The opioid epidemic is all over the news, and has become both a national political football and a health care crisis. It might be worthwhile to look at some of the factors that got us here.
The opioid epidemic has become a national emergency because of multiple factors: deaths related to overdose, lost employment, harm to families and relationships, and the cost for treatment. The US now consumes 80% of the world’s opioids.
Prior to the 1980s opioids were rarely prescribed. Pain was looked at differently. People used to look at pain with the mantra “What doesn’t kill you, makes you stronger”. That view has changed over time and there is now more of a drive to stop pain by external means. Previously, because of concerns about addiction, providers were uncomfortable with prescribing opioid medications. That view shifted in large part due to misinformation about newer pain medications, including (1) that these medications are effective for chronic pain; (2) that no dose is too high; and (3) that very few patients with chronic pain actually develop an addiction. In reality, after one month of use of opioid pain medications, tolerance develops which increases the risk for addiction even when a patient is taking the medication for an actual pain disorder.
The opioid epidemic is seen by many as a symptom of a faltering health care system. Opioids are prescribed across medical specialties and most people who get addicted first access these medications directly or indirectly from providers, not off the street. So how did we get here?
Providers generally have a fast-paced schedule and are challenged to find time to have difficult conversations with patients. The current health care reimbursement system weighs heavily in favor of providers doing procedures and prescribing medications. As a result, the practice of medicine has moved away from the doctor-patient relationship and has become more based on customer service with a focus on patients liking providers versus trusting them.
The question of where do we, as prescribers, go from here involves a longer conversation, but there are some practical steps to start with. It starts with limiting access to opioids to situations when it is appropriate (they are not effective for pain syndromes like fibromyalgia and not needed in every post-operative situation). It is important to prescribe the smallest dose for the shortest length of time (ideally 1 month or less) with careful psycho-education about the use and risks of opioid medications. There is a need for time and training on motivational interviewing for providers to help patients with addiction become invested in sobriety.
There is a need for de-prescribing clinics and providers who understand the need for slow taper off long-term opioid medication use. Co-location of rehabilitation, mental health and general healthcare services would allow for better coordination and team based treatment. Ultimately, there is a need for a chronic care model which brings back the primacy of the doctor-patient relationship as important to healing.