In August 2016, the Surgeon General of the United States sent a letter to every physician in the United States asking for help combating the opioid crisis. In October 2017, President Trump declared the opioid crisis a National Public Emergency.
What is the opioid crisis?
In 2017, an estimated 66,000 Americans died of opioid overdoses — 180 per day. That is five times higher than 20 years ago. Approximately one third of those overdose deaths were from prescription opioid pills — morphine, oxycodone, hydrocodone and methadone. Another third was from diamorphine, also known as heroin. The last third of those deaths was from fentanyl, a highly potent opioid — 20 times as potent as heroin — which has become popular as a substitute for heroin on the street.
Uncountably more are hopelessly trapped in the cycle of addiction.
The opioid crisis has been caused by a huge increase in opioid prescribing by doctors, which began in the 1990s. Many of those who become addicts start with prescribed opioids, then buy opioid pills on the street, and then turn to heroin because it is cheaper and more available. Youths abuse opioids pills as just another party drug, and once addicted, turn to heroin for the same reason.
The Surgeon General succinctly spelled out the reason doctors have become willing to put patients on high doses of opioids.
“… We arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training or support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught — incorrectly — that opioids are not addictive when prescribed for legitimate pain.”
Chronic pain is real and many suffer from it intensely. The problem is that, although opioids produce excellent short-term pain relief, opioids are neither effective nor safe for long-term pain relief.
The longer a person takes opioids the less effective they are, and the higher the dose needed for the same pain relief. This is called tolerance. Alongside tolerance, opioids actually increase pain sensitivity — actually make the pain worse. This is called hyperalgesia. The result is that patients ask for higher doses, and doctors prescribe higher doses, until many patients are on enormous doses of opioids, and yet, those patients still have pain.
A situation has been created in which doctors fear they are doing harm — actually causing addiction and overdose deaths — by prescribing such high doses.
At Eastern Plumas Health Care, beginning several years ago, the hospital board of directors, hospital administration and hospital physicians agreed that opioid prescribing had to be reduced. With much difficult work over several years, we have had remarkable success. What I see in the emergency department is that patients are happier and healthier — and often say they have less pain — once off opioids or on lower doses.
Our success at Eastern Plumas Health Care can be reproduced elsewhere. What is needed is agreement that that is the right direction to go.