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In the ’90s, chronic pain was rampant in America. Opioids, which had previously been taboo, were suddenly being prescribed by doctors. A supposedly safer opioid had been developed which, as a physician wrote in the New England Journal of Medicine, was “not a hypnotic” and carried no “danger of acquiring the habit.”

This movement created a monster, addicting millions of Americans to opioids. Global overproduction fueled even more demand and, as authorities clamped down, many of those addicted to these medicines turned to more potent ones, making an overdose only a minor miscalculation away.

I’m referring, of course, to the eighteen nineties, which eerily echo how the modern opioid epidemic emerged a century later.

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The 1890s and 1990s were both characterized by unopposed amplification of the benefits of opioids, the transformation of physicians into unabashed cheerleaders, and the central role of China — first as a global consumer of opium and later as a manufacturer of fentanyl. In the 1890s, the compound marketed by Bayer to supposedly treat morphine addiction was heroin, while in the 1990s, the drug made by Purdue Pharmaceuticals and marketed as a painkiller with low potential for abuse and addiction was OxyContin.

In his 1932 book, “Brave New World,” Aldous Huxley foresaw the modern opioid crisis by depicting a society addicted to a drug called soma, which mirrored the effects of opium, instantly overcoming pain while providing a sense of well-being. Soma was provided free to citizens, and its characterization predated our modern inclination to look to pills to overcome our ills.

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The current opioid epidemic is a huge tragedy, albeit one that could have been mitigated, had we learned from the epidemic of yore. While the pharmaceutical industry has been singled out for retribution — and it does carry the greatest burden of responsibility — other groups have largely escaped accountability. This includes physicians as well as the regulators who spectacularly failed to protect the public. If we focus only on punishing pharmaceutical companies, this won’t be the last time opioids infest our society.

Americans constitute 5% of the world’s population but use an estimated 30% of the world’s prescription opioids. This disproportionate use of prescription drugs in the United States is not an accident but arises from a culture deliberately crafted by the pharmaceutical industry. The United States and New Zealand are the only countries that let drug makers directly advertise their claims to consumers. Their sales pitches have been so potent that, over time, Americans’ responsiveness to placebos has increased while that in other countries remains the same. This sustained marketing blitz means that when the average American takes a pill — any pill — for pain or depression, his or her expectation of relief is greater than it is for someone living in another country.

The pharmaceutical industry had help pushing opioids. The other recurring aspect of these cyclical opioid crises has been the role played by physicians in propagating them. At the end of the 19th century when heroin was first marketed, it could be acquired only with a prescription from a physician. Many of them fell over themselves to praise opioids like heroin.

One doctor wrote in the Journal of the American Medical Association in 1915, “I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.” Decades later, in 1980, a five-sentence, 101-word letter in the New England Journal of Medicine concluded — incorrectly — that “the development of [opioid] addiction is rare in medical patients with no history of addiction.” That letter would be cited hundreds of times to make more false claims about opioids. While the senior physician who wrote the letter now regrets doing so, the damage has been done.

Every prescription opioid that killed an American had a physician sign off on it. That’s why it is essential for the medical community to examine itself to see how it contributed to this tragedy.

When I was a young resident in the early 2010s, I struggled with balancing the need to alleviate my patients’ pain but also make sure they avoided becoming dependent on opioids. Yet “Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education, and Research,” a Congress-mandated report published by the Institute of Medicine (now known as the National Academy of Medicine) read more like a marketing brochure for narcotics. Subsequent investigations revealed that almost half of those who wrote this guideline had undisclosed financial conflicts of interest and they used grossly exaggerated estimates of how many Americans suffered from chronic pain. I felt betrayed when I learned they weren’t the only offenders: Other physician-led organizations that advocated for opioids were being heavily supported with funding from pharmaceutical companies.

The biomedical industry holds broad sway over not just what physicians do but what they are taught, shaping them throughout their careers. Most training materials about opioids have been funded and developed by opioid manufacturers themselves.

