Who’s to Blame for the Opioid Epidemic
Our fear of complexity might be leading us to over-simplify this complicated problem
Who’s to blame for our current, horrifying opioid epidemic? A recent article in The New Yorker placed the blame squarely on the Sackler family that owns the drug company that makes the prescription opioid OxyContin. A group of healthcare leaders blamed the Centers for Medicaid and Medicare Services (CMS) for questions on a hospital survey “that have had the unintended consequence of encouraging aggressive opioid use in hospitalized patients and upon discharge.” President Trump emphasized that “an astonishing 90 percent of the heroin in America comes from south of the border, where we will be building a wall which will greatly help in this problem.”
So, which is it, the Sackler family, CMS, or the countries “south of the border?” And what’s the magic bullet solution? Punishing the family? Stopping federal agencies from emphasizing the importance of pain management for hospitalized patients? Building a wall at the U.S.-Mexico border?
None of these solutions will, of course, have a sufficient, if any, effect on the staggering number of people who are addicted to opioids or die from opioid overdoses. But as with all crises, we want to find the single culprit upon whom we can mass our outrage and from whom we can demand redress. The fact is, of course, that there are many factors that have come together to produce the perfect storm that is the opioid epidemic in the U.S. The solutions, therefore, will have to be multifaceted. And that kind of complexity makes us uncomfortable.
In trying to help the public understand the roots of the opioid epidemic we have a typical problem in science and healthcare communication. If we want to be accurate, we must include many aspects, some of which involve technical details that are hard to explain. These include:
- Opioids are very effective analgesics and they are appropriately used in many instances, such as following major surgical procedures, for acute, severely painful medical events like small bowel obstruction and long-bone fracture, and for people with moderate to severe cancer-related pain. We cannot simply tell people never to take opioids or doctors never to prescribe them.
- The medical profession largely ignored the importance of pain management until the 1970s. Then, however, pain became a major area of preoccupation and physicians were increasingly strongly urged to evaluate and treat pain. This led to the growth of professional pain medicine societies, standards for pain management, and inclusion of the question “was your pain adequately treated” on patient surveys. Pain became the “fifth vital sign.” Physicians and hospital administrators have thus felt increasingly pressured to treat pain aggressively and that seemed to mean prescribing opioids.
- Doctors are not well-trained to communicate with their patients about pain. A recent study showed, for example, that patients often overestimate the amount of post-surgical pain they will experience. According to science writer Tinker Ready, “the data suggest providers are doing a poor job of counseling patients on realistic pain expectations.” Patients who are anxious and frightened that they will experience severe pain may be more likely to demand opioids, even if other options might actually be as good or better.
- There are many alternatives to opioids for pain management, often with equal efficacy and far fewer risks. Some of these are medication, but many are non-medication options like acupuncture, yoga, and cognitive behavioral therapy. But until recently, health care providers were taught very little about these alternative pain management interventions.
- Health insurance companies’ reimbursement policies make it much cheaper for patients to take opioids for pain than to engage less risky non-pharmacological solutions. Physician W. Clay Jackson recently pointed out at the 28th annual meeting of the Academy of Integrative Pain Management (APIM) that a patient in pain might pay a $4 or $5 co-payment for a generic opioid prescription, but a single session of acupuncture would cost the patient $70.
- There is no question that the pharmaceutical industry, including the Sackler families’ Purdue Pharma, market opioids aggressively, often minimizing the risks of addiction and overdose. They are subject to many lawsuits and have paid heavy fines for these practices, but as The New Yorker article makes clear, those losses do not compare to the enormous profits drug companies have made from selling opioid painkillers. Individuals at these companies rarely suffer any personal consequences, even when criminal mis-branding of a drug is involved.
- Opioid misuse and abuse have strong connections to feelings of despair and hopelessness. For example, West Virginia is one of the hardest hit states by the opioid epidemic and opioid use in the state has been linked to high rates of joblessness, particularly among those in the dwindling coal mining industry. Socioeconomic factors like unemployment and poverty are intimately associated with opioid abuse.
- Compared to law enforcement interventions, treatment for substance abuse, including opioid abuse, has received less attention and less funding. Although there are now three FDA-approved medications to treat people with opioid addiction, access and reimbursement to medication assisted treatment (MAT) is poor and some critics wrongly insist that MAT is merely substituting “one drug for another.” Similarly, although substance abuse is especially high among people with other mental health problems, like depression, access to and reimbursement of psychiatric treatment in the U.S. is severely lacking.
There are even more factors than those listed here, but this list should make it clear that there are multiple reasons behind the opioid epidemic. And consequently, multiple elements to the solution. But if we try to describe all of this complexity in public science and healthcare information efforts, we run the risk of losing our audience. It is much easier to grasp a single villain than to realize that combating opioid abuse and overdose requires at least these interventions:
- Retraining physicians and other healthcare providers about pain management-including how to talk with patients about pain—and about alternatives to opioid analgesics, without restricting their use by patients who truly need them.
- Rethinking how our regulatory agencies like CMS and the Joint Commission set standards for pain management and their requirements for consumer evaluation of how well healthcare providers treat their pain.
- More generous health insurance reimbursement for alternatives to opioid medications.
- More generous health insurance reimbursement for treatment of mental health disorders, including substance use disorders.
- More severe penalties for pharmaceutical companies that mis-brand opioids and illegally promote addictive drugs, including criminal penalties resulting in jail time for any complicit executives.
- Recognition that opioid abuse is also a socioeconomic issue and that hopeless, impoverished people are especially vulnerable.
We know precious little about how to communicate complex scientific issues involving health and safety issues to consumers. Science writer Francie Diep recently interviewed five public health experts about the CDC’s new campaign to reduce opioid addiction and overdoses and reported that “The videos are incredibly moving and yet, according to nearly every public-health researcher Pacific Standard consulted, they probably won’t do much. Why not? Everyone pointed to the same fatal flaw: the ads tell viewers that prescription opioids are a big problem, but don’t tell them what steps to take.” The public health experts wondered why the CDC campaign seemed devoid of influence by what is known in health psychology.
But defaulting to blaming a single villain is clearly not an adequate or morally responsible solution. In his speech declaring an opioid emergency, President Trump listed a number of important solutions. There are some he did not mention and at least one—building a wall—that is likely irrelevant. It is time for federal agencies like the CDC and NIH to test methods for educating the public on the complexities of this problem, what role individuals play in helping to solve it, and what the public should be demanding from policymakers. Complexity is uncomfortable and makes us feel helpless to intervene. It is up to scientists, public health experts, and healthcare providers to treat those helpless feelings by figuring out how best to educate us about the opioid epidemic.