The United States opioid epidemic is a multi-faceted, complex challenge to modern medicine rooted in both structural and social deficiencies. In order to fully address this epidemic and develop a lasting effective response, professional medical societies need to evaluate the factors that gave rise to the current crisis.
The opioid epidemic can be divided into three separate phases: the prescription phase, the heroin phase, and the fentanyl phase. The first phase, or prescription phase, began in the 1990s with an increased effort to treat patients with chronic pain. A report from the Institute of Medicine in the 1990s attributed the rise of non-cancer chronic pain patients to multiple causes, including an aging population, obesity, increased survival rates following injury/cancer, and increased expectation for pain relief among patients.1
Dr. Mitchell Max, MD, a prominent pain specialist with the National Institutes of Health, authored an opinion piece in Annals of Internal Medicine citing a need for an improved approach to the treatment of pain. In his article, Dr. Max encouraged the development of bedside tools to quantify a patient’s pain and enable patient’s to communicate this to their physician.2 After publication of these remarks, the American Pain Society released quality assurance standards for the treatment of acute pain and cancer pain.3 In 1995, the American Pain Society instituted the “pain as the 5th vital sign” campaign to implement the previously mentioned quality improvement guidelines.4 In 1999, the California Legislature passed a bill stating that every licensed health facility in the state should, “include pain as an item to be assessed at the same time as vital signs are taken.”5 In 2000, the Joint Commission (formerly JCAHO) released its standards for pain management which supported the 10-point scale model consistent with the positions of multiple societies and agencies.6,7
These well-meaning intentions for the treatment of pain also created an environment for abuse. Pharmaceutical companies became increasingly involved in the medical management of pain by funding “pain management educational programs”, partnering with physicians and pharmaceutical sales companies to promote use of their drug, OxyContin, and minimizing the addictive potential of opioids in their marketing strategies.8,9 Their marketing strategy was fueled by two small, retrospective studies published around that time that suggested opioid treatment of non-cancer pain was non-addictive, which led to decreased oversight by regulatory agencies over opioid prescribing. 2
While this resulted in some early success in the treatment of non-cancer pain, by 2004, concerning research and evidence of over-prescribing led to the removal of “pain as the fifth vital sign” from the Joint Commissions’ standards.7
Around 2010, increased regulation of OxyContin made it increasingly difficult to be turned into a drug of abuse. As a result, many patients who had formerly been abusing prescription opioids began to use heroin. The emergence of heroin as the primary opioid of abuse marks the start of the second phase of the epidemic. In this timeframe, heroin superseded Oxycontin as the cause of the majority of opioid overdose deaths.1 As the demand increased, the supply of pure heroin became more costly to secure and considerably more expensive to produce. As a result, in 2013, dealers began switching to Fentanyl and its analogs, as Fentanyl is considerably cheaper to manufacture. The emergence of Fentanyl marked the start of the third and current phase of the epidemic .1
It is also important to acknowledge the social underpinnings of the epidemic. Many victims of substance abuse also suffer from undiagnosed or mis-managed psychiatric condition, and their drug use is a form of self-medication.1 Many also suffer from poverty. In an analysis of opioid overdose deaths, the highest concentration of deaths are clustered in geographic areas like Appalachia and New England where deindustrialization has left many manual laborers without gainful employment. Years of physical labor such as coal mining and other manufacturing, increases the risk for these individuals for injury and chronic pain. As a result, these individuals turn to illicit opioid use as a way to self-medicate.1
As emergency medicine physicians, we find ourselves on the front lines of this crisis. We are witnesses to the devastating effects this epidemic is having on our patients, our children, and our communities. We are also uniquely qualified to offer and implement lasting solutions to curb opioid abuse. To do so effectively, we must understand the origins of our current crisis and the objective and subjective factors driving its continuance.