The number of opioid prescriptions being written has finally started to decline. The Centers for Disease Control (CDC) announced that this occurred during the years 2012 to 2015 – the first reduction since the modern opioid epidemic began. Encouragingly, non-government organizations such as insurance companies indicate a continued decline since 2015.
Beginning in the late 1990’s the pharmaceutical industry, led by Oxycontin manufacturer Purdue Pharma launched a massive and effective campaign to convince physicians that the danger of addiction to opioid medications was not as great as they had been taught. At the same time, they promoted the idea that opioids were effective not only for acute pain but also for chronic pain, although the evidence for this was weak.
To me, the CDC announcement indicates that the extensive measures implemented to remedy the problem are finally having an effect. The pharmaceutical companies were forced to stop their misinformation campaign and some of their leading spokespersons’ physicians publicly recanted. Law enforcement disciplined a small number of irresponsible physicians who were prescribing an astonishing volume of opioid medication in high volume “pain mills.” After the CDC released guidelines for the proper prescribing of opioid medications, some states, such as Massachusetts made the guidelines mandatory. In Maryland, the medical society negotiated with the governor and legislature to adopt a modified version of the guidelines.
Some might describe this as the “end of the beginning” of the first wave of opioid addiction. Tragically, the overprescribing of opioids set off a second opioid addiction wave – heroin – and we are now in the throes of a third wave – synthetic opioids, such as fentanyl. What’s more, data indicates that overprescribing of opioid medication while reduced, does persist. Curiously, this appears to be a regional phenomenon – heaviest in the Southwest, New England, and parts of Appalachia.
Two lessons about physicians that I take from this story are:
- Despite their training and commitment to “evidence-based medicine,” physicians can be persuaded by sufficiently sophisticated commercially driven campaigns to establish clinical practices that are destructive to patients under their care and the community in general.
- Public health efforts – both legal and informational – can be effective in restricting exploitative industry practices and getting physicians back on track in their clinical work.
What’s next? Most physicians take seriously the dictum, “Above all, do no harm.” I have not yet seen formal studies of the practices of the newest generation of physicians who were not “re-educated” by the pharmaceutical companies. My personal experience, however, with the medical students whom I teach at Georgetown University is that they are aware of the overprescribing problem and I believe are not likely to perpetuate these problematic over-prescribing patterns. Now that the addictive potential of opioid medications has been re-established, only time will tell whether a more balanced approach to the use of them in the management particularly of chronic pain will occur.