When President Obama made reference to the problem of opioid addiction in this year’s State of the Union Address, I was encouraged by the continued high-level focus on this issue, which is now 20 years old.
In 2007, Congress took the first major government action on this issue by giving the Food and Drug Administration expanded powers to address this issue. The FDA decided to focus on two areas: 1) encouraging pharmaceutical companies to develop drug formulations of extended-release opioid that could not be so easily diverted and 2) educating physicians about safe prescribing practices.
At the same time, the Centers for Disease Control and Prevention released draft guidelines for the prescribing of opioids for chronic pain. While I found the recommendations — which are evidence based and non-binding— to be quite reasonable, controversy about them has been intense. While this is not surprising, given the diversity of the affected parties from patients to pharmaceutical companies, my hope is that a reasonable compromise can be reached without too much further delay.
Reasons for some optimism can be found in a recent excellent New England Journal of Medicine article that historian David Courtwright wrote (NEJM 373:22, 2095-7, 2015. David Courtwright, Preventing and Treating Narcotic Addiction). He notes that a similar prescription opioid epidemic was sparked in the 19th century by the overuse of the newly invented hypodermic needle and too liberal prescribing practices by physicians. Concerted education and pressure by reform-minded physicians and pharmacists succeeded in changing these practices and improving the situation. Unfortunately, the government intervention at that time, in the form of the Harrison Act of 1915, was not only belated but also brought in a criminal justice focus that led to the criminalizing of opioid addiction and those clinicians who attempted to treat this disorder.
Current data suggests a flattening of the previously rising curve of prescription opioid use, albeit with an apparent simultaneous increase in heroin use. In our treatment program at Kolmac, the percentage of patients with opioid addiction that we have been seeing has stayed about the same for the past three years and is down slightly from its peak during the previous years. Hopefully, we can learn from history and not inadvertently worsen an already complicated problem by yet another heavy reliance on law enforcement aka “war” approach.