Painkiller nation: How did we get here?

Physicians traces the rise of narcotic prescriptions

Writing in The New Yorker this week, physician and author Celine Grounder traces the rise of narcotic painkiller misuse in the United States and attempts to identify the key players to blame for the epidemic.

Last month: FDA calls for new limits on painkillers

The rise of painkillers' predominance in the United States

Until recently, U.S. physicians only prescribed opioid narcotics for short-term pain, such as the pain experienced immediately after surgery, or for pain related to cancer or end-of-life treatment, Grounder writes. But two papers published in the 1980s changed how physicians thought about the medications and laid the groundwork for their expanded use:

  • The first paper—published in 1980 in NEJM—reported that less than 1% of patients who received narcotics while hospitalized at Boston University Medical Center became addicted; and
  • The second paper—published in 1986 in Pain—reported that narcotics can be "safely and effectively prescribed" as alternative pain therapy for patients with pain that is not related to cancer.

Around the same time, drugmakers began to "aggressively market their products for long-term, non-cancer pain, including neck and back pain," Grounder writes. Their campaign included appeals to physicians through "highly regarded publications," offers for continuing education courses in pain management, and funding for not-for-profits such as the American Academy of Pain Management.

Then, the Joint Commission in 2001 issued pain-management standards instructing facilities to measure pain and prioritize treatment for it. Joint Commission spokesperson Elizabeth Zhani told Grounder that the standards were "based upon both the emerging and compelling science of that time, and upon the consensus of a broad array of professionals."

Through all this, prescriptions of opioid narcotics soared. CDC found that the number of fatal painkiller overdoses more than tripled from 1999 to 2008; the Associated Press reported in 2012 that painkiller addictions were fueling a wave of pharmacy robberies; and medical professionals were arrested more frequently for their roles in pill mills.

Who is to blame?

Grounder writes that the rise in narcotic prescriptions may have been fueled by the pharmaceutical industry, but patients welcomed the change. "[W]ith a customer-is-always-right mentality having pervaded the doctor's office, patients were able to pressure physicians to satisfy their requests for the pain pills they’d begun hearing about," Grounder adds.

Physicians, too, were eager to relieve patient suffering and give them what they wanted to prevent them from going to another physician, claiming malpractice, or giving a bad online review. A few groups—including the Federation of State Medical Boards (FSMB)even drafted policies calling on medical boards to punish doctors for inadequately treating pain by not providing patients with painkillers, the Wall Street Journal reported in 2012.

Meanwhile, the Department of Justice, FDA, and the Senate Finance Committee have investigated pharmaceutical companies' questionable marketing practices and financial relationships. As a result, Purdue Pharma and three of its top executives pleaded guilty in 2007 to criminal charges that they had misled the physicians, patients, and the FDA about the risks of OxyContin addiction (Grounder, The New Yorker, 11/12).

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