A public health emergency was declared by the CDC in 2016 for opioid misuse and related deaths. Opioid overdose deaths are outlined in three waves by the CDC. The first began in the 1990s with increased prescribing of opiates. The second wave was in 2010 with increased heroin use. This is thought to be directly related to the decrease in availability of prescription medications as prescribers stopped prescribing so liberally. Patients sought out other sources of opiates. The third started in 2013 with an increase in use of synthetic opioids such as fentanyl.
At a recent Biologic Therapies Summit, speaker Haider Warraich, M.D., from Brigham and Women’s Hospital, shared some ideas of how the medical community was complicit in allowing “so much misinformation about both opioids and chronic pain to spread.”
The first myth he talked about was a statement that came out years ago that opioids cause addiction in less than 1% of pain patients. He states, “This really became the hallmark, the bedrock, of not only education but also the marketing drugs for people with chronic pain.” This claim originated in a research letter that was published in The New England Journal of Medicine in the 1980s. Following its publication, the paper was cited thousands of times without any further exploration of its conclusions. This paper is still accessible but includes a disclaimer.
The second myth he addresses is that patients who are under-treated for chronic pain are at risk for developing “pseudo addiction.” This piece of misinformation came from a single case of a teenager with leukemia. The authors recommended that the treatment for a patient with addiction behaviors should be more opioids. One of these authors became the chief medical officer at Purdue Pharma. No other research was done to validate these findings.
The third myth was that long-acting opioids are not addictive. This was on the FDA label for OxyContin made by Purdue Pharma. An FDA label sets the standard and basis for how you can market drugs. Warraich stated that there was no evidence that Purdue made this claim, implicating that the FDA did, although other articles cited Purdue as the owner of this claim.
The fourth myth he discussed was the that opioids are effective treatment for chronic pain. He states that today we know there is no evidence to support that.
The last myth he addresses was the racist idea that Black patients have a higher pain threshold than other patients. He assigns this myth to a doctor named Samuel Cartwright. Cartwright stated that Black patients were insensitive to pain and could not feel violence inflicted upon them. This myth still lingers today. In a recent survey of medical students and residents, they found a third of them believed that Black patients’ skin was thicker than white people’s, and believed they had a higher pain tolerance. These students and residents were less likely to provide pain relief to their Black patients.
Also guilty in contributing to the opioid crisis was the concept of pain as “the fifth vital sign” and the responsibility of prescribers to alleviate pain. Concurrent with this was surveys of patient satisfaction including pain relief. Reimbursements are based on patient satisfaction.
This was endorsed by Joint Commission, which accredits and certifies health care organizations. Meanwhile, pharmaceutical agencies are marketing and advertising opioids as not being addictive. Thus over-prescribing became a key factor in opiate misuse.
The depth of involvement in our sociopolitical-economic arena is too complex to address in this article. To scratch the surface, we know large donations are made to politicians by the pharmaceutical industry, which influences policy decisions. Profit motive of the pharmaceutical industry is clearly an obvious cause. The coronavirus pandemic amplified the opiate crisis with anxiety and isolation. It also reduced access to care and prevention.
Although laying blame does not singularly solve anything, identifying the root causes of this terrible health crisis as a means to correcting and not repeating the same mistakes is important. Along with government, medical community and pharmaceutical industry changes, a multifaceted approach to conquer the opiate crisis advocating for greater access to addiction prevention, treatment and recovery service is needed. Public health emphasizes moving away from law enforcement and the criminalization of addiction. It should be treated as a disease with a focus on harm reduction strategies.
Take care of yourself and someone else.
Westfield Health Department staff and Board of Health members Juanita Carnes, FNP-BC, Carrie Hildreth-Fiordalice, LICSW, and Stan Strzempko, M.D., are dedicated to protecting the public health of this community and keeping you safe.
