused my pain medication. We pain patients are being punished because of the ones who abuse their meds and it’s not fair. We are being put in the same category as those who are addicted and overdose on heroin. There are those that abuse their meds and then there are others like me, who benefit greatly from it’s use and don’t have problems with them by over taking them, etc. It is barbaric to take away pain patients pain medication, especially when they have been taking them responsibly. The Govt. needs to stay out of the doctor/patient relationship. I currently have a very compassionate doctor who knows my pain is legitimate. She has me on a daily pain medication because she has COMPASSION and doesn’t want me to suffer needlessly. She knows that I take my meds as prescribed and she is careful not to prescribe other medicines that would interact with my pain medication. In other words, she monitors me closely. Again….the Govt., the DEA…Jeff Sessions…they all need to stay out of the patient/doctor relationship. If they take pain medication away from all of these legitimate pain patients, there will be a lot of suicides taking place because they won’t be able to live with the pain. I am already reading comments from people who have already had their pain medication taken away and they are suffering and some are threatening suicide. Like I said, it is barbaric to take away something that helps so many people! My specialist was constantly giving me steroid shots and epidural blocks in hopes of getting me off of said pain medication but they made me worse. I have been damaged from those injections. And that is what is going to happen to many more….doctors are going to be left with having to try all these other things to combat the pain for their pain patients. In other words, the patients will become guinea pigs more or less. Take my pain medication away and you take my life away…..but perhaps that is all part of the Govt’s plan….crowd control. Sounds ridiculous but that is exactly what is going to happen.

  • Regarding the belief that ‘patients are still in pain’ despite being prescribed opioid pain relievers, I believe that the authors and purveyors of this misguided belief need to realize some things, and then see how wrong this concept is.
    First, most pain patient who are at a stage where they are prescribed these medicines, are typically ‘non responders’ in that they have already tried ALL the other so called ‘alternative therapies’, and each one of them have either had hardly ANY effect, or had ZERO effect in achieving adequate, and consistent analgesia.
    Second, pain patients are told literally “ZERO PAIN IS NOT THE GOAL!!!!”
    As if saying , pain patients are forced to endure some pain, and will never be treated in a manner that will substantially reduce their pain,and allow them to be comfortable. Doctors are literally saying “I will not do what it takes to get rid of all your pain.” So of course, chronic intractable, persistent pain patients will still have some pain. Because it is intentional. The medical community needs to let go of some of that Puritanical, sanctimonious holier than thou stuff, and recognize the suffering, and unnecessary torture and suffering done to them by the medical industry who have taken it upon themselves to torture pain patients who need relief because addicts are shooting up heroin.
    Third, pain patients are told “Dont take those medicines because they dont take away all the pain. They just mask it.” But they NEVER acknowledge that most pain patients , again, have already done all the therapies, up to surgery, and have had little effect. So they are desperate for at least SOME relief.
    So they are told a neurotic mixed message in that ‘zero pain is not the goal’, so they must suffer ‘some pain’, yet also told ‘we dont/wont prescribe those medicines (even if they offer you benefit) since they dont take away all the pain.’ So which is it? it’s crazy making to an already tortured, abused, and battered pain patient community who has taken too many lumps from government agencies, legislators, the media and anyone else who feels like taking a swing at innocent, vulnerable pain patients.
    So theyre not ‘allowed’ ENOUGH relief for completely irrational and arbitrary reasons.
    So they will still have pain. Most of it is unnecessary though.
    Because in many of these cases proper titration of dosages to analgesic effect is ALL that is needed. But no…cant have that. Think of the children..or something. Anything but offering actual, concrete and tangible benefit to pain patients, because…reasons.
    So you have hundreds of thousands, maybe more of pain patients who are suffering now, NOT because of ‘too many pills’ but in actuality ‘not enough pain medicine to actually, adequately treat pain patients’.
    It’s not a case of ‘dont give them more than x amount, because they will get addicted!’ Addiction doesnt even work that way.
    A pain patient simply wants relief. An addict craves a substance for how it makes them feel, and how they can escape life.
    Once analgesia is achieved the pain patient, doesnt seek more. Yet they are PORTRAYED as such. Which is wrong.
    Pain patients are considering suicide due to poorly managed pain.
    Comorbidities not only develop, but many patients already had/have certain other medical vulnerabilities, that untreated/undertreate pain exacerbates.
    But again…no pain medicine for you since addicts are shooting up heroin.
    Sure, makes sense. When I want to fix a flat tire, I just change the spark plug and battery. It never works for some reason. But hey, I just KEEP doing it.
    Likewise, prescriptions are down, even the CDC said they ‘overstated the role of painkillers in the epidemic’ , and more and more agencies are recognizing that it is heroin and street fentanyl, both not prescribed that are the culprits, and that the majority of addicts dont go to a doctor or have a prescription. But hey, facts, right? who care about them?? Im sure you fix your flat tire by changing out the batteries and spark plugs like me!
    You have generations coming up that have been working heavy , manual labor jobs, veterans who have been injured, professionals who have also been injured on the job, an aging population, and people are surprised we ‘still have people in pain’? Seems to me critical thinking and reasoning are not found in that question.
    Stop pointing the fingers at innocent pain patients, and start looking at the illicit drug market. Stop asking dumb questions, and simply ASK PAIN PATIENTS.

