The dramatic escalation in the availability, use and abuse of, and addiction to prescription opioids that began in the mid to late 1990s, and led to a dramatic resurgence in heroin use and addiction, along with record increases in overdoses and deaths that continue today, begs a critical question: How did this happen?
Historically, doctors had generally been conservative about prescribing opioids to anyone outside of those in acute pain due to broken bones or surgery, or pain related to cancer or other terminal illness. Although there has long been widespread agreement in the medical community regarding the use of opioids in the treatment of acute and cancer-related pain, there is no substantive research that supports the efficacy of the long-term use of opioids for chronic pain not associated with cancer.
Arguably, the most important issue related to the use of opioids in the treatment of chronic non–cancer-related pain is the potential for addiction. There are numerous studies that demonstrate a significant incidence of addiction occurs in the treatment of chronic non–cancer-related pain with opioids, though the rates of addiction reported vary, depending on the criteria used and the subpopulation studied.[i] [ii]
However, an unusual intersection of well-intentioned pain specialists and profit motivated pharmaceutical companies combined to help create a body of scientific research that served to allay the traditional concerns about opioids. This involved a small handful of studies that purported to demonstrate the risks posed by opioids, including addiction, were minimal. The research was uncritically accepted by the US Food and Drug Administration (FDA), as well as by certain US medical journals. In response, state medical boards loosened their opioid prescribing standards,[iii] and, the use of opioids was expanded to the treatment of people with a wide variety of chronic pain conditions.
In the mid-1990s, the American Pain Society assertively advocated for the concept of pain as the fifth vital sign.[iv] The stated goals included raising awareness that patients with pain were undertreated, in large part because pain was not regularly assessed at physician office visits or even in the hospital after surgery. In 2001, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations), the largest and most influential healthcare accrediting organization in the US, adopted the standard that pain needs to be regularly assessed in all patients, and that since, unlike the heart rate or blood pressure, pain is a subjective measure, physicians must accept and respect patient self-reporting of pain.
Concurrent with these events, pharmaceutical companies mobilized a concerted effort to shape medical opinion and practice. An article in the American Journal of Public Health described how, for the first time in history, a drug company effectively created a tsunami of drug abuse and addiction. “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” provides an in-depth analysis of how OxyContin (a high-dose, sustained-release form of oxycodone) was aggressively promoted and marketed by its manufacturer, Purdue Pharma.[v]
Aided by a full-court-press sales and marketing campaign, retail sales of OxyContin in the US grew from $48 million in 1996 (when it was first introduced) to almost $1.1 billion in 2000. The mushrooming availability of OxyContin correlated with dramatic increases in abuse, diversion, and addiction. By 2004, OxyContin had become one of the most abused drugs (and the most abused prescription drug) in the United States.[vi]
During that same five-year period, Purdue Pharma sponsored dozens of all-expenses paid national pain-management and speaker-training conferences attended by thousands of physicians, pharmacists, and nurses—who were then recruited and trained for the pharmaceutical company’s national speaker bureau. Purdue Pharma sent salesmen out to physicians across the country, plying them with marketing materials and distributing promotional items branded with the OxyContin name to such a degree that, according to the US Drug Enforcement Agency, it was unprecedented for a Schedule II narcotic.[vii]
It was a highly coordinated effort to convince medical professionals that OxyContin was safe and effective for patients with chronic pain. And, it worked. When the FDA was struggling to come up with an opioid policy, it relied on a panel of doctors, many of whom had financial relationships with Purdue Pharma and other drug makers.[viii] Pain brings more people into contact with medical professionals than any other problem. The most common medical treatment for all forms of pain became opioid medications (the so-called “painkillers”), such as hydrocodone (Vicodin, Lortab) and oxycodone (Percoset, OxyContin).
As has been well documented, subsequently, rates of opioid abuse, addiction, and overdose in the US skyrocketed. Enough culpability was determined that in 2007, an affiliate of Purdue Pharma, along with several company executives, pleaded guilty to criminal charges of falsely claiming that OxyContin was less addictive and less likely to be abused and diverted than other opioids, and were required pay more than $600 million in fines.[ix] It should be noted that many of the physicians who advocated loosening the restrictions on opioid prescribing acted on a sincere desire to help patients suffering from chronic pain, and some ultimately expressed regret and acknowledged being mistaken.
The addictive potential of opioids is so high because their chemical composition closely resembles that of heroin, and these medications pull all of the same neurochemical levers and create the same effects in the brain and body. As a result, taking opioids (even strictly as prescribed) inevitably causes physical dependence and creates a tolerance that necessitates higher doses over time to achieve the same effects, along with an often brutally uncomfortable withdrawal syndrome when these medications are reduced or unavailable.
The opioid epidemic is a solely human created catastrophe, disrupting and devastating the lives of individuals, families, and communities. It was born of sincere intent that was mutated by unadorned profit-motivated greed, and emerged from the confluence of unfortunate events within the medical-political economy. It did not have to happen. And, given what was known nearly a decade ago, it should have been addressed systemically beginning around 2010, but it hasn’t. It is only within the last one to two years that more serious efforts have even begun to coalesce.
This is part one of a two part series. Part two will pick up where this post leaves off.
Copyright 2017 Dan Mager, MSW
Author of Some Assembly Required: A Balanced Approach to Recovery from Addiction and Roots and Wings: Mindful Parenting in Recovery (coming July, 2018)
[i] Art Van Zee, The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy, American Journal of Public Health 99, vol. 2 (2009): 215–21
[ii] J. Hojsted and P. Sjogren, “Addiction to opioids in chronic pain patients: a literature review,” European Journal of Pain 11 (2007): 490–518.
[iii] http://www.washingtonpost.com/business/economy/rising-painkiller-addiction-shows-damage-from-drugmakers-role-in-shaping-medical-opinion/2012/12/30/014205a6-4bc3-11e2-b709-667035ff9029_story.html (accessed Sept 11, 2017).
[iv] American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995; 274:1874–1880.
[v] Art Van Zee, The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy, American Journal of Public Health 99, vol. 2 (2009): 215–21
[vi] Art Van Zee, “The promotion and marketing of OxyContin: Commercial triumph, public health tragedy,”
American Journal of Public Health 99, vol. 2 (2009): 215–21.
[vii] General Accounting Office, Publication GAO-04-110, Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem (Washington, DC: General Accounting Office, 2003).
[viii] http://www.washingtonpost.com/business/economy/rising-painkiller-addiction-shows-damage-from-drugmakers-role-in-shaping-medical-opinion/2012/12/30/014205a6-4bc3-11e2-b70seventy9-667035ff9029_story.html (accessed Sept 11, 2017).
[ix] Art Van Zee, The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy, American Journal of Public Health 99, vol. 2 (2009): 215–21.