Are Doctors to Blame for Prescription Opioid Overuse in America?

A RECENT JAMA NEWS release asked whether the marketing of opioids to physicians was associated with overdose deaths. The article pointed the finger at both the marketing tactics of pharmaceutical companies and at the physicians who are prescribing the medications. But the truth is, there are multiple stakeholders, individuals and entities contributing to the opioid epidemic. So, to cure it, we all have to play a role.

The JAMA study set out to investigate a potential association between the marketing of opioid medications to physicians and the opioid-related death rates of the counties in which those medications are marketed. In short, the research found that the more marketing dollars pharmaceutical companies spent in the counties studied, the more physicians prescribed the drugs and the higher the associated death rates were. Though the study pointed only to correlation, not causation, the picture it paints oversimplifies the equation. The bigger picture can be much more complicated – for doctors and their patients, as well as for society as a whole.

As a physician with sub-specialty expertise in the treatment of acute, post-operative and chronic pain, I know how difficult and elusive successful treatment can be. I believe strongly in the concept of education as analgesia. In other words, the more insight individuals have about the nature of pain signals, the anatomy of pain pathways and the reasons for why they feel what they feel, the better their pain management. I'm aware of the benefits of multi-disciplinary approaches that incorporate combinations of medication, therapy, rehabilitation, cognitive-behavioral therapy and interventional procedures (as compared to a focus on pain pills alone). I understand that opioids have a long history of providing very effective pain relief in certain circumstances. But there are specific considerations that must be understood to optimize their benefit and minimize their risk. And I understand how neuromodulation is evolving as a state-of-the-art approach to pain management that can minimize or eliminate the need for opioids by applying stimulation to the brain or peripheral nerves to overcome and eliminate pain.

But just like the contributing factors to the opioid epidemic can be oversimplified, many tend to think of pain itself in simplified terms. Many people's concept of pain is that it's a warning sign or signal that something is wrong, something has been injured or is at risk for injury. This is often true of acute pain. It is a symptom. But chronic pain is much more complicated and can be quite different. As opposed to just a symptom, chronic pain can be considered a disease in and of itself. The biopsychosocial model of pain tells us that there are emotional, cultural, and other contributing factors. And neuroscience is showing that the brains of individuals who've had early traumatic experiences may develop to process pain signals differently and place those individuals at increased risk of intractable pain. Add to this complexity the societal pressures and demands for instant answers, instant results, and instant access to an internet full of medical information and recommendations. Clearly, treating pain is complicated. No pill, even an opioid, can be a simple cure for chronic pain. There may be no simple cure. It's been said that chronic pain is less like a puzzle than a mystery. Puzzles have an "answer." But sometimes there's no clear answer or resolution to a mystery. The search for a chronic pain cure in a pill (or an injection, or a surgery) is elusive. It's not that simple.

Ironically, some of the additional factors that likely contributed to the opioid epidemic were related to the genuine desire by prescribing physicians to be a "good doctor." At the same time pharmaceutical manufacturers were doing their marketing, medical societies, medical authorities and state medical boards were educating physicians on the need to address pain in every patient. In fact, physicians were required to view pain assessments as the "fifth vital sign," something that must be specifically and explicitly assessed at every patient interaction. In many states, physicians were obligated to demonstrate that they had undergone additional continuing medical education credits in pain management in order to renew their licenses. In addition, direct-to-consumer marketing resulted in patients evolving to much more "aggressive" requests from doctors to cure their pain – ("not now, but right now"). The opioid epidemic didn't occur as a result of a simple equation of manufacturer marketing resulting in increased physician prescriptions. It was a perfect storm with multiple variables and factors.

Curing the opioid epidemic will require a multifaceted effort by all stakeholders. Well-intentioned efforts to point out simple correlations without taking into account systemic factors significantly increase the risk of un-intended consequences. For instance, in the interest of addressing the opioid epidemic, there has been a recent focus on what many physicians feel are heavy-handed laws and protocols meant to reduce physician prescribing. Some physicians have simply stopped prescribing these medications all together, rather than judiciously prescribing to the subset of patients who are appropriate candidates, which likely results in a significant reduction in appropriate pain management. Un-treated and under-treated pain reduces patient productivity and quality of life – but also has physiological consequences that may result in other dangerous medical problems. And some individuals who cannot secure necessary pain control from their physician will resort to illegally acquired drugs that place them at higher risk of misuse/abuse, or consider catastrophic alternatives such as suicide. Holistic approaches to this epidemic are needed. Cooperation between manufacturers, physicians, patients, medical societies, medical boards, legislators and other stakeholders is needed and necessary to appropriately address the pain of the opioid epidemic.