Unless we make wholesale changes in how the biomedical industry can manipulate patients and physicians, we will surely find ourselves back in this quagmire at some point down the road. Training materials need to be vetted for bias, and physicians with financial conflicts of interest should be restricted from medical journal editorial boards as well as from FDA and medical guideline committees.

The FDA should be strengthened by expanding its budget and the approval process for new drugs, and post-market surveillance of approved drugs must be made more stringent. The desperate need to develop better medications to treat pain should not lead to lowering the regulatory threshold for approving new treatments. Until the FDA revamps its mechanisms to ensure opioid safety, it should heed the moratorium on additional opioid approvals filed by Public Citizen, a consumer protection group.

We should also expand how we address chronic pain, not by writing more prescriptions but by focusing on and developing nonpharmacologic approaches. A good place to start reversing our pill-popping culture is banning direct-to-consumer pharmaceutical advertising.

Unless we learn from the past, and focus only on punishing opioid producers and distributors while ignoring the role of physicians and regulators, it is inevitable that the wheels of time will keep churning, and this tragedy will recur.

Haider Warraich, M.D., is a physician and researcher at the VA Boston Healthcare System and Brigham and Women’s Hospital, and an instructor at Harvard Medical School.

  • Hard to read propaganda. Many pain patients have done multiple different Therapies before pain medication. When age Disease takes toll on body, choice medication for any quality of life. Certainly not addiction may come dependent on. Why is addiction and chronic pain that difference isn’t seen between two. This issue is causing millions of people much suffering. Many things wrong with this article.

  • This article is filled with errors. Opiates have never been “taboo” in American medicine, and certainly were not taboo in the decades immediately following the Civil War. Heroin was not commercially marketed until 1898. There was no heroin “epidemic” during the 1890s. That came later. The assertion that heroin could only be purchased with a prescription in the 1890s is factually incorrect: the Harrison Narcotic Act was not passed until 1914, and even after that enforcement was spotty for many years. And so on.

    You might want to consult a historian the next time you want to write an article like this. There are lots of us around who write about this stuff.

    • “Dependence does not equal addiction!!!”

      No it does not. A person can be addicted to gambling, video games, sex, etc and those are certainly not dependence. Dependence is a biochemical state that causes severe, unpleasant, usually debilitating, possibly even life threatening, changes in physiology. Addiction is an emotional state and while it too (via stress response) causes physical symptoms and physiological changes, it is not ever life threatening (barring suicide) and can overcome by changing mental focus and supportive emotional therapy and connection.

      I have personally known people who became dependent on a drug, heroin in one case, Vicodin in another, who while very uncomfortable and physically ill, had zero desire or drive to continue using that drug.

  • I, for one, think it is time we move beyond mere monetary fines and start putting pharma execs who oversee prescription fraud in jail where they belong. What Purdue Pharma and the Sackler family did with paid misinformation and misleading market claims that 12-hour oxycontin was effective was absolutely criminal and such bad behavior will absolutely continue so long as monetary fines for malfeasance are merely part of doing business.

  • I find a the concepts of condemning physicians in this article disturbing. I take it the author does not typically treat patients with rare, painful diseases in which opioids, while a last resort, are essential. Unfortunately, our disease treatments, especially for painful diseases, are stagnant in their research discoveries. I might also add, the way a person becomes an addict (as in no real drug of choice; just polypharmacy use and trying to escape) should not be compared in any way to the road a patient travels (and the multitude of treatments they endure) to find a limited, functional normal. One effective way to help chronic pain, and to stop it early on, is early diagnosis and treatment of the condition causing the pain. That would require nurses, physicians, and medical assistants to listen more and leave off their beaurocrat hat long enough to work with a patient to get a diagnosis. We all need to look at ourselves and what we can do and stop “kicking the can”.

