Doctors: The Opioid Epidemic’s Biggest Contributor

In this paper, I address adolescent to adult American citizens because most of the opioid statistics were based on numbers from within the United States. Also, the United States has the largest struggle with opioids out of other prominent countries. This audience is crucial to the issue because they are the ones seeing and feeling the effects of the opioid epidemic. With the mass media coverage and strong opinions on the crisis, it becomes difficult for the public to distinguish the foundations and solutions of the epidemic. Therefore, I find it increasingly important to bring them into the conversation and fully educate them on what is happening, what the main contributors are, and to offer a solution that they can take part in. It will be hard to give my audience every piece of information they need to fully understand the epidemic as there will be a variation in what they already know and what knowledge they lack. However, by proposing a solution that brings awareness to the deficiencies and side effects of the opioid prescription system, the citizens will walk away from the essay better informed and knowing what they can ask their doctors to better reduce their risk of opioid addiction.

“Don’t worry, I’ll make sure we fix this problem,” were the exact words of my grandmother’s doctor when my family approached him about her opioid addiction. At the time, she had just completed a round of surgeries and was prescribed opioids by two doctors. Initially, we thought she may have needed them and were quick to dismiss the looming danger. However, after she spiraled down into a heavily addicted pattern, we knew we had to step in. I watched as my mom called her arthritis doctor and desperately asked them to terminate their prescription of opioids as she already had one from her surgeon. When they reassured us that they would correct the error, we felt so relieved and trusted them to take care of the issue. After a couple of weeks with no changes, we realized that nothing would be done. Both doctors knew she was getting two maximum doses of opioids, and yet, they did nothing. This lack of concern for my grandmother’s health left me dumbfounded. It led me to not only want to explore more about the opioid epidemic, but also examine the key role that doctors may play in it.

The opioid epidemic - the increasing prevalence of the class of drugs known as opioids - is a complex, ongoing problem. Opioids are either prescribed by physicians as heavy strength painkillers for intense chronic or post-surgery pain or circulated illegally for their pain-relieving effect (Krieger). Common prescription opioids consist of oxycodone, hydrocodone, and morphine. Common illegal opioids include fentanyl and heroin, and while they will not be focused on, it is important to note that many addictions to these illegal opioids stem from prescription opioid addictions (Cicero and Ellis). As the number of overdoses for strictly prescription opioids increased from under 10,000 deaths in 2002 to 19,354 in 2016, an expansion of awareness for the crisis occurred (“Overdose Death Rates”). Suddenly, people wanted to know more about the crisis: how it started and what primary catalyst allowed the direct and collateral damage to get to this level. It soon became apparent that one of those questions was a lot easier to answer than the other as defining a primary contributor proved to be a hard task.
The question of how the epidemic began has a clear answer. The opioid epidemic first became apparent in the 1990s when an influx of opioid prescriptions resulted in an overcorrection to the previous lack of these prescriptions. In the early 90s, physicians were criticized for not providing adequate pain treatment to patients, particularly those in cases of chronic pain and cancer (Jones, Mark R., et al. 15). As doctors were pressured by the public to prescribe more opioids, the prescription rate of these drugs began its steady ascent. In 2012, over 250 million prescriptions for opioids were written, which would have allowed every American adult to have their own prescription (American Society of Addiction Medicine). All of this led to where the epidemic is now: a continual upward climb.

This paper will examine the critical role that doctors have played and play in furthering the opioid epidemic: how they are the main factor fueling the epidemic and how they must be required by the US Agency for Healthcare Research and Quality to give information on the addiction risks and substitute drug options to opioids that can help mitigate their negative effects. To do this, it is crucial to analyze the incentives doctors get from pharmaceutical companies that may drive opioid prescription rates. These incentives along with doctors’ faulty prescription methods and a lack of education on how to treat addiction, all point towards doctors holding the main role in the crisis. While some actions have been taken to reduce the furtherance of the opioid epidemic caused by doctors, I argue that it is important to define physicians as the leading contributor to the epidemic in order to use their connections to create a patient-centered solution.

One of the most prominent rationales for considering doctors to be the largest contributor to the epidemic is the benefits they receive from pharmaceutical companies to sell that company's opioids. In a study conducted by Harvard T.H. Chan School of Public Health, Harvard Medical School (HMS), and CNN, more than a hundred doctors were found to earn six figures strictly from opioid manufacturers in 2014 and 2015. Moreover, thousands of other doctors made over 20,000 dollars off opioid manufacturers (Harvard School of Public Health). Their study also pointed out that physicians and their employing facilities frequently receive smaller gifts (such as food) that are not even tracked. This type of incentive system is a key catalyst in the furtherance of the opioid epidemic. When doctors start entering these deals to sell a company’s opioids, it creates an atmosphere of placing monetary gain over patient welfare. In instances where a competitor’s drug (particularly a non-opioid) may work better, doctors are instead pressured to prescribe an opioid due to the money they receive from it. This can be seen during a February 8, 2015 episode of Last Week Tonight with John Oliver, which featured a report titled “Marketing to Doctors,” in which Oliver reacts to a clip of a pharmaceutical representative discussing how his company would hound doctors into selling their opioids over a competitor’s drugs if they felt like prescriptions of their opioids were lagging (Oliver 7:20). As the opioid epidemic progresses, it becomes even more crucial for doctors to pay attention and adapt to the patients’ needs in a healthier, more ethical way in order to discontinue the uncontrolled opioid prescriptions that flow through the pharmacies.

