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August 5, 2019

Lessons Learned From the Opioid Epidemic

Author Affiliations
  • 1Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 2Institutes for Behavior Resources Inc, Baltimore, Maryland
JAMA. 2019;322(9):809-810. doi:10.1001/jama.2019.9794

Oklahoma’s recent settlements with Purdue Pharma and Teva Pharmaceuticals, and the trial in the state’s lawsuit against Johnson & Johnson, signal that the opioid epidemic is entering a new era of accountability. Hundreds of cities and counties and about 2 dozen states are also pursuing litigation against opioid manufacturers.

The legal system should hold the pharmaceutical industry responsible for the overzealous, misleading, and, at times, illegal marketing of opioids. Regulators should consider new ways to monitor drug manufacturers to reduce the chances of such conduct in the future. Yet the lessons of the opioid epidemic go further. It is important for physicians, payers, hospitals, and accreditors—as well as for patients and their families—to consider what else went wrong and what can be fixed moving forward, so that a tragedy of this scale does not occur again.

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    4 Comments for this article
    Opioids and Addiction
    Steven King, M.D., M.S. |
    The authors fail to mention several important issues:

    1. Most doctors receive little education on pain management either in medical school or postgrad training. This problem was identified at least 30 years ago yet little has been done in the interim to remedy it.

    2. We know very little about iatrogenic opioid abuse where patients were started on these meds for legitimate pain complaints and ended up abusing and becoming addicted to them. We don't know if this is the same disorder as opioid use disorder stemming from nonmedical use of prescription of opioids.
    In fact, as far as I'm aware, this isn't even part of any diagnostic classification system. And there are virtually no studies on the best way to manage it.

    3. if one wants to know the major reasons why pain management doctors know so little about substance abuse simply look at what department pain management is part of in most medical schools and hospitals: anesthesiology. Probably few clinical specialties receive less training in substance abuse than anesthesiologists and the doctors who receive the most training in substance abuse, psychiatrists, usually receive little training in pain management because psychiatry departments don't consider pain management to be part of their specialty. There is absolutely no reason why the management of chronic pain should be part of anesthesiology and not psychiatry.
    Complicity of the Three Big Fish in the Opioid Epidemic
    Umbrine Fatima, MD, FACP | Kenmore Mercy Hospital, Buffalo, NY
    First, sincere thanks to the authors of this article.

    With deep regret I, too, have been watching the opioid epidemic. I find it disturbing that news of some physician colleagues and healthcare professionals have frequently splashed the media outlets. There seems to be some dark gratification in shaming and naming the physician community by the media for some reason. I have also seen the trend to shame and litigate the pharmaceutical industry in their role in promoting the epidemic as well. However, I think there are more important and seriously complicit players in the field that no one
    is paying any attention to. These are the medical organizations that have been regarded highly for their role of creating and implementing the supposed disease treatment "guidelines" as well as the payors who have historically and habitually denied payment of costly yet safe and effective treatments.

    I have attended hundreds of CMEs from the most prestigious organizations and peer-reviewed outlets and taken my board exams three times in my practice lifetime. With many pain management options available worldwide, including interventional pain management with massage therapy, low level laser treatments, trigger-point injections, PRP, LED treatments, acupuncture, and others, none have ever been presented as even an option to consider in pain management guidelines or algorithms. Instead these modalities have always had a dark shadow of doubtful benefit cast over them (minimized with "small, generally low-quality studies") by any number of guidelines that a majority of physicians are pressured to follow by their regulatory organizations.

    Unfortunately, treatment guidelines have cost savings as the driving force of all care delivered. Nowhere in the Triple Aim is individual health a part of the equation. Scapegoating physicians and other health care providers for this epidemic is too simplistic and rather naïve. Physicians are merely puppets trained by the organizations responsible for their curriculum, and kept under an ever-tightening cost-saving leash by the payors (insurance companies, Medicare, Medicaid). The main culprits in this horrific epidemic are Three Big Fish: 1) the payors that refused to cover interventional pain management because it is so much cheaper to give 100 Vicodin or percocets, 2) organizations churning the pain management guidelines and algorithms that focused only on pharmaceutical options, and 3) the pharmaceutical players that provided the ammunition to fuel this epidemic.

    While I am extremely sad for the loss of lives with the opioid addictions, I remain reluctant to accept prescribers as the sole perpetrators. I believe they acted in their concern to alleviate pain and suffering of their patients within the constraints noted above. I believe that most prescribers had no intention of causing addiction, and even less, of causing death. I also find it sad that most are reluctant to hold responsible the Three Big Fish in the pond which were the driving forces of this outcome.
    Why Not in Italy?
    Luca Puccetti, Medical Doctor | University of Pisa
    The apocalyptic scenario described in the paper is far from the italian situation. We had strict regulatory rules for prescribing opioids in the last decades of the last century. As result we had a high volume of NSAIDs prescriptions which in turn causes heart attack, deaths, renal impairment, serious GI complications with hospitalizations and excess morbidity and mortality. The levels of opioid prescriptions were so low as to create embarrassment in comparison with other European countries. In the last decades opioid prescription regulations became similar to that of other medications and the number of opioid prescriptions increased but we did not experience significant abuses. I feel that the abuse described in the paper is caused by social, political issues and grading of values in US society. The mantra about competition as a fundamental cornerstone in US society causes guilt and inadequacy in those who fail and push to find comfort in drinking and drugs. It should pursue the achievement of a more inclusive society rather than blaming those who produce drugs. Otherwise it is like weapons, the culprit is not who produces the weapon but who shoots.
    Fourth, Recognize conflicts of interest
    Michael Plunkett, MD. MBA | Community hospital
    All the authors’ points are excellent. But I think their fourth point is most important. Conflicts of interest permeate American medicine. Almost everything you read is tainted.

    I teach my students to follow the money. See who paid for it. Who paid the speaker? Who paid the authors? And it’s even worse when you can’t find who paid for them because then you know they’re probably telling you a lie.

    The opioid epidemic is starting to wind down. Can’t you just wait for all the fun with the upcoming marijuana epidemic?
    I hope we apply Dr. Sharfstein’s 4 rules to the upcoming epidemic more than we did to the opioid epidemic