#20 How did we get here (Part 2)

Last time, we discussed the history of opioids in the United States during the 1800’s. We learned of the pendulum swing from completely unregulated opioid use during the mid-1800s  to the tight regulations of the early 1900s when drug use was criminalized to the point that even those suffering from extremely painful illnesses such as terminal cancer were denied opioid prescriptions.
 During the last half of the twentieth century, the pendulum swung back again. In the 1980’s, the American Pain Society as well as the Veteran’s Administration introduced the concept of pain as the fifth vital sign.  Physicians were mandated to treat pain aggressively, and opioids were viewed as an easy solution for pain management. 
Soon, hospital and provider reimbursements were connected to patient satisfaction surveys which incorporated pain management as a component.  Medical providers felt pressured to begin prescribing opioids in spite of their fear of their patients becoming addicted. With advent of the pain score, patients began to think that the idea of zero pain was the goal.[1]
Pharmaceutical companies began developing and aggressively marketing more powerful opioid pain killers such as OxyContin® in response to the increased demand for pain relief.  Insurance companies began refusing coverage of non-medical approaches to pain management in favor of prescription pain medications.
As more and more people began taking prescription opioid medications, a black market of abuse flourished.  Those caught in addiction found heroin to be easier and cheaper to obtain than illicit opioid pain killers. 
Changes in the American culture also contributed to the problem. As consumers, Americans developed the view that instant gratification and quick fixes were to be expected.    The breakdown of the traditional family, lack of connection to neighbors, sense of entitlement and the view that parents should protect their children from every kind of pain, discomfort or convenience further contributed to the epidemic. Changes in the treatment of mental health and an increase in mental health issues added another layer.
In 1959, the development of Fentanyl in 1959 (a pain killer and anesthetic), changed the landscape of substance abuse.   Fentanyl is one of the deadliest opioids developed and is 50-100 times more potent than morphine.  It is cheap and often mixed with other drugs.  This mix causes drug users to become addicted very quickly, increasing the demand for additional drug sales. Each year thousands of Americans die of a fentanyl overdose, many of them unaware that the substance they were using was spiked with fentanyl.
All these factors have contributed to the increase in opioid abuse and dramatic increases in opioid overdose death.  Americans make up 5% of the world’s population but consume 30% of the world’s opioids.[2] More than 72,000 Americans died of drug overdose in 2017, two thirds of these deaths involved opioids.[3] The average American life expectancy decreased in 2016 and 2017 due to increased drug overdose and suicide.[4] American’s are now more likely to die of a drug overdose than a car accident.[5]    
In spite of these dire statistics, the pendulum is beginning to swing back again.  

[1] Beth Macy,   Dopesick: Dealers, Doctors and the Drug Company that Addicted America, (New York, Little, Brown and Company, 2018), page 29.

[2] https://www.politifact.com/missouri/statements/2017/may/10/claire-mccaskill/mccaskill-cites-long-disproven-figure-opioid-use/

[3] https://www.nytimes.com/2018/08/15/upshot/opioids-overdose-deaths-rising-fentanyl.html

[4] https://www.washingtonpost.com/national/health-science/us-life-expectancy-declines-again-a-dismal-trend-not-seen-since-world-war-i/2018/11/28/ae58bc8c-f28c-11e8-bc79-68604ed88993_story.html?utm_term=.5d2dd28a8f10

[5] https://www.usatoday.com/story/news/nation/2019/01/14/odds-dying-opioid-overdose-higher-than-car-crash-analysis-finds/2567996002/