Countering the prevailing narrative about the causes of the US opioid crisis

Heimer, Robert, et al. “Countering the Prevailing Narrative about the Causes of the US Opioid Crisis.” The Lancet Psychiatry, vol. 5, no. 7, 2018, p. 543., doi:10.1016/s2215-0366(18)30167-6.

Downloaded from https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30167-6/fulltext.

Correspondence

On Aug 8, 2017, President Trump tweeted that opioid use problems constituted a national emergency, but he has yet to commit Federal funds needed to mount an effective response. Instead he has posted National Guard troops to assist US Custom and Border Protection Agency attempts to interdict the flow of opioids into the country and proposed drastic funding cuts to the Office of National Drug Control Policy, the agency charged with solving the opioid crisis. This gap between words and actions typifies the response of the USA as a whole and is emblematic of the supply-side, evidence-averse approaches that characterise the history of the US opioid crisis.1

Nowhere is the incoherent US response clearer than in the origins of the crisis, a classic case of the road to hell paved with good intentions. In the 1980s and early 1990s, unaddressed pain loomed large as the US health-care systems shifted towards patient-centred medical care. Clinicians realised that patients’ poorly controlled pain slowed their recovery from trauma or surgery and that terminal pain was unnecessary and undertreated. Pain came to be characterised as the fifth vital sign. Yet pain is a symptom, not a vital sign and cannot be measured objectively. Very limited research was done to determine whether opioid medications really were a safe and effective tool for treating chronic, non-terminal pain.2 Insurance companies were loath to provide coverage for more time-intensive and expensive alternative pain therapies. Bolstered by exceedingly aggressive marketing campaigns, opioids became the treatments of choice as the pharmaceutical industry expanded four-times the supply of traditional formulations after 1991, peaking at approximately 220 million prescriptions for a population of 312 million in 2011.3 The opioid crisis was fueled by increases in all forms of opioid medication, not just the extended release formulations.3,4

Subsequent supply-side attempts to control diversion of prescribed opioids—the initial driver of the crisis—have led to widespread replacement of so-called pill mills and other sources for diverted pharmaceuticals by narco-trafficked heroin and even more potent fentanyl compounds.5 The creation of new black markets has produced results that add HIV, hepatitis B virus, and hepatitis C virus transmission risks to the harms of misused pharmaceutical opioids. In summary, both the origins of the crisis and subsequent outcomes are the result of inadequate assessment of medical risk and benefit and the failure to fund research and opioid agonist evidence-based treatments.

We declare no competing interests.

Robert Heimer, Kathryn Hawk, Sten H Vermund

robert.heimer@yale.edu

References

1. Werb D, Kerr T, Nosyk B, Strathdee S, Montaner J, Wood E. The temporal relationship between drug supply indicators: an audit of international government surveillance systems. BMJ Open 2013; 3: e003077.
2. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol 2006; 16: 405–16.
3. Guy Jr GP, Zhang K, Bohm MK, et al. Vital signs: changes in opioid prescribing in the United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 697–704.
4. Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician 2014; 17: E119–28.
5. O’Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 897–903.