Over 5,000 years ago, the Sumerians in Mesopotamia began cultivating what they called Hul Gil, or “the joy plant.” Fast forward to the 21st century, and we see that these leaves of “joy,” which was in fact opium, take 130 American lives every day, and opioid overdoses have been a leading cause of death for years. I had the privilege of speaking with McLean Hospital and Harvard Medical School professor Dr. Bertha Madras about tangible steps we can take to end this epidemic. Nominated by President George W. Bush in 2006 and unanimously confirmed by the Senate, Dr. Madras served as the White House Deputy “Drug Czar” where she oversaw the nation’s anti-drug efforts. In 2017, President Trump appointed Dr. Madras to a 6-member commission on combating drug addiction and the opioid crisis. Tackling the opioid epidemic is far from a simple task, and Dr. Madras made clear that we cannot just prevent, treat, or arrest our way out of this crisis—we must do all three.
More than 190 million opioid prescriptions were written in the US in 2017 alone. So how did the numbers get this high? When we look at the history of opioid prescriptions in America, we don’t have to look back too far to find a problem. In 1980, a five-sentence letter to the New England Journal of Medicine from Dr. Hershel Jick declared that “addiction is rare in patients treated with narcotics.” Cited affirmatively in hundreds of manuscripts, this fatally flawed letter was used by opioid advocates as evidence that opioids are innocuous in pain management. In the late 1990s, Purdue Pharma introduced OxyContin, a strong semi-synthetic opiate with an incredibly high addictive potential. In its first four years on the market, OxyContin sales grew from $48 million to $1.1 billion. And Purdue Pharma is not alone… well-known companies such as Johnson & Johnson have played a huge role in the production and prescription of several highly addictive opioids. These pharmaceutical companies were well aware of the high addictive potential of their drugs, yet they intentionally and vigorously marketed their drugs as highly effective drugs for non-cancer pain with a low addictive potential. Dr. Madras says that the “evidence for the safety of opioids was so thin and so weak, yet it was marketed to physicians in a way that they simply accepted the marketing without critical evaluation.” Dr. Madras stressed the importance of starting fewer patients on opioids because “the literature shows that the likelihood of an individual becoming a long-term opioid user is strongly correlated with the number of opioids prescribed to them for the first time.” This is especially important because non-steroidal anti-inflammatory drugs, such as Ibuprofen (Advil, Motrin), can be just as effective as opioids in treating the most common causes of pain, such as lower back pain, which is why Dr. Madras says that it is “critical to evaluate whether an alternative medication will suffice” in treating a patient’s pain.
So how do we get doctors to prescribe fewer opioids? First, Dr. Madras stresses that we need much better medical education when it comes to prescribing opioids. It is crucial to better train current and future physicians to know when opioids are appropriate for a patient. Second, we need to better incentivize patients and doctors to rely on non-opioid medications or other treatments. Dr. Madras notes that alternatives such as exercise are less reimbursable, saying that “healthcare insurers reimburse a doctor less for telling a patient to jog around a track or take over-the-counter anti-inflammatory medications.” But, physicians are well-reimbursed for writing an opioid prescription. While physical therapy is also an effective treatment option, Dr. Madras says that physical therapy is labor-intensive and more expensive for patients. Patients often demand immediate relief of their pain, which can be satisfied by the prescription of opioids. Because of the current physician reimbursement structure, “there’s a tremendous incentive to prescribe opioids—and a tremendous disincentive to look at alternatives for pain management, such as physical therapy.”
Dr. Madras also discussed patient satisfaction scores as another incentive for physicians to prescribe more opioids, as some research suggests that patients who receive more opioids report higher satisfaction scores compared to those who receive fewer opioids. To solve this problem, Dr. Madras and the other members of the President’s Commission recommend that pain survey questions are completely removed from patient satisfaction surveys. In this same vein, making pain a fifth vital sign has come into question in recent years. Vital signs are supposed to be limited to measurements that assess a patient’s vital functions, such as heart rate and temperature. However, some entities recognize pain as a fifth vital sign, which Dr. Madras calls “a disaster.” To exemplify why, she says, “Patients coming into the ER with a runny nose and sore throat are asked ‘Do you have any pain?’ and the patient thinks, ‘Well maybe I do’” Bringing pain up to the level of a vital sign is yet another route for heightened attention to pain and opioid prescribing.
Recent regulations have limited the number of opioids being prescribed by physicians. However, while physicians began to change their practices of high-volume opioid prescribing, fentanyl emerged as the primary driver of the opioid crisis. China and Mexico are the major sources of fentanyl and fentanyl-analogs, with U.S. Customs and Border Protection seizing over 2,500 pounds of fentanyl in 2019 alone. It’s important to note that fentanyl quantities as low as a few grains of salt are enough to kill you. In recent years, the United States government has strengthened its borders by using new technology that detects drugs passing through the US Postal Service, the primary mail carrier used by fentanyl-producing labs in China. The US has also attempted to improve relations with both Chinese and Mexican officials so that adequate cooperation is attained in shutting down fentanyl-producing laboratories, and Dr. Madras believes that talks with these two nations must continue.
As we look forward, it’s important to note that America is quite unique when it comes to opioids. No other country in the world prescribes even close to the number of opioids as we do for patients experiencing acute or chronic non-cancer pain. Western European countries prescribe four times fewer opioids than we do, despite chronic pain rates being similar. By cutting down on opioid prescriptions, financially incentivizing alternative treatment options, improving medical education, treating those with an addiction, and cutting the fentanyl supply, the United States can greatly reduce opioid overdose deaths, improve public health, and become an even greater nation.