The Opioid Crisis: Anatomy of a Doctor-Driven Epidemic

Laird Harrison

Disclosures

April 01, 2016

An Ambiguous Guideline Sets the Spark

The speech of a specialty society president at a doctors' meeting doesn't usually get attention outside the conference center. At best, a handful of trade publications might report the remarks. On November 11, 1996, however, something different happened.

Standing before his colleagues, James N. Campbell, MD, president of the American Pain Society (APS), announced a new initiative. "Vital signs are taken seriously," he said. "If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly."[1] It was the kickoff for the APS's new campaign to convince doctors they should treat "pain as the 5th vital sign."[1]

And the initiative got instant traction, with the Veterans Health Administration and the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission) adopting the slogan and calling on US physicians to manage patients' pain.[2]

But just as quickly, some researchers say, the campaign got off track. Where leaders said, "Manage pain," doctors and patients seemed to hear "Prescribe opioids."

Orthopedists Are Among the Highest Prescribers

Today, governmental and professional groups are frantically trying to hit the rewind button. In February, American Medical Association president Steven J. Stack, MD, issued a "call to action" on opioid overprescription.[3] The same month, President Barack Obama requested $1.1 billion to address opioid and heroin abuse.[4] And on March 15, the Centers for Disease Control and Prevention (CDC) issued new guidelines calling for reduced use of opioids in chronic pain.[5]

Among orthopedists, the calls for action carry particular urgency. By some measures, orthopedists are the third highest prescribers of opioid medications among medical specialties.[6] "In the United States, the current expectation of opioid use as the primary treatment for acute and chronic pain has created an opioid epidemic," the American Academy of Orthopaedic Surgeons (AAOS) said in a statement released in October.[7]

A look at the statistics explains this tone of urgency. In the decade following Dr Campbell's speech, sales of prescription opioids in the United States quadrupled. And rates of overdose, death rates, and substance abuse treatment admissions spiraled in tandem.[8]

In 2013, almost 2 million Americans 12 years of age or older either abused prescription opioids or were hooked on them.[9] Also that year, more than 16,000 people in the United States died of an overdose related to opioid pain relievers.[9] The drugs killed more people than heroin and cocaine combined, more than suicide, and more than car crashes.[10]

The prevalence of pain remained undiminished during this period.[11]

"There's a fear that we're going to get in trouble if we don't control pain appropriately," says Loree K. Kalliainen, MD, MA, who specializes in wrist and peripheral nerve surgery at the University of North Carolina in Chapel Hill. "But we're creating people who are habituated to these medications, which is tragic, and we're not using things that actually do work instead of or in addition" to opioids.

For example, whereas doctors were dramatically increasing their opioid prescriptions, they did not prescribe more nonopioid analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.[12]

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