    • Your analogy of repairing a car is fantastic! May I use it in future writing? It really exemplifies the definition of insanity: “Insanity: doing the same thing over and over again and expecting different results.” — Albert Einstein

  • In your statement: “Despite this increase, there was little to no improvement in Americans’ pain.” There’s a HUGE reason for this: the escalation of spinal injections and other invasive procedures, especially epidural steroid injections. This has led to enormous suffering of those damaged by these interventions, including Adhesive Arachnoiditis, Cauda Equina Syndrome, CSF leaks, CSF blockages, RSD/CRPS, and other conditions. MILLIONS have been affected, yet NORD still has arachnoiditis listed as a “rare” disease. It’s only rare because it’s under-reported, under-diagnosed, and very well hidden by the doctors who caused it and refuse to admit it. The patient loses valuable time searching for an honest doctor for a diagnosis, allowing the disease to progress and further cripple the patient. (I see that the article was written by an anesthesiologist.)

    Secondly, PAIN RARELY KILLS??? Go back to med school, because you are waaaayyyyyy off-base here. Untreated and under-treatment of severe chronic pain shortens the patient’s life span. Every day, chronic pain patients are dying an early death brought on by adrenal failure, chronic pain-induced diabetes, heart attacks, strokes, and for those who are kicked to the curb by their doctors, overdose deaths from street drugs and heroin ALL BECAUSE THE PHYSICIAN WILL NOT DO HIS JOB OF DOING NO HARM!!!

    If the above-mentioned conditions do not kill the patient, then many attempt (and succeed) at their last resort: SUICIDE. When I was a teenager I walked into my mother’s bedroom just in time to pull the rifle out of her hands as she was trying to end her pain. So don’t LIE TO ME and tell me that chronic pain does not kill!

    EVERY DAY I read yet another article of a pain patient taking their own life. None of this is going to save a single addict, ever. 22,000 deaths? The following is from the CDC:

    Tobacco deaths: More than 480,000 deaths annually (including deaths from secondhand smoke)

    Alcohol deaths: Excessive alcohol use led to approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) each year

  • I have read one too many articles about opioids like yours. These articles have several things in common:

    1. They treat chronic illnesses and the severe pain they cause tens of millions of Americans as a secondary concern to addiction, even though debilitating, life-altering (and sometimes life-ending) pain affect many millions more people than does addiction. It is estimated that over 100 million Americans live with chronic pain and 40 million with severe chronic pain. This is an epidemic.
    2. They assume that doctors are often using opioid medications as first line treatments for pain. This is absolutely not my experience nor has it been the experience of almost any chronic pain patient I have heard from. And if it was once common, it certainly has not been common for several years. In fact, many patients report having a hard time finding a doctor who will treat chronic pain in any fashion.
    3. They assume that most chronic pain patients are ignorant of alternative treatments. Most patients with ongoing illnesses have generally tried a variety of pain treatments, frequently paying out-of-pocket if they are able to, for things like acupuncture and massage. Opioids are often only one component of a patient’s pain management plan, which also includes a variety of other treatments. Opioids are often not tried until other medications and treatments have failed to be effective or effective enough to allow a patient to function. 4. They also assume that patients expect to have their pain fully eliminated. Putting aside the question of why that should be a bad goal, most patients, especially those of us who are years into our diseases, know that there is no such thing as complete elimination of our pain. We are looking for enough pain relief to function day-to-day.
    5. That there is strong evidence for the effectiveness of treatments like acupuncture for severe pain. There is not. Further, the often touted lack of evidence for long-term effectiveness of opioids is due to lack of research, not proven ineffectiveness. Many articles give the impression that medical science has a good handle on treating pain, and that doctor and patient education will eliminate the need for opioids. Opioids are not a wonderful treatment. Neither are any of the “alternative” treatments. Some, epidural spinal injections and NSAIDS for instance, can be actively harmful. We continue to need opioids because our understanding of and treatments for pain are hugely inadequate.
    6. That NSAIDS are a safe alternative to opioids. NSAIDS taken properly kill over 15,000 people a year, far more than opioids taken properly. NSAIDS cause severe gastrointestinal problems and raise patient risk of heart attack. Many chronic pain patients, including me, use NSAIDS until their GI tracts can no longer tolerate them.
    7. That pain is an annoyance and not a scourge that destroys lives as completely as addiction does. For many people living with serious illnesses, pain destroys their ability to work, sleep, do basic self-care, take care of their children, think, or do any of the activities that give their lives meaning. Further, untreated pain kills — both directly and indirectly. Untreated pain can cause severe hypertension, organ failure, and even, studies have now shown, shrink the brain. Untreated pain also prevents people from sleeping and exercising, and lack of both lead to serious long-term health consequences. The psychological impact of constant agony (imagine unrelenting physical torture) coupled with loss of meaningful life activity leads to suicide. Many diseases, by the way, cause pain as or more severe than cancer pain. Cancer pain is terrible but not unique.
    8. That the problems with opioids outweigh the benefits. See above. This is in no way a given. Also, any study that looks at whether Americans’ pain has improved since the 90s would have to distinguish between pain levels while medicated and unmedicated. There is no reason why opioids should be expected to cure pain — they do not cure the underlying disease or injury, they just make it more bearable. What we really need is more research into and cures for severely painful genetic, autoimmune, and neurological diseases.

