Right around the time I was finishing my neuro-surgery residency in 2000, the consumption of prescription pain pills, known as opioid analgesics, was growing at a staggering rate. Over the next decade, sales of these medications would quadruple and the United States would earn the dubious honor of becoming the most pain-medicated country in the world.
With less than five percent of the planet’s population, we were consuming 80 percent of its opioids and 99 percent of its hydrocodone by the year 2010. In the wake of these pain-pill prescriptions came lethal overdoses—one every 19 minutes on average. By 2014, overdoses—61 percent of which involved opioids—were overtaking traffic fatalities as the number one cause of accidental death in the U.S. It was an American epidemic, and it was fully man-made.
We got here on a winding road paved with good intentions, as well as downright greedy ones. One thing is certain: There’s plenty of blame to go around.
Our culture has become frighteningly accustomed to “a pill for every ill.” Nearly 40 percent of all Americans over the age of 65 take five or more medications, and every American fills 12 prescriptions a year on average. Far too many of them are for pain pills.
Of course, many patients suffering chronic pain will read this and wince, worried that it represents another attempt to rob them of relief. That’s not my intent. But pain pills weren’t expected to be effective long-term, with most scientific studies lasting only three to four months. Additionally, most of my patients understand the concept of hyperalgesia: Sustained use of pain pills can make certain patients more sensitive to pain. As one escalates the doses, the hyperalgesia intensifies, as does the risk of overdose. The pain pills don’t just become less effective; they can actually make things worse.
If that’s the case, you may wonder, why do doctors prescribe so many of these pills? The charitable answer is that most doctors don’t like saying no to their patients. The vast majority of my colleagues derive tremendous satisfaction from helping people, and doling out pills is sometimes part of that. The more typical reason, though, is likely that it’s easier to write a prescription than to spend the time finding effective alternatives.
And then there’s the tremendous cultural shift that took place in medicine during my surgical training, between 1993 and 2000. At first, I was taught to reserve opioid analgesics for three very specific indications: postoperative pain, cancer-related pain and pain at the end of life. Even in the field of neurosurgery, where we treat many pain-related disorders, we were taught to prescribe much more physical therapy and far fewer opioid analgesics. Over the years, I saw an increasing number of pharmaceutical advertisements in medical journals and guidelines from the American Pain Society—which is funded by pharmaceutical companies—making the case that long-term use of narcotics was safe for an ever-growing range of conditions.
Pain even came to be known as the fifth vital sign, a measurement to be taken along with blood pressure, heart rate, respiratory rate and temperature. The message was: Always ask about pain, typically using a smiley-face pain scale. If the patient pointed to a frowny or crying face, treat the pain, even with opioids.
All this helps explain why, by the time I graduated, the pain-pill epidemic was running near full throttle.
Since then there has been a concerted, if complicated, effort to better monitor who is prescribing these drugs and what drugs they’re prescribing. States and federal agencies have started to clamp down on “pill mills.” While that has made access to prescription drugs more difficult, it has pushed many addicts to the streets in search of cheaper alternatives. For many, that alternative has been heroin or fentanyl, a synthetic opioid that can be up to 50 times more powerful than heroin. From 2002 to 2013, the number of heroin-related deaths increased by 400 percent by even conservative estimates. Between 2013 and 2014, overdose deaths involving synthetic opioids increased by around 80 percent.
There is some hope. Earlier this year, President Obama pledged $1.1 billion of next year’s budget to fighting the opioid epidemic, much of it geared toward treatment—expanding access to medication-assisted therapies such as methadone and buprenorphine. The administration is also making efforts to expand the use of naloxone, an opioid antidote that can reverse overdoses, and to ensure parity in addiction-treatment coverage. When I sat down with President Obama at this year’s National Rx Drug Abuse & Heroin Summit, he said we need to think of addiction as a disease and treat it that way.
There are many diseases in the world, physical and cultural, with no cure in sight. But right now we have an opportunity to solve the opioid problem—to put an end to this monster we created.
Dr. Sanjay Gupta, a practicing neurosurgeon, is CNN’s chief medical correspondent.