  • Yes, history does repeat itself. But the repetition isn’t ignoring drugs as the cause of addiction, it is in calling them the cause of addiction. No drug causes addiction. For the answer of the REAL Cause of Drug Abuse and Addiction, go to my video on http://www.doctorsofcourage.org/videos/, or the webinar list on the home page where the latest presentation was recorded on Jan. 29th. We do need to learn from history, but the fact that this young doctor has learned the wrong thing and is now teaching it is what will put this country into the dark ages in the very near future.

  • Since addicted Americans continue to buy counterfeit Oxy-Contin on the Black Market, all the hub bub about MD’s and Opiates is largely a false flag. We can re-examine our prescribing practices and be more judicious. Nonetheless, a decade from now I suspect we have roughly the same number of addicts and the same amount of oxy- contin/heroin sold. MD oversubscribing has gone in the other direction. Now we undersubscribe. MD’s will be punished and Pharma will be too. I think “the crisis” is well known and has already past. It’s time to look at the elephant in the room, illegal drugs. As far as that goes, legalization and normal regulation is worth trying. Prohibition has made the problem worse for addicts and non- addicts alike. People dying from Heroin and other overdoses come from lack of consistency in drug strength. Phillip Seymour Hoffman and countless others have died from the lack of pharmaceutical regulation of prohibited drugs. We could save a lot more lives finding ways for addicts to get safe drugs. By bringing this into the light we can actually try to help the millions of addicts we have in the country. The carnage we create with illegal drugs far exceeds whatever we are going to solve with our continued focus on the least important component of our drug crises.

  • It is not the drugs that cause addiction. They do cause physiological dependency which can be relatively overcome. Addiction is a mental/emotional state that is created out of the superficiality and emptiness of our entire culture and way of life. People who are alienated from themselves and each other, who perform endless, mind numbing work that accomplishes nothing more than feeding the endless cycle of frantic consumption and chasing the next “cool” thing. All that is where addiction comes from and that is what needs to be addressed and changed.

  • I was prescribed an opiate to relieve pain after some tooth extractions. I felt no need to crush the pills, snort them, inject them, etc. Addicts are using these drugs in a manner never intended by the manufacturers. If taken as directed, they are not automatically addictive. Do individuals bear no responsibility for the misuse of these drugs?

    • I urge you delete this dangerously misinformed and condescending comment.

      Other people are not like you. Your experience is not universal. If you are an adult, you should understand this by now.

  • This is an informative article, and one which reminds us of how history can repeat itself. Also, the article suggests the prescription opioid crisis is multifaceted and therefore requires a multifaceted solution. I wholeheartedly agree. I would also add payers to the mix of stakeholders that were and even to this day are part of the problem. They approve for reimbursement (deem “medically necessary”) and pay for over 90% of prescription opioids. Their formulary decisions – made by P&T Committee members who are physicians – placed prescription opioids in preferred positions, often without prior authorization or step edits. They didn’t pay for, and still often don’t, non-opioid pain therapies. It was and is myopic, but then again payers often have a short-term horizon as they either must meet stringent budgetary requirements (Medicaid), or face churn of beneficiaries who rarely stay with a payer for longer than 2 years.

    I do have a few points of criticism. With respect to prescription opioids, oversupply doesn’t necessarily lead to more demand. The multiple checkpoints involved from the point of supply to demand imply that effective demand is more a function of what occurs at those checkpoints than the supply itself: From regulatory approval, payer formulary positioning, to doctor’s prescribing. These are learned intermediaries, who know much more about the products than the end-users, who impact demand far more than supply in this particular market. This leads to my second point of criticism. I don’t believe prescription opioids were ever marketed directly to consumers. So, DTC did not play a role in boosting demand by end-users. A third point has to do with how doctors viewed opiates in 1915. The fact that they thought highly of them makes sense. And not only in 1915. Currently, the World Health Organization includes a number of modern-day prescription opioids on the essential drug list. This is a bare bones list or formulary of about 400 products that every hospital/clinic in the world should stock. Prescription opioids have vital uses to relieve cancer pain, post-surgical pain, and even a number of non-cancer chronic pain indications.

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