Inside the Opioid Crisis: The Intersection of Policy, Industry, and Health Outcomes

July 31, 2017 — Guest commentary by Michael Parenti

America’s opioid crisis is a major issue and the subject of ongoing debate. But before we can begin to tackle this problem, we need to take a look at the policy decisions that got us here.

War has a way of embedding itself within the public consciousness. Vietnam. Iraq. Afghanistan. Each has a rich history, yet for many Americans, these countries’ names are synonymous with our nation’s military conflicts. Without minimizing the profound sacrifice of our men and women in uniform, it is worth noting that the American lives lost during wars in Vietnam, Iraq, and Afghanistan combined amount to roughly the number of Americans who are expected to die from drug overdoses in 2017.

Driven in large part by opioid abuse — and exacerbated by the spread of cheap and potent synthetic opioids like fentanyl — fatal drug overdoses in the United States increased by 19% from 2015 to 2016, the largest annual jump ever recorded. So deadly is this spike that the U.S. FDA Commissioner Scott Gottlieb, M.D., recently requested the removal of the powerful opioid painkiller Opana ER from the market — the first time the agency has taken steps to remove a currently marketed opioid pain medication from sale due to the public health consequences of abuse.

Despite the fact that drug overdoses are the leading cause of death among Americans under 50 years of age, our national addiction — more than 236 million opioid prescriptions were written in 2016 — remains, at best, a peripheral concern for anyone without a personal or professional connection to one of its victims.

[Interactive Overdose Map]

Where Did the Opioid Crisis Begin?

In his 1995 Presidential Address to the American Pain Society’s Annual Scientific Meeting, Dr. James Campbell proposed that “pain” should join temperature, blood pressure, respiratory rate, and heart rate as a standard vital sign. “Vital signs are taken seriously,” Campbell asserted. “If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated.”

Of course, unlike the four established vital signs, pain is not easily quantifiable — a challenge that did not prevent Campbell’s clarion call from having significant effects. In 1998, the Veterans Health Administration (VHA) incorporated the treatment of pain as the fifth vital sign into its new strategy for improving pain management among its patients. According to the VHA toolkit, “It is important to emphasize that pain as the fifth vital sign is a screening mechanism for identifying unrelieved pain. Screening for pain can be administered quickly for most patients on a routine basis. As with any other vital sign, a positive pain score should trigger further assessment of the pain, prompt intervention, and follow-up evaluation of the pain and the effectiveness of the treatment.”

In practice, “intervention” typically consisted of prescribing painkillers previously used only for palliative care or to treat short-term acute pain. Minimizing pain was of paramount importance, and opioids appeared to be a powerful solution.

Where the government went, the private sector followed, and many doctors began treating pain as a vital sign. Just as they routinely measured temperature, blood pressure, respiratory rate, and heart rate, it became standard practice for doctors to inquire about their patients’ pain regardless of the ailment for which they were being treated. This ultimately resulted in more prescriptions for pain-managing opioids.

With increased demand came increased supply, and pharmaceutical companies began diverting significant R&D resources to the development of increasingly potent — and addictive — opioid painkillers. Throughout the late 1990s and early 2000s, the percentage of total new drugs approved by the FDA comprised by opioids grew dramatically, so much so that opioids are now the most prescribed class of drug in America.

As long-term — and often uninformed — opioid use became the norm, overdoses began to skyrocket. Fatal opioid overdoses have quadrupled since 1999, and there was a 99% increase in emergency room overdose cases from 2005 to 2014. These shocking figures, argues erstwhile Surgeon General Vivek Murthy, are the natural — if unintended — outcome of the policy change initiated by Dr. Campbell. In an open letter penned in August 2016, Murthy summarized, “It is important to recognize that 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 and support to do so safely.” Compounded by the widespread misinformation that opioids are not addictive when prescribed for legitimate pain, those good intentions are in large part responsible for the crisis in which our nation now finds itself.

A Step in the Right Direction

Fortunately, the healthcare community is finally beginning to correct for the crisis’ root causes. In addition to the FDA’s request that Opana ER be removed from the market, both the Centers for Disease Control and Prevention (CDC) and the American Medical Association (AMA) have released statements discouraging the use of pain as a fifth vital sign. Further, major lobbying groups like the Pharmaceutical Research and Manufacturers of America (PhRMA) now require members to devote a portion of their R&D budgets to studying the potentially addictive qualities of their drugs.

And it may well be working: the CDC recently announced that prescriptions for highly addictive painkillers such as oxycodone dropped 13 percent from 2012 to 2015 — a trend that can in large part be attributed to messaging from medical and public health authorities urging doctors to cut back on the number of prescriptions they write, as well as the dose and duration of those prescriptions. That’s a huge shift from 15 years ago, when physicians were aggressively encouraged to treat their patients’ pain. A seemingly modest drop like this could hold significant implications for the overall trajectory of the crisis, as most addicts start with opioid prescriptions and graduate to street drugs when those prescriptions become unavailable.

The salient point here, however, is that even seemingly innocuous healthcare policies — whether mandated by the government or driven by private sector consensus — have very real effects on our public health. “Assessing pain with the same zeal as other vital signs” may initially have seemed like an innocent, and indeed valuable, suggestion, but as we’ve seen, it didn’t play out that way.

The (unfinished) story of America’s opioid crisis is extremely complex — the outline sketched above barely scratches its surface — but it is a story that needs to be told. The insights we draw from this narrative may not single-handedly prevent the next public health crisis, but they will certainly drive home the remarkable influence that healthcare policy has on each of our day-to-day lives. Such awareness is itself tremendously important, and, at the very least, will prevent us from legislating ourselves into a public health war that we cannot win.

Michael Parenti is a Manager of Analytics and Data Strategy at Saatchi & Saatchi Wellness with a background in public health research.