Lessons from the opioid crisis, a case of overtreatment with devastating consequences

Cristina Roure
 

If you are regulars of American series such as House, The Affair or This is us, you will be familiar with the classic protagonist who, after an episode of acute pain, ends up becoming addicted to prescription opioids such as Vicodin®, OxyContin® or Percocet®. Do not think that this is a writer’s exaggeration.

In 2015, life expectancy in the United States changed the trend and began to decline for the first time since the First World War. Among the causes, the epidemic of deaths from opioid overdoses, which multiplied by six between 1999 and 2017 (1), surpassing deaths associated with AIDS at its worst or those related to the Vietnam War. The epidemic was declared a national emergency by the United States Department of Health in 2017 and, despite the campaign deployed to combat it (2), 130 people still die in that country every day from opium overdose. If you are interested in the subject and want to delve into it, read the supplement that Nature dedicated to it in September last year.

According to the CDC, this epidemic has its origin in the massive overprescription of opioids by the medical community that occurred in the mid-1990s (2), with an unjustified liberalization of the indications, the doses used and the duration of the treatments. Until then, opioids had been restricted to short-term treatments for acute pain in hospitalized patients and terminal cancer. Coinciding with an aggressive launch of new opioids, their chronic use began to be promoted to treat low back pain, headaches or fibromyalgia. Purdue, the manufacturer of OxyContin®, promoted its massive use through the continuous training of physicians (more than 20,000 courses in six years), using scientific societies and opinion leaders as channels, in which it "invested" huge amounts of money to promote the discourse that the addictive power of opioids was overrated and that, with such highly effective and safe pain control drugs, it was unacceptable that they were not used more liberally. The American Pain Society launched the concept of pain as "the fifth constant" and agencies such as JCAHO included demanding pain control standards in their accreditations, thus also encouraging more liberal prescribing (3). Purdue donated $ 3 million to Massachusetts General Hospital to change its pain unit to MGH Purdue Pharma Pain Centre.

The promotion also targeted patients, promising a life free of any pain or discomfort, and all of this resulted in a huge sales success. Prescriptions for OxyContin® for non-cancer pain increased 10-fold between 1997 and 2002. In 2015, 37.8% of the adult population in the United States were taking opioids and the amount prescribed was enough to treat the entire population of the country for three weeks (2). Medication flowed, not only into the hands of patients but also into those of their families and the black market. Patients who had developed addictive disorders began to resort to cheaper illicit alternatives such as heroin, so that this first wave was followed, starting in 2010, by another characterized by deaths from heroin overdoses and later by a third, which began in 2013, in which there was a spectacular increase in deaths from overdoses of synthetic opioids, especially fentanyl or tramadol, of illegal use but also subject to medical prescription.

Uncontrolled prescribing began to be contained in 2011. The Department of Health launched a campaign in 2017 to combat the epidemic. Alex Aztar, Secretary of State for Health, summarizes the five basic pillars of the strategy in an informative video. The Choosing Wisely movement also developed specific initiatives such as “Opioid Wisely” from Choosing Wisely Canada.

However, overdose deaths have continued to rise, exceeding those from motor vehicle accidents and firearms. It’s a case of overtreatment with unprecedented consequences, in which factors typically implicated in overtreatment cases were added by others typical of the American health system. Let's see some of them:

• Medicine based on "evidence" clearly biased by commercial interests. Opioids aren't that effective for long-term chronic non-cancer pain, and it's not true that the risk of addiction is low.
• Lack of knowledge about pain and of critical and independent evaluation of the evidence by clinicians. The message that only 1% of patients develop addiction was based on a 1980 letter to the editor that was quoted and quoted repeatedly. This was a retrospective study in patients who got opioids during an episode of hospitalization and which, therefore, was not able to be generalised to patients undergoing chronic treatment (4).
• The influence of commercial interests on opinion leaders, scientific societies and the Administration.
• The impunity with which pharmaceutical companies acted for years, using corrupt practices to increase their sales and reaching financial agreements with families in cases of complaint.
• Direct advertising to the consumer. Unlike what happens in Europe, since 1997 the FDA allows direct advertising to the consumer.
• The great accessibility to opioids thanks to the proliferation of so-called pill mills or express consultations for pain treatment that were in fact dispensers of opioid prescriptions with practically no medical visit. In the United States, no system allowed the detection of several prescriptions for the same patient.
• Lack of accessibility to addiction care programs. In the early years of the epidemic, addiction was not considered a disease and was a source of stigma and punishment. There were no programs for methadone, needle exchange, narcotics, access to naloxone, etc.

Spain, with 1.48 deaths per 100,000 inhabitants per year due to opioid overdoses in 2016, and European countries, in general, are far from the United States figures, which exceed 13 deaths per 100,000 inhabitants. However, the consumption of prescription opioids in Spain grew by 83.59% between 2008 and 2015, especially at the expense of tramadol and the various forms of rapid-release fentanyl that are used mainly in the treatment of chronic non-cancer pain.

The worst adverse effects of opioids are not immediate and do not go away simply by stopping treatment. In the same way, the worst effects of the wave of opioid over-prescription of the 1990s, a veritable epidemic of addiction and death from overdoses of all kinds of drugs, were not immediate and continue to destroy lives, families and communities despite that the prescription of opioids began to be controlled from 2011 (1). We should study and understand how this crisis arose in the United States and its long-term effects to reflect and prevent the same phenomenon from repeating itself in other countries like ours.

Bibliography

1. DeWeerdt S. The natural history of an epidemic. Understanding how the opioid epidemic arose in the United States could help to predict how it might spread to other countries. Nature 2019; 573:S10-S12.   

2. CDC overdose understanding the epidemic.

3. Baker D. History of The Joint Commission’s Pain Standards. Lessons for Today’s Prescription Opioid Epidemic. JAMA 2017; 317(11): 1117-8.

4. Porter J. Addiction rare in patients treated with narcotics. N Engl J Med 1980: 302: 123. 

5. Helmerhorst  GT. An epidemic of the use, misuse and overdose of opioids and deaths due to overdose, in the United States and Canada. Is Europe next? Bone Joint J 2017;99-B:856-64.