Viewpoint: Are Doctors to Blame for Prescription-Drug Abuse?

Conscientious and well-trained physicians have contributed to the crisis of opioid-pain-medication addiction

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Prescription painkillers are creating a massive public-health crisis. Since 1990, deaths in the U.S. from unintentional drug overdoses have increased by over 500%. Most of this rise can be attributed to prescription painkillers, which now kill more people than heroin and cocaine combined. Where are all these pills coming from? Not Mexico. Not all from those Florida “pill mills.” Many of them are coming from prescriptions generated by doctors like us who are seeking to help our patients with real pain. It’s true: conscientious and well-trained doctors are partly to blame for the rapidly rising death rate among Americans from prescription pills.

The backstory goes like this: in the 1980s and ’90s, the medical community recognized that patients in pain were often undertreated. Oligoanalgesia, the scientific term for undertreatment of pain, rightly concerned a lot of people. Studies showed that doctors didn’t do a good job asking about pain or treating it properly when they did identify it. Worse, there were documented disparities in pain treatment: affluent white patients were much more likely to get their pain addressed than poor or minority patients.

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In response, there was a major effort to redress this oversight. Doctors were encouraged to think about patients’ pain severity on a self-reported numerical score as a “fifth vital sign” (in the same league as blood pressure and body temperature). Next, medical students and trainees were instructed that patients could never become dependent on narcotics if prescribed for legitimate pain. (We both remember being taught this myth.) Last, opioid pain medications like oxycodone (the active ingredient in Percocet) and hydrocodone (the active ingredient in Vicodin and Lortabs) were framed as safer alternatives to nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen and Vioxx that could trigger peptic ulcers or cardiac conditions. Some of this push toward opioids was driven by the drug companies that made them. And some of it was driven by patient-advocacy groups (many with opaque ties to these drug companies) and medical societies seeking to boost treatment for patients with debilitating pain.

Unfortunately, we went too far in that direction. From 1999 to 2010, the amount of opioid narcotics prescribed by American doctors tripled. The numbers for kids are just as worrying: narcotic prescriptions for children have doubled since the 1990s. Let’s try to put these numbers in context: in 2011, enough hydrocodone was prescribed to medicate every American around the clock for a month.

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Beyond the increase in prescriptions, doctors are more likely than ever to diagnose patients with chronic-pain syndromes. The Institute of Medicine estimates that 100 million Americans have chronic pain. That would mean that almost 1 in 2 people has chronic pain, if you exclude children.

It’s hard to know what has changed so drastically to drive these massive numbers, either on the diagnosis side or the treatment side. But one thing we do know is that chronic pain almost always starts as acute pain, usually from an injury or surgery. Many of the afflicted patients are given opioid prescriptions, but their pain persists — possibly from hyperalgesia, a hypersensitivity to new pain caused by those very opioid prescriptions. Between tolerance and hyperalgesia, patients often need escalating doses of opioids just to feel pain-free. Higher doses of painkillers may disturb breathing patterns during sleep, and the additional use of sleeping medications or alcohol can be lethal. This is at least partly why we are seeing so many prescription-medication deaths.

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Medical guidelines already state that doctors shouldn’t choose opioids for most patients with chronic pain. But we doctors also need to start scaling back on prescribing opioids for acute pain, since some acute pain turns into chronic pain. Everyone with new pain should be started on a high dose of ibuprofen (like Motrin or Advil) or acetaminophen (like Tylenol). These medications have been proved to work as well as the opioids even for conditions like gall-stone attacks. For some patients, we can add a prescription for a limited number of opioid pills to be filled only if absolutely necessary. With that small prescription should come a big warning. Something like: “These drugs are highly addictive, even in short-term use. These drugs have been associated with death, even in therapeutic dosing. These drugs, when accidentally ingested by children, are fatal.” As doctors, we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain. It may take an extra few minutes, but it will save lives.

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