Anatomy of an epidemic

Massachusetts officials are suing Purdue Pharma, maker of OxyContin, alleging that its sales tactics fueled a surge in opioid addiction. Massachusetts is also suing the Sackler family, which owns and runs Purdue Pharma. The lawsuit underscores the controversy over the pills: Did the increase in opioid prescriptions reflect doctors finally addressing untreated pain or becoming tools for sales at any cost?

Psychiatrist and addiction specialist Anna Lembke argues in the 2016 book Drug Dealer, MD that doctors believed they were finally addressing pain issues. They viewed as outdated the World Health Organization’s 1986 guidelines, which advised doctors to start with non-opioid drugs (like Tylenol and Motrin), proceed if necessary to opioids like codeine, and reserve stronger opioids like morphine for when other drugs failed.

But had medical opinion changed or was propaganda at work? New guidelines emphasized aggressive pain control, but those guidelines stemmed from Big Pharma. Lembke discovered that the Federation of State Medical Boards (FSMB) received almost $2 million in support from opioid makers. The FSMB in turn “urged state medical boards to punish doctors for undertreating pain. Doctors lived in fear of disciplinary action from the board, and the lawsuit that usually followed, if they denied a patient opioid painkillers.”

In 1999 the Department of Veterans Affairs declared pain level to be the “fifth vital sign,” which meant it had to be checked whenever a nurse or doctor checked a patient’s vitals. In 2001 the Joint Commission on Accreditation of Healthcare Organizations said appropriate (i.e., aggressive) pain control would be a factor in maintaining accreditation.

Doctors listened: A University of Southern California study found American opioid prescribing rose 471 percent between 1996 and 2012. Purdue offered various educational and promotional materials, even via the Joint Commission’s own website. Purdue’s representatives canvassed the country, promoting OxyContin as an ideal choice with a time-release formulation that was both convenient and less likely to produce addiction.

OxyContin may have been convenient, but time proved that it certainly was addictive—especially when users realized that crushing the original version of the pills released all of the active ingredient at once. (A 2010 reformulation later addressed the problem.) A burgeoning street market for the drug showed addicts knew about this feature. Potential profits induced many people to get prescriptions and illegally resell them.

Some doctors remained skeptical of the fifth-vital-sign approach. A 2006 study found the new dispensation did not improve pain control, but the CDC took a decade to issue guidelines calling for reduced opioid use. Yet even before those restrictions, patients who had grown dependent on opioids often sought illegal sources when they could no longer get prescriptions. That’s even more dangerous now that drug gangs have learned to counterfeit popular prescriptions: When the musician Prince died of an overdose in 2016, pills found with him bore a code for generic Vicodin, but proved to contain fentanyl and two other drugs.

Both Lembke and the CDC guidelines offer practical advice: nonpharmacological and non-opioid pain management whenever possible, rational opioid prescribing to prevent further addiction, and—perhaps most important now—strategies to help those already addicted.

But why stop there? Let’s replace our society’s current addiction to rules and guidelines with a commonsense understanding that life after the Fall can’t be entirely devoid of pain, any more than corporate funding can be entirely without strings. Let’s bring back the idea of doctors and patients knowing each other, as individuals, and of doctors using that relationship to help encourage patients as they manage their pain, one day at a time.