Alan Frischer, MD, MPH
One of the most difficult, complex, and costly issues of our time is this nation’s opioid epidemic. During 2016, 116 people died every day from opioid-related drug overdoses. That comes to 42,249 deaths for the year. The cost from 2001 through 2017 has been estimated at over a trillion dollars.
These drugs stimulate opioid receptors in our nervous system. Opioid receptors regulate pain and reward systems, making opioids powerful painkillers, and also enormously addictive.
The original opioid was opium, a narcotic that comes from a variety of the poppy. From opium came a number of other similar drugs. The first derivative was heroin, followed by Vicodin, Percocet, and OxyContin. In addition, there are man-made compounds that behave like opiates but are not derived from the poppy, including methadone and fentanyl. Collectively, these are known as opiates or opioids.
While opioid addiction goes back centuries, the current crisis started in the 1980s. The thought back then was that doctors weren’t treating pain aggressively enough, and that patients were suffering needlessly. During the 1990s, doctors were required to take continuing medical education classes on pain management. The pharmaceutical industry took note of this, and began aggressively marketing OxyContin and other painkillers. This shift put less emphasis on the obvious concerns about addiction, and more on patient satisfaction and the elimination of pain. Clinics providing opioid prescriptions sprang up all around the country, and as a result, an ever-growing number of people grew addicted.
At the same time, the heroin market was changing. The price plummeted, and drug distribution networks and counterfeit pharmaceuticals became easily available. A ready and willing heroin customer base sprung up from those who had started by taking prescription opiates.
In 2014, fentanyl entered the market. Fentanyl is a synthetic opioid 50 times more potent than heroin. While heroin is derived from a plant that requires fields, labor, and time to grow and harvest, fentanyl is synthetic. It found a useful place in medicine, both as a surgical anesthetic and for the treatment of severe pain, usually in terminal patients. However, almost all of the fentanyl on the streets is illegally manufactured, and smuggled in from China or Mexico.
The vast majority of deaths come from heroin (an illegal drug) and illegally manufactured fentanyl. In 2000, the typical age of death from opioids was age 40. Currently, most deaths occur among those in their 20s and 30s.
Where do we go from here? Can doctors simply stop prescribing opioids? They are a vital component of modern medicine that has improved the quality of life for millions of people, including cancer patients and those in acute pain. However, new DEA rules have made it more difficult for doctors to prescribe them, and prescriptions for opioids have been declining since 2010. They have become less available to those with chronic pain, where the benefits of opioids are less clear, especially when weighed against the risks of overdose and addiction.
There are no easy solutions to the opioid crisis. We need to carefully control prescription opioids, but maintain access for those with legitimate needs. We need to improve the way our medical system currently manages pain, and insurers should cover more options for pain management, including acupuncture, massage, physical therapy, counseling, hypnosis, and herbal remedies. We need to continue to improve access to and effectiveness of opioid treatment programs for those already addicted. This is a huge crisis that destroys lives and families, and has no simple or quick solution.