a chronic nature

How the most recent opioid epidemic in the US is both similar to, but also different from that of the 19th C
COLLAPSE

The most recent opioid epidemic in the US took place from 2007-2017; however, there was a lot of significant changes within medical and pharmaceutical practices during the 1990s that saw significant increases in the prescribing of opioids over the course of more than a decade leading up to what would eventually be called the “opioid epidemic” (Kolodny et al., 2015Dayer et al., 2019).
Nor was it the first opioid epidemic experienced in the US: In the mid-1800s, opium and morphine became more readily available, and by the 1890s the use of these drugs peaked, which brought about calls for changes in the prescribing and general access to these drugs. The epidemic occurred at a time when pain management and mental health were not as well understood as it is today, so easily-accessed opioids were utilised by a range of different people, for a variety of reasons. However, in the article by Kolodny et al. (2015) It is noted that at this time the “model opioid-addicted individual was a native-born white woman with a painful disorder, often of a chronic nature” (p. 561). Part of the problem was that opioids were seen as a cure-all by the medical practitioners at the time, and so they used it for just about every ailment and complaint presented to them. There simply wasn’t the range of other pain management treatments available to them as we have today.
A major similarity between the opioid epidemic of the late-19th century, and the most recent one in the US is over-prescription. There was a period from about the early-20th century through to the mid-1980s where opioids were not used for non-cancer pain. Then in 1986 a (somewhat suspect) report came out applauding the effectiveness of opioids in the treatment of chronic, non-cancer pain, which was followed up by studies undertaken by pain organisations that claimed medical professions were unaware of, and therefore under-treating pain conditions. This in turn brought about the principle of “pain as the fifth vital sign”, whereby pain was assessed with the same weight as other vital signs, such as blood pressure, even though pain measurement is a subjective measure. Dayer et al. (2019) delve into the social and cultural changes that were taking place during this period (1986 through to 1996) as a this shift in perspective by the pain organisations was picked up by the pharmaceutical companies. The influence that major pharmaceuticals have had on how people now think about and use opioids cannot be understated, since up until the 1990s there was no real market for these (and other) opioids beyond that required for cancer pain.
The mid-1990s through to the the early 2000s saw a repeat of the 19th century habit of over-prescribing opioids, this time specifically for non-cancer pain. This was in spite of the fact that pain management treatments now include physical therapy, surgery, behaviour therapy, and counseling. Dayer et al. (2019) notes, however, that part of the reason for this over-prescribing is that many people in the US are unable to access non-pharmaceutical options due to availability and costs. Therefore, prescription opioids are simply easier to access, which is something that struck me about the Australian studies into opioid use, too – see for example Gisev et al. (2016) and Rogers et al. (2013).
The 19th century prescribers and users of opioids didn’t have the same level of understanding of pain management and treatments that we do today, so it is particularly interesting (although not entirely surprising) that pharmaceutical options have been promoted and preferred over and above those non-pharmaceutical treatments, especially in countries like Australia where the government subsidises these drugs through the Pharmaceutical Benefits Scheme (PBS). It seems to me that the treatment of symptoms through the prescribing of opioids is merely a quick fix for what could essentially be long-term problems that will only worsen with time, and then need stronger and more frequent opioid administration in the future. When there are other options available it seems to me that opioids should be a last resort when it comes to pain management. They have a valid use, such in cases of end-of-life pain management, but it cannot be surprising that the over-prescribing of these drugs has resulted in a significant use problem.
What are your thoughts: Do you feel there is a correlation between access to treatment and the use of opioids for pain management?
References:
Bohnert, A. S. B, & Ilgen, M. A. (2019). Understanding the links among opioid use, overdose, and suicide. The New England Journal of Medicine, 380, 71-79. https://doi.org/10.1056/NEJMra1802148
Dayer, L. E., Painter, J. T., McCain, K., King, J., Cullen, J., & Foster, H.R. (2019). A recent history of opioid use in the US: Three decades of change. Substance Use & Misuse, 54(2), 331-339. https://doi.org/10.1080/10826084.2018.1517175
Gisev, N., Nielsen, S., Cama, E., Larance, B., Bruno, R., & Degenhardt, L. (2016). An ecological study of the extent and factors associated with the use of prescription and over-the-counter codeine in Australia. European Journal of Clinical Pharmacology, 72, 469-494. https://doi.org/10.1007/s00228-015-1995-8
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health,36(1), 559-574. https://doi.org/10.1146/annurev-publhealth-031914-122957
Rogers, K. D., Kemp, A., McLachlan, A. J., & Blyth, F. (2013). Adverse selection? A multi-dimensional profile of people dispensed opioid analgesics for persistent non-cancer pain. PLoS One, 8(12), Article e80095. https://doi.org/10.1371/journal.pone.0080095

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