    There is a rapidly growing crisis among people in this country living with chronic pain, which includes loss of all treatment because doctors are no longer willing to treat chronic pain, reduction or removal of working medications (with no replacement) even when patients have never had problems with addiction, patients with documented illnesses being treated as drug seekers and treated disrespectfully and dangerously, and increasing despair and suicide. Studies have shown that chronic pain patients have low rates of addiction (under 6%) and that those who have problems tend to have prior histories of substance abuse. Patients, in general, are stunned at the lack of concern being shown by most media. Disabled Americans, including disabled veterans, are being abused by legislators and by a scared medical system, because it is easier to target doctor prescribing and patients than the underlying societal issues that lead to addiction or the flow of illegal heroin and fentanyl into our country.

    I am a 38 year-old children’s author who was diagnosed with Hypermobile Ehlers-Danlos Syndrome at the age of 27, after several years of having my pain and symptoms dismissed by doctors. EDS is an extremely painful genetic disease that causes the body to produce defective connective tissue. It affects the joints, tendons, muscles, digestive system and more. For me and the thousands like me, there are not yet any specific medications or other tailored treatments for my disease. I rely on a combination of therapies, including a weak opioid medication and a breakthrough opioid medication to allow me to live a semi-functional life. Long-term physical therapy, surgery, medical marijuana, talk therapy, topical NSAIDS, and other medications are all not enough. Acupuncture and massage were very expensive and largely ineffective. I am in no way unique. I am millions of Americans. There is no ethical solution to opioid addiction that does not take our needs at least as seriously as those of addicts.

  • The opioid epidemic is mostly a social problem, not a medical problem. I’m not aware of the authors’ qualifications in social policy, but anyone who thinks such a simplist solution will eliminate a complex problem is not credible, in my opinion.

  • So the needs of the few(drug addicts) outweigh the needs of the many(pain patients)?? Is this communist Russia? I’m so disappointed in stat’s quality of articles. It’s like the buzzfeed staff is working here now

    • In response to Smulch:

      Today is 08/03/2017
      2016 in review … what killed us
      2600 Americans will die EVERY DAY – from various reasons
      2700 people WILL ATTEMPT SUICIDE
      140 will be SUCCESSFUL – including 20 veterans
      270 will die from hospital acquired antibiotic resistant “bug” because staff won’t properly wash hands and/or proper infection control.
      350 will die from their use/abuse of the drug ALCOHOL
      1200 will die from their use/abuse of the drug NICOTINE
      1400 will contract C-DIF from Hospital or Nursing home because staff doesn’t properly wash their hands are adhere to infection control 80 WILL DIE – mostly elderly.
      850 will die from OBESITY
      700 will die from medical errors
      150 will die from Flu/Pneumonia
      80 will die from Homicide
      80 will die in car accidents
      70 From ALL DRUG ABUSE

      from http://www.pharmaciststeve.com/

    • Hi Lauri, many of those numbers are way off. That’s a little puzzling considering how easy it is to get those stats. And, as is so often the case, if you dig a little deeper, you discover that even the ones that are correct aren’t all clear-cut. For example, that estimate of medical errors is from a study that vastly overestimated the problem because it counted (among other things) a correctly chosen and executed, but unsuccessful, procedure to save someone’s life as an “error.”

  • I agree with the authors that we need policy change in and around the use of opiates. Many individuals who go on to use illicit opiates start with prescription opiates. I would add that we need to also shift the paradigm of treatment for substance abuse disorder. What we are doing now simply isn’t working. The current concept of medical Detox is an overall failure as this is infrequently coupled with long-term in or outpatient treatment and many people who undergo this treatment return multiple times. We need to couple medical Detox with strong efforts focused on the underlying mental health issues that accompany this disorder. We also need to engage the mental health issue at all levels and provide better initiatives for treatment that doesn’t involve simply over-medicating. We need to start engaging users and those in recovery to understand how we can help curb this epidemic and provide more patient-centric treatment. This is an epidemic that has been continuing to grow despite our current efforts. These four steps are a good start but we need to start thinking long-term and developing initiatives that address mental health issues alongside of management of the substance abuse disorder.

    • There is an article that just came out that states (surprisingly to the researchers) that most addicted folks got started by buying, stealing, taking prescription meds from friends/family, not from some prescription a doctor gave them. If they got their start from pills, they were used illegally in the first place.

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