19th century philosopher, Karl Marx once said “religion is the opium of the masses” but one could also make the case in the 21st century America that “opium is now the religion of the masses.” More people in the United States now die of opioid overdoses in 1 year (72,000) than all the U.S. deaths in the Vietnam War. How did this happen and how can we solve this crisis?
There was a time in medicine (pre-1980s) where pain was perhaps undertreated but that all changed by the late 1990s. There was a new philosophy taking hold when I was in training in the 1990s that basically said pain is the fifth vital sign (the other four being blood pressure, pulse, respiration rate, and temperature) and we, as physicians, needed to record that at every visit and take appropriate measures. On one level, that sounds reasonable and compassionate but this modern idea “pain is dangerous” did not necessarily improve patient outcome. Instead, this sentiment unleashed the overprescribing of opioids 4-fold between 1995 and 2010. There was also a 4-fold increase in opioid related deaths between 1995 and 2010. The United States prescribes more opioids than any other nation with the highest rates in the southeast U.S. (especially Arkansas, Alabama, and Tennessee). The other hidden epidemic is with benzodiazepines in which there have been a 7-fold increase in overdoses between 1999-2015.
We need to shatter the myth that less than 1% of patients get addicted to opioids if prescribed by an M.D.—that number is closer to 25% of patients who misuse the prescription and 15% of patients who develop an opioid use disorder. It is challenging to know ahead of time who will misuse/abuse the prescription and be able to tease out treating someone’s physical pain versus someone abusing the prescription for euphoric effects when there is clearly some overlap between the two. The other myth that is starting to become clear is that we always assumed opioids were effective for chronic pain but the studies are not backing that up. As a psychiatrist, I have not prescribed opioids in an outpatient setting as it has never been part of my scope of practice. I did prescribe opioids on a regular basis at a rehabilitation center in the early 2000s as part of a detoxification protocol. What that meant was I would have 4-5 days (which was not enough time but insurance dictated the length of stay) to take a patient off opioids by a gradual reduction in their dose and after that depending on insurance and patient motivation they would either continue with a 30 day or more rehabilitation or return home. Some patients did succeed but I’m pretty confident at least 90% of the patients relapsed on opioids at some point (even the ones that did an extended rehab). At that time, there was no methadone or buprenorphine maintenance treatment as a realistic option which has since changed.
Dr. Anna Lembke, MD in her book, How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, offers a 7-step solution to reverse the opioid epidemic:
Mandate prevention with strict policies on who gets opioids.
Change the perverse incentives inside health care driving overprescribing. That would include reimbursing providers for educating and spending time with patients, not just for pills and procedures as well as providing coverage for non-medication alternatives for chronic pain.
Create De-Prescribing clinics by teaching doctors how to taper and replace with non-addictive alternatives.
Think of addiction as a chronic relapsing and remitting disease (even if you don’t believe it is one) rather than a biological issue. Medical schools now agree that doctors need to be trained from the first day of medical school to detect and intervene for substance use problems. That also includes embracing opioid agonist treatment (like buprenorphine)…it works—there is no euphoria or respiratory suppression and people won’t die.
Reform disability. Medicine has now become the safety social net and too often the prescription of pills is being used to care for psychospiritual issues and socioeconomic distress.
Limit influence of special interest groups. Pharmaceutic companies have had too strong a hand in influencing treatment.
Provide alternative sources of wellbeing which would include connecting to people, the outdoors, music, and spirituality.
I still believe opioids are important pain therapies that can make people’s lives worth living but we need to return to a more judicious approach in managing them and understand their limitations and when they are doing more harm than good. Addiction is treatable and we need to improve access and affordability for those that are currently in the depths of the addictive process. We also need more compassion and less judgment about those who are struggling with addiction. Ultimately, people need social and spiritual connection in their recovery. When we encourage others to connect around what’s broken in them (such as recovery meetings) and explore mutual recovery interests (music, yoga, movement, etc.), we help them connect to others as a means to replace drug-cued compulsive behaviors. Over the years, I have received letters from former patients who struggled with addiction including opioids, reminding me that recovery is possible and a sober life is worth living despite their struggles along the way.
“Suffering is the sine qua non of the radical personality change that is required for lasting recovery from addiction. Suffering is the principle of individuation. Thus, all attempts to abolish suffering are simultaneously and inextricably obstacles to growth. No pain, no gain. But because we are opposed to pain, any pain, we are in danger of forgetting that familiar truism in our zeal to create a pain and risk free world. It seems to me without suffering nothing substantial can be hoped for.”
—Dr. Floyd Garrett, MD
“We have the tendency to run away from suffering and to look for happiness. But, in fact, if you have not suffered, you have no chance to experience real happiness.”
—Thich Nhat Hanh