A Step to Stem an Epidemic

More than 47,000 people in America died of drug overdoses in 2014. But the majority of them were not abusers of illegal street drugs. The substances they ingested were totally legal, and are regularly prescribed by doctors. Those prescriptions are for opioids, drugs like oxycodone (OxyContin) and hydrocodone (Vicodin), which are commonly and casually referred to by most people as “painkillers.” (“Opioid” is the term for lab-produced synthetic forms of opiates — like morphine and codeine, natural substances that are derived from poppy plants. The molecular similarities yield similar properties.)

The word “epidemic” is usually associated with infectious diseases like those spread by bacteria or viruses. But if the word’s definition is expanded to include any uncontrolled and widespread increase in sickness and deaths, it can well be used to describe the over-prescription and abuse of opioid painkillers, which millions of people in Western countries take and which kill an average of over 40 Americans each day.

According to the Centers for Disease Control and Prevention (CDC), the nation’s top federal health agency, almost half a million people in the United States have died from drug overdoses since 2000. Over that time, drug overdose deaths in total have increased by 137 percent; and opioid overdose deaths, by 200 percent.

An important step to combat the opioid epidemic was taken this past week by the CDC. It issued, for the first time ever, guidelines for doctors in the treatment of their patients’ pain. The guidelines urge physicians to avoid prescribing opioid painkillers for patients with chronic pain, and first try physical therapy, weight loss (for arthritics), exercise and safer pain medications — like nonsteroidal anti-inflammatory drugs, or NSAIDs (such as aspirin, ibuprofen and acetaminophen) — before turning to opioid painkillers for chronic pain.

And when doctors determine that opioid drugs are necessary in other situations, the CDC advises that they prescribe the lowest possible dose for the shortest amount of time, both to minimize the risks they pose and to lessen the likelihood of addiction to the drugs. Doctors are also recommended to prescribe immediate-release opioids, rather than extended-relief tablets that are more likely to be abused.

Some health authorities have been critical of the guidelines, claiming that there are patients with cancer or chronic pain that cannot be managed effectively with anything less strong than opioids. But the guidelines in fact make an exception for patients receiving cancer treatment or end-of-life care.

And patients with acute pain, like that caused by an injury, usually do not need prescription opioids for more than three days. Massachusetts, as it happens, recently signed into law a seven-day limit on first-time prescriptions for opioids — the first of its kind in the nation.

The CDC’s shift from conventional wisdom about relieving pain is born of the recognition that opioids are themselves dangerous, addictive, along with a dearth of evidence that, at least in the case of chronic pain, they are in fact helpful, a fact explored in a recent editorial in JAMA (the Journal of the American Medical Association).

Another factor in the larger equation, though, and one that informs the overuse of a host of medications, is the robust promotion of drugs by pharmaceutical companies. In some cases, manufacturers have minimized the risks of misuse and addiction of opioids, leading doctors to miss signs of addiction in their patients. In 2007, in fact, OxyContin’s maker, Purdue Pharma, after a multi-million dollar advertising campaign for the drug, ended up pleading guilty for misleading the public about its risks.

What is more, while there are useful new medications that deserve to be brought to the attention of patients and doctors, there are also ineffective ones, sometimes carrying potential danger. And it is not uncommon for drugs to be marketed heavily for new “syndromes” that have never before been recognized as illnesses, and that are sometimes illusory, essentially vehicles created for the hawking of new products.

Those, though, are larger issues, not addressed by the recent guidelines, whose purview is limited to opioids. Even with that limited focus, though, some medical groups stopped short of embracing the recommendations. The American Medical Association, the largest professional group for physicians, cautioned that the guidelines could create problems if they steer patients toward pain treatments that aren’t accessible or covered by insurance.

But there seems little reason to fear that. The new recommendations are not only voluntary but, by virtue of their coming from the CDC, are likely to be adopted by hospitals, insurers and governmental health systems. They are a worthy first step toward stemming an epidemic.