The Origins of the Opioid Epidemic

The U.S. Healthcare System directly created the recent Opioid Epidemic.  It is, arguably, one of the greatest failures of 21^stcentury medicine.  This is a purely iatrogenic disease; generated by greed, manipulation, poor science and the wrong incentives.

Per the CDC,we have seen overdose drug deaths rise from 16,849 in 1999 to 70,237 in 2017.  This is not an accident. There are direct correlations from big pharma initiatives, federal government directives and volume-based payment incentives for physicians and hospitals.  As an ED Physician practicing since the mid 1990s, I have not only watched this unfold, but have “unknowingly” participated in the making of this healthcare crisis.

Opioids; Image Source: hankjohnson.house.gov

We will cover the following contributors that helped the epidemic evolve:

1. Big pharma, particularly Purdue
2. Joint Commission (JCAHO)
3. Patient Satisfaction Scores
4. The Lay Press and Pain Societies

Big Pharma:

In 1996, Purdue Pharma brought Oxycontin to the market. Oxycontin was promoted as a BID drug with “fewer surges of euphoria and less depression”.  Both claims are unproven. Additionally, their marketing team claimed: “addiction less than 1%”. This assertion was based on a five-sentence letter to the editor, published by the New England Journal of Medicine in 1980 by Ms. Jane Porter and Dr. Hershel Jick. This letterwas an observation of hospitalized patients who received narcotics, and in no way extrapolates to outpatient prescribing of opioids. By the late 1990s, many physicians, including myself, believed that opioids were not as addictive as once thought. Opioid prescribing began to increase, as the result of the false perception of their non-addictive property.  Purdue has generated billions of dollars revenue from Oxycontin, alone.

In 2000, JCAHO called for organizations to quantify pain on a “self-reported” 10-point scale.  Hospitals would receive a “requirement for improvement” if they failed to meet this standard. While not directly stated, the front-line healthcare professionals (and patients) felt that a score of “zero” was the goal.  Over-the-counter agents such as Acetaminophen and NSAIDs often were not enough and opioids were generally considered the second-line agent. To add fuel to the fire, JCAHO published a book for hospitals and physicians in 2000. On page sixty, it stated “addiction occurs very rarely in patients who receive opiates for pain control”. The publication was supported by unrestricted grants from Purdue Pharma and the American Pain Society.

Patient Satisfaction Scores:

Patient satisfaction scores became widespread during the above time frame.  Hospital executives believe that there is a direct correlation between patient satisfaction scores and financial success of the organization.  One of the high yield areas of these scoring tools is the question of “how well was your pain treated?” To say that there was some pressure to prescribe opioids in order for one to avoid complaints and help meet the organization’s patient satisfaction goals would be an understatement.  This was compounded further in 2013 when CMS linked federal funding to these scores.

The Lay Press and Advocacy Groups:

In the background, public pressure was being placed on healthcare providers.  In fact, in 2001 TIME Magazine published an article titled Less Pain, More Gain. The article stated, “patients have been under-medicated for decades, suffering needlessly” and “worries about the physical and psychological risks of using large doses of narcotics have largely been proved unfounded.” The article referred to P&J as a “Landmark Report”.

The American Pain Society, marketed as a patient advocacy group, pushed the concept of “pain as the 5^thvital sign”.  The 5^thvital sign was endorsed by the VA in 1998 and spread throughout the healthcare system.  A senate finance committee later revealed that the society received 90% of its funding in 2010 by the drug and medical-device industry. While not obviously apparent to those in clinical practice, many of these patient advocacy groups were heavily financed by big pharma.

The Result:

We have seen a steady increase in opioid prescribing from the late 1990s through the early 2000s. A percentage of patients developed opioid dependence and tolerance.  During this time period, Heroin (and Fentanyl) became cheaper. Those patients who developed opioid-use disorder, began to experiment with injecting or snorting prescribed opioids. Many later moved to heroin.  Studies have demonstrated that 80% of all heroin users began with prescription opioids. Heroin and Fentanyl are now leaving death and destruction in its path.

Learning Points from History:

• Pharma is driven by revenue – Be critical and diligent about their published data and sales tactics.
• Regulatory bodies are not obligated to use evidence when developing directives – Healthcare is at the mercy of regulations.  However, the opioid epidemic is a good example of how JCAHO pushed hospitals to follow guidelines that were poorly researched AND funded by industry.
• Patient Satisfaction Surveys are well intended – However, be careful of unintended consequences.  A 2012 JAMA study demonstrated that there was an association of increased patient satisfaction scores with increased cost of Healthcare, increased cost of Drugs and increased mortality.
• In 2018, nearly 18% of the U.S. GDP was spent on healthcare.  The modern medical system is at huge risk for adverse incentives and conflicts of interest.

Conclusion:

The modern opioid epidemic took decades to evolve and will take decades to diminish.  We need to learn from healthcare’s mistakes and be vigilant about not repeating them in other areas within the medical field.

References:

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
https://www.nejm.org/doi/10.1056/NEJM198001103020221
“Pain Assessment and Management, An Organizational Approach”.  Joint Commission Resources. 2000.
https://www.cbsnews.com/news/opioid-epidemic-doctors-say-hospital-patient-satisfaction-survey-fuel-dependence/
http://content.time.com/time/magazine/article/0,9171,158154,00.html
https://www.mdedge.com/ccjm/article/109138/drug-therapy/fifth-vital-sign-complex-story-politics-and-patient-care
https://www.washingtonpost.com/national/health-science/senate-panel-investigates-drug-companies-ties-to-pain-groups/2012/05/08/gIQA2X4qBU_story.html?utm_term=.326d675af988
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108766
https://www.amazon.com/Dreamland-True-Americas-Opiate-