Speak Out Rheum: How Did We Go So Wrong with Opioid Prescribing?

This is not meant to excuse the fact that the key hypothesis was not tested, but rather to offer perspective for how difficult and expensive it would have been to perform a study to adequately test the hypothesis that opioid medications would be safe and effective for the treatment of chronic nonmalignant pain. In retrospect, phase 4 postapproval studies should have been done to search for safety signals. Instead, the medical community (and the lay public) relied upon a badly flawed assumption.

The stage was set for the evolution of an enormous problem, which was not anticipated, based on what we now realize were faulty assumptions, especially in a society in which chronic pain was gaining a high profile, and for which a consensus existed that something needed to be done to relieve the suffering of all these people.

A second huge mistake was to recommend administering analgesic medication in the same manner as for cancer pain.

“Stay ahead of your pain,” we advised patients. “Don’t wait until you have pain: Take your pain medicine on a schedule, so you always have a good level of medication on board.” This might make sense for someone with painful bony metastases, but chronically, this is a formula for the development of tolerance to an opioid medication.

Opioid tolerance is “characterized by a reduced responsiveness to an opioid agonist, such as morphine, and is usually manifest by the need to use increasing doses to achieve the desire effect,” and “more than 10-fold escalations of dose in chronic pain management are common,” according to Morgan et al.⁷ Patients treated this way typically require progressively higher doses of opioid analgesics to achieve pain relief, sometimes reaching doses that suppressed respiration and resulted in fatal overdose.

Standard practice was to advise patients to take their opioid medications in a manner that virtually guaranteed they would develop tolerance, resulting in ever-increasing doses (and toxicity) and physical dependence that produced withdrawal if the dose were decreased or discontinued.

Between 1997 and 2002, morphine, fentanyl and oxycodone prescriptions increased by 73%, 226% and 40%, respectively.⁸ Around 1999 it was recognized that overdose deaths from prescription opioids were increasing, and of course, this trend has continued for years.

Opioid Crisis

The opioid crisis is a very complicated phenomenon. The Centers for Disease Control and Prevention (CDC) divides it into three general phases: the first from 1990–99, dominated by prescription opioids; the second from 2000–13, dominated by heroin; and the third from 2013 on, dominated by fentanyl.⁹ From the standpoint of physician prescribing, the first phase dominated by prescription opioids is of the most interest to me.