The Opioid Crisis: It Is Not Physicians

Blaming physicians for the “opioid crisis” is so far off the mark as to be potentially harmful. Then throw in pharmaceutical companies, and politics has definitely been substituted for truth. On “Face the Nation” former New Jersey Gov. Chris Christi, chair of the president’s opioid commission, blamed overprescribing doctors. He said, “This crisis started not on a street corner somewhere. This crisis started in the doctors’ offices and hospitals of America.” In the following discussion I will not even mention the significant contribution to the crisis related to the obsession with pain management by JCAHO, Medicare, Medicaid and finally by private insurance companies. But remember it was these bodies that forced the definition of pain as the fourth vital sign.

Correlation does not mean causation, but there are some correlations that seem not only interesting, but important relative to opioid abuse. If you have a job, are married, older than age 50, female and black the scourge of opioid abuse is less, much less. Recent studies though have shown cocaine related deaths to be greater in the African-American community. Being unmarried, divorced, unemployed or a young adult correlates with greater risk. One can wonder if the increased geographic risk in West Virginia, New Hampshire, Kentucky and Ohio might be related to these. None of this has any basis in physicians’ offices.

Young adults, especially adolescents, account for the majority of first-time abusers. According to a Columbia University CASA (Center for Addiction and Substance Abuse) study in 2011, adolescent physiology and other issues typical of this age group such as peer pressure, adverse childhood events, genetics and engagement in other risky behaviors contribute to addiction risk. Additionally, there is interesting data related to the deterioration of the family. Almost half, 45.4 percent, of teenagers live with a parent who is a risky substance user. Some 17.8 percent live with an adult who has a substance abuse issue. Less than half, 42.6 percent, of parents list refraining from tobacco, alcohol, marijuana, or abusing prescription or illicit drugs as one of their top three concerns for their teenage children. Other than lack of education on the subject, one can only ponder the reasons for this tragedy. Again, none of these have their basis in physicians’ offices.

According to the National Survey on Drug Use and Health, 75 percent of opioid pill abusers and almost all heroin addicts got hooked without ever having been prescribed pain medication. As published in JAMA only 13 percent of opioid overdose patients presenting to emergency rooms started taking drugs because of pain.

One does not choose to become ill, and chronic diseases do not go away by choice. In contrast, experimenting with opioids is nearly always a choice. Also, half of addicts who quit do so without treatment. One cannot quit rheumatoid arthritis or heart failure. With this in mind, maybe just maybe, labelling drug addiction as a disease might be an error. This could be another example of misguided political correctness aimed at not stigmatizing addicts or injuring frail psyches, just something else to consider.

That drug companies are at fault is an interesting supposition. There has never been a drug-free society. The problem of abuse was present long before these companies existed. During my 35 years of medical practice never have I personally promoted, nor have I ever heard of any pharmaceutical company promoting, opioid use or suggesting that opioids are not addicting. This seems almost ludicrous. Now that these companies are being sued by states’ attorneys general it is fair to speculate this as simply another attempt at government extortion. This of course will raise the price of pharmaceuticals, confiscate dollars that could be used for research and development and ultimately lead to shortages of this important therapeutic class of drugs. Acute and chronic pain does exist with opioids often an appropriate adjunctive treatment choice. Dollars extorted from drug companies at the same time as development of opiate alternatives is encouraged presents an interesting quandary.

There then exist cultural components, intellectual or educational components, biological components and the most unfortunate component, that which is political. If the analysis selectively adopts the political consensus of certain individuals within the scientific community, then it is political consensus. This then concludes with science reflecting opinion rather than, as it should, the opposite. Scoring political points by simplistically blaming physicians caricatured as a group at fault for the multifactorial nature of the opioid epidemic avoids the truth. Quid ist Veritas? This gets us nowhere.

Physicians have a role, but not as depicted. They can help but cannot resolve the societal and cultural problems that if unrecognized and unaddressed will continue to provide the pollution underlying the opioid epidemic.