It pains me to write this column. The opioid epidemic is arguably the most catastrophic and enduring public health crisis since the flu epidemic of 1918—yes, even worse than the HIV/AIDS epidemic of the ‘80s. Since 2000, over 200,000 people have died from overdoses of prescription opioids alone, another 300,000 from heroin and synthetic opioids. Now synthetic fentanyl has infiltrated the market with the most toxic opioid ever known. The overdose death curve is steepening. There is no fix in sight and our response is already too little, too late.
Of course, there is no shortage of commentary on the root cause of the crisis, and there are many people and motivations to blame. During residency, I distinctly remember all those No Pain buttons the anesthesiologists wore proudly on their lab coats. That campaign, not surprisingly, was initiated and funded by big pharma. Pain was first promoted as the “5th vital sign” (a concept long-since discredited) by the VA hospital system in the late 1990s; then, in 2001, the Joint Commission published pain assessment and management standards supported by Purdue Pharmaceuticals, the makers of OxyContin.
Scientific inquiry obsessed over short-term pain reduction, not long-term addiction. And what about the doctors? Like entranced rats, we followed the sweet music of the Pied Piper, diligently parroting the benefits of pain medication without any pause for doubt about the potential for addiction.
So, we are finally awakening to our self-made catastrophe and taking pride in our reversal of course. The pharma companies have paid some fines (no executives are going to jail), pill mills are being raided, and physicians have self-imposed restrictions on their own prescribing. And what is all this doing? Driving addicts that we “created” into the streets to use heroin and synthetic fentanyl.
Reducing access to prescription opioids does not solve the immediate crisis for patients who are already addicted. Thousands more will die before this fire burns out. What a tragic shame and a major blemish on our profession!
But, is this really a one-off story of greed and blind trust, or is this just the tip of the iceberg? Isn’t it time that all of us in the scientific community scrutinize other ticking time bombs and intervene on behalf of our patients before it’s too late?
Go back, if you will, to your training and think about negative feedback loops and receptor downregulation. Much of physiology and pathophysiology as we know it follows this pattern. When the balance is disrupted, endogenously or exogenously, dysfunction ensues and over time the physiology becomes resistant and treatments become less effective (eg, insulin and Lasix). Now think about neurotransmitters. Yes, the same neurotransmitters that are manipulated by one of the most profitable classes of medications in history: so-called “lifestyle” medications. These include the antidepressants, anxiolytics, ADHD treatments, and a host of other stimulants and sedatives. And every one of them has the potential for dependence and tolerance in one way or the other. But if you are a pharmaceutical company, what better way to ensure a customer for life than to make him/her dependent on your drugs? The opioid epidemic has already demonstrated that pharma is a poor moral steward, so don’t expect it to police itself. All told, you see many of the same patterns evolving here: Lots of direct-to-consumer advertising, praying on societal and social ills, blurred lines between disease and “dis-ease,” and too many physicians falling victim to patient/parental pressure and pharma influence.
As physicians and scientists, we must stand up to these influences and resist the same mistakes that led to the opioid crisis. We must learn the hard lessons, and scrutinize more diligently. We must remember the mechanisms of dependence and addiction. We must be very wary of manipulating delicate physiology in the absence of real disease.
And we must never be complicit with dangerous pharma tactics again.
Lee A. Resnick, MD, FAAFP
Editor-in-Chief, JUCM, The Journal of Urgent Care Medicine
