From the beginning of the opioid crisis in the 1990s, when reports of addiction and overdoses involving OxyContin first surfaced from Appalachia and New England, spokespersons for the drug’s manufacturer, Purdue Pharma, insisted that problems were limited to drug abusers, not average patients. Prescribers and policymakers were told, misleadingly, that the development of addiction, even with long-term daily use, occurred in less than 1 percent of patients. By the early 2000s, when it became clear that opioid prescribing was soaring far beyond levels that could be clinically needed, and that rates of addiction and overdose death were rising in parallel, industry-funded opioid advocates continued to argue that addiction in patients was rare and that diversion from legitimate medical channels was the root of the problem. Policymakers were cautioned that efforts to reduce prescribing would unfairly penalize pain patients for the bad behavior of drug abusers.
These familiar arguments are repeated a recent article in Politico Magazine by Dr. Sally Satel, a resident scholar at the American Enterprise Institute. Satel writes that “we must be realistic about who is getting in trouble with opioid pain medications. Contrary to popular belief, it is rarely the people for whom they are prescribed.” Yes, it oversimplifies matters to suggest that every opioid-addicted American developed the condition from legitimate medical use. But let us be clear: Opioid use disorder is common in chronic pain patients treated with long-term opioids, and our nation’s opioid addiction epidemic stems largely from the overprescribing of opioids for the treatment of pain. Satel suggests that efforts to promote more cautious prescribing are harming patients with chronic pain. We suggest the opposite: that a lack of understanding of chronic pain, and an overreliance on opioids to treat it, is compounding both the opioid crisis and the problem of inadequately treated chronic pain.
There are some forms of chronic pain that can be helped by intermittent use of low-dose opioids. However, the most common forms of such pain are not diseases, but symptoms of underlying conditions, such as arthritis or diabetes, which we believe are best managed without resort to opioids. In fact, for many common pains, opioids are ineffective or can worsen both the pain and the long-term outcome. Sometimes, through their sedating effects, opioids can also reduce the motivation to utilize safer approaches such as stretching and exercise.
Satel’s assertion that addiction rarely develops in patients taking long-term opioids for pain is dangerously misleading. The two systematic reviews she cites, to support a claim that the risk of addiction in chronic pain patients could be less than 1 percent, combine data from clinical trials that are several years old and are largely industry-funded. Clinical trials that limit the type of patient, the doses and the duration of treatment are not reflective of real life. Studies that have attempted to assess real-life rates of addiction in populations of patients receiving opioids for chronic pain have calculated much higher rates: up to 25 percent using strict addiction criteria and even higher—around 50 percent—for problematic use more broadly. Even this ignores that there is no consensus on what constitutes addiction when it arises in patients who are treated continuously and legitimately with opioids and who may not even reveal addictive behaviors until they are denied opioids.
It is true that our record high levels of opioid overdose deaths have not been produced entirely by opioid-addicted pain patients overdosing on their medication. Many individuals become addicted to prescription opioids through medical or non-medical use, and then switch to heroin after becoming addicted. Over the past few years, overdoses deaths have risen rapidly among these black-market opioid users because illicitly synthesized fentanyl is increasingly mixed with heroin or sold as heroin.
But to deny that the sharp increase in prescribing of opioids, caused by a multi-faceted marketing campaign, contributed significantly to today’s epidemic, is to deny the obvious. Millions of legitimate pain patients that continue to take opioids exactly as prescribed are struggling with poor pain control and lives ruined by opioid dependence. Even if only a small percentage of people briefly exposed to opioids after minor injury or surgery become addicted, that is too many; if non-opioid medications were used, those people might otherwise never have been exposed or become addicted.
We agree with Satel that the answer is not to force millions of chronic pain patients to rapidly taper off medications they are now dependent on. But then neither is the answer to absolve overprescribing for pain.