The opioid abuse epidemic: How healthcare helped create a crisis

In 1996, pharmaceutical firm Purdue Pharma launched a campaign informing patients and doctors that a new, safe drug was available to combat pain that was not the result of cancer, surgery or trauma.

This pill could relieve chronic back pain caused by daily physical demands. And it was safe because it would slowly release its narcotic ingredients, making it unlikely to become addictive, it said.

The drug caused a cultural shift in the way physicians treated pain and how Americans viewed it.

“It was this change in prescribing practices that would lead to our public health crisis,” said Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing.

Two decades later, the country faces record mortality rates associated with drug overdoses, including those related to heroin, an option many addicts turn to as a cheaper and more accessible alternative to painkillers.

Now the federal government, states, drug manufacturers and health providers are scrambling to find ways to confront an epidemic that began in the doctor's office rather than the street, and is affecting a more diverse swath of America.

The number of deaths from prescription drug overdoses jumped 242% in less than 20 years, from 7,523 in 1999 to more than 25,000 by 2014, according to the National Institutes of Health. The number of opioid prescriptions also rose significantly in the U.S., from 116 million in 1999 to 207 million in 2013, according to figures from IMS Health.

Kolodny said the rise was largely the result of that 1996 campaign touting Purdue's new drug OxyContin. Its sales grew from $45 million in its first year to $1 billion four years later.

It was not until 2007 that Purdue would plead guilty to federal criminal charges of misinforming doctors when it claimed OxyContin's time-release mechanism made it less likely to be abused. Addicts quickly learned that simply crushing the pill released the narcotic.

But by that time, the culture shift within the medical community was established. Physicians were asked to improve how they assessed and managed patient pain. Doctors saw opioids as the answer to the pain affecting blue-collar and rural patients.

In 1995, the American Pain Society said pain should be considered a fifth vital sign, adding it to the indicators that assess overall health.

Further demands came in 2001, when the Joint Commission issued its pain standards for healthcare providers. To receive payment, providers had to follow the standards.

“There was a time when doctors faced civil penalties and professional penalties for not prescribing opioids,” said Dr. Steven Cohen, director of the Pain Medicine Division of Medical Education at Johns Hopkins Medicine.

The Centers for Disease Control and Prevention estimated that as many as 259 million painkiller prescriptions were written in 2012 alone, with the U.S. responsible for 99% of global sales for hydrocodone and 81% of the world's consumer market for oxycodone.

The same data show that the highest rates of drug overdose deaths in 2014 occurred in New Hampshire, West Virginia and in Kentucky, which last year filed a civil lawsuit against Purdue, alleging the drugmaker's campaign led to the state's addiction epidemic.

But the increased rates of opioid prescriptions and deaths have not led to more physician training in pain management, said Dr. Ed Michna, an anesthesiologist at Brigham and Women's Hospital in Boston and a member of the board of directors for the American Pain Society. Current training is relatively weak, he added.

The federal government recently introduced a number of plans to combat the opioid-abuse epidemic.

In December, the CDC delayed release of guidelines that recommended primary-care physicians prescribe the smallest effective dose of opioids and that they test patients to identify other drugs they might be using.

Pain management medical groups weighed in, saying the guidelines could cause many primary-care physicians to avoid prescribing opioids altogether if they are heavily regulated or carry the possibility of a lawsuit.

The Food and Drug Administration said this month it would change its opioid review policy and re-examine the “risk-benefit paradigm for opioids.”

And just last week the White House requested $1 billion in its fiscal 2017 budget to help doctors administer medication-assisted treatment.

Some physicians have begun to look at prescribing alternative pain therapies, which often aren't reimbursed as well as opioid prescriptions.

“I think the acceptance of alternative therapies needed to have a vacuum to fill,” said Dr. Houman Danesh, director of Integrative Pain Management at Mount Sinai Hospital in New York. “Essentially what the opioids did was create that vacuum.”

More providers have also begun taking an overall care team approach to limit the amount of opioids prescribed. But such strategies require talking with patients to change their expectations when it comes to treating their pain.

“When our patients complain of pain, we need to be better at alternative treatments and not always just quickly writing a prescription for opioids,” said Dr. Gail D'Onofrio, chair of the Yale School of Medicine's Department of Emergency Medicine.

“The problem is that they take longer, but that's where we are right now. We can't keep just prescribing these drugs the way we have been doing,” D'Onofrio said.