In 2018, opioids were responsible for nearly 70% of drug overdose deaths (“Understanding the Epidemic,” 2019). That’s 128 people per day who lost their life to an opioid overdose (including both prescription and illicit forms). The National Institute on Drug Abuse estimates that 20-30% of patients who are prescribed opioids for chronic pain misuse them, or take a dose other than prescribed by their doctor. These individuals are then likely to transition to heroin, a more potent drug which delivers greater amounts of pain relief and euphoria. An alarming 80% of heroin users report that they started using the drug after the misuse of prescription opioids (“Opioid Overdose Crisis,” 2020). This raises the question: why would a physician ever prescribe a drug that is so addictive and life threatening?
To understand how this drug destroyed the lives of so many Americans, it’s important to look at the history behind the opioid epidemic. The first surge in opioid addiction and opioid-related deaths occurred in the 1990s when doctors began prescribing opioids to relieve pain at much higher rates than ever before. The sudden rise in prescriptions was fueled by pharmaceutical companies who falsely assured the medical community that opioids were perfectly safe and carried little to no risk for addiction. This claim was derived from a single faulty letter published in the New England Journal of Medicine in 1980. Titled “Addiction Rare in Patients Treated with Narcotics,” the letter reported that out of 12,000 hospitalized patients that received a narcotic (another name for opioid) only 4 patients had developed an addiction.
These too-good-to-be-true findings were the result of a flawed methodology. The doctor who wrote this letter observed individuals who were admitted to his hospital for a short stay. Whether those individuals continued pain medication use after they were discharged from the hospital is completely unaccounted for. Furthermore, they did not observe patients with chronic pain conditions, which calls for extended use of pain medicine. We know today that long term use of opioids is associated with developing a tolerance, meaning that more of the drug is needed to feel the same amount of pain relief, putting the patient on an ever-increasing dosage (“Prescription Opioids,” 2019).
Although the over-prescription of opioids clearly has had devastating effects on the public for several decades now, physicians still reach for opioids as the first line of treatment for people who experience moderate to severe pain. This trend is largely driven by how lucrative the business of opioids is. Opioids do not treat the injury or underlying cause of the pain. They simply mask it. Thus, when the pain relief effects wear off, the patient will need to take more pills. Opioid manufacturers reimburse doctors for every opioid prescription that they write, so the more they prescribe, the more they will get paid (Kessler, 2018). Doctors are thereby incentivized to keep their patient reliant on opioids rather than exploring other avenues for pain relief.
Not all doctors who prescribe opioids are doing so with the intention to hurt their patient though. It can be difficult to gauge the appropriate dosage to prescribe because pain is subjective and not something that can be measured with an instrument, like blood pressure, for instance. Doctors mostly rely on the patient’s account of their pain to decide how much they will prescribe. To help offset the possible risks of opioid use, the physician must carefully monitor their patient’s use, educate them on the risk for addiction due to misuse, and be aware of the signs of a developing addiction.
Medical school curriculum is also to blame for physicians’ overreliance on opioids for pain relief. In the United States, only about 11 hours are allotted for the topic of pain management (Shipton et al., 2018). Students are told to assess a patient’s pain level by asking them to rate it on a scale of 1 to 10. A higher rating equals a higher dose of pain medication, yet pain is more complex than that. A more useful assessment of pain would include asking the patient about how the pain is affecting their day-to-day life and ability to function effectively (Greenfieldboyce, 2019).
There are, however, alternative, safer forms of pain relief out there, which doctors aren’t encouraged to provide and not sufficiently educated about (Greenfieldboyce, 2019). One underutilized pain management technique is acupuncture. Acupuncture is a procedure in which hair-thin needles are strategically placed into the skin, around different parts of the body called “acupoints.” Although we don’t exactly know how this procedure eases pain, one theory is that the needles stimulate nerves, which send a signal to the brain to release endorphins (Temma Ehrenfeld, 2019). Endorphins are neurochemicals that, when released, have pain-relieving effects on the body. Endorphin is a combination of the word “endogenous,” meaning from within the body, and “morphine,” the commonly used opioid. Thus, they are considered our body’s natural pain relievers. In summary, acupuncture activates our body’s potential to heal itself. There are extensive studies that show the efficacy of acupuncture in treating back and neck pain, osteoarthritis, and headaches. Physical therapy and massage therapy are also promising lines of treatment that can have more lasting effects by restoring function to muscle groups and bones that are affected.
For those who do not benefit from non-opioid treatments, there are some more advanced options such as administering radio waves, nerve blockers, and spinal cord stimulation. In a procedure called radiofrequency ablation, an electric current made by radio waves is delivered to the nerves responsible for the pain via a needle, thereby blocking the pain signal (“Non-Opioid Treatment”). One such procedure can produce up to a year of pain relief.
Although pain is a physical sensation, emotional and physical wellbeing heavily interact with one another (Lee et al., 2017). Times of increased stress can greatly impact the intensity of one’s pain. Hence, psychological interventions like cognitive behavioral therapy (CBT) can be a great complementary option for pain management. Rather than blunting the symptoms of pain, this kind of intervention gets to the root and contributing causes of it.
Unfortunately, health insurance companies do not typically cover the costs of these alternative pain management treatments. People are much more likely to get coverage for pain medication, making it the cheapest option. This is just a reflection of the influence that pharmaceutical companies have had in pushing opioids to the forefront of pain management.
Opioids have been prescribed as the primary pain management tool for far too long. People who suffer from chronic pain deserve far better. However, making safer treatments more accessible to the public is easier said than done. It requires health care workers and policy makers to undermine the power of the prescription opioid manufacturers, educating doctors on the complexities of pain, as well as informing the public that they have other options and empowering them to vouch for higher quality pain management.
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