Another way in which doctors problematically facilitate the opioid crisis is the frequency with which they assign opioid prescriptions. Martin Mackary and his colleagues found that after one type of common surgery (a laparoscopic cholecystectomy) many doctors routinely gave every patient a bottle of between 30 and 60 opioid tablets. This drug was commonly oxycodone and if patients followed the recommended dosage times, they would be taking 90 MME per day. A level of 90 MME opioid consumption level per day is above the Center for Disease Control and Prevention’s cautionary dosage for increasing opioid addiction risk by twofold (Mackary, Martin A, et al.). This means that a substantial number of patients are now receiving a prescription that puts them over a two times risk of opioid addiction. This overprescription may be related to the large pressure doctors feel to completely eradicate patient pain. In many cases, doctors will develop a “pills for pain” mindset to try and accomplish this goal of zero pain (Gorman and Gorman). Therefore, many physicians prescribe pills as a complimentary solution in hopes of getting rid of each patient’s pain, even when this goal may not be attainable and places the patient at risk of an addiction.

Astounding statistics such as these leave the question of how it is possible for these high prescription rates to continue in the current state of emerging prescription drug monitoring programs (PDMP, an electronic database that tracks a patient's prescription history) and general awareness of opioid addictions. One possible explanation is that prescription drug monitoring programs such as the PDMP are not being used enough. A study done by Dora Lin and her colleagues to determine how physicians used this program showed that only 53% of doctors incorporated it into their practice (Lin, Dora H., et al. 312). The absence of use of the PDMP program leads to missed opportunities in identifying chronic opioid abusers. Making these identifications can lead to a reduction of opioid addicts as the doctors are able to distinguish patients that are at high risk of addiction and can provide them with a more appropriate treatment plan. By failing to implement programs that provide a better understanding of patient history, doctors have the odds stacked against them in lowering patient opioid addiction and reducing future addictions. Moreover, the study that Lin and her colleagues conducted discussed how “of the physicians who used PDMP data, 62% examined the drug utilization history for more than three-fourths of the patients they suspected of prescription drug abuse” (313). The grim reality of this statistic is the fact that 38 percent of doctors do not bother to examine the drug history of three-fourths of the patients they think may be a drug abuser. With information so easily at hand that would better the prescription fit for patients’ needs, the neglect of it by doctors is hard to believe.

In response to the claims that doctors practice faulty prescription methods, emerging data on the drop in opioid weight and opioid prescriptions leads some researchers to believe that prescription practices are no longer a major problem. Brian Piper and his colleagues support this notion, claiming that the epidemic is changing and the rate of prescribing opioids is decreasing. Their statistics show that “the total weight for the ten [most common] opioids over the past decade peaked in 2011 at 389.5 MME metric tons” (Piper, Brian J., et al.). It is true that some types of prescribing rates are decreasing which therefore reduces the weight of opioids being distributed. The Centers for Disease Control and Prevention reports that opioid prescription rates hit an all-time low in 2017 with 58.7 per 100 persons receiving an opioid prescription (“Opioid Overdose”). While this is an improvement within the epidemic, it is crucial to hold doctors accountable for their prescription methods that continue to exacerbate the epidemic. One of these methods is the increased supply of opioids given to a patient. For example, Mark Jones and his team are quick to recognize that the annual prescribing rate by number of days has steadily increased alongside the average daily supply of opioids (Jones, Mark R., et al. 14). This means that while fewer overall prescriptions are being written, patients are continually getting a larger supply of them. Therefore, doctors are simply overprescribing in terms of supply, which can lead to further opioid addiction and abuse as patients have an extended dosage.

These faults in prescription methods may derive from an even deeper problem: doctors not having adequate knowledge to observe and treat opioid addiction. Jan Hoffman attributes this lack in knowledge to the absence of addiction education in many medical schools. She discusses how only 15 of 180 medical programs include prescription drugs in their definition for addiction (Hoffman). This restricted access to necessary knowledge on how to identify, deal with, and treat an opioid addict during consultation and prescription is only hurting physicians’ ability to help stop the furtherance of the opioid epidemic. Another large problem with the variation in covering addiction in medical school is the incongruity it can create when doctors are trying to define addiction. Doctors who were sufficiently taught about addiction paired with patient care may have a different definition from those who were never taught about addiction. Michael Rass discusses the discrepancies in the definitions of addiction that doctors have. While some physicians feel that addiction should be classified as a disease, others feel it is a disorder (Rass). A disease is more of a foundational problem that may require multiple methods and modes of treatment. In contrast, a disorder is a disruption in function caused by the disease and can have a more targeted solution. This inequality in definition may lead to a fluctuation in prescriptions, something that further complicates the opioid epidemic.

When looking at the opioid epidemic as a whole, some argue that doctors may not be the main contributing factor to the epidemic. Among the other prominent contributors that people argue to be the leading cause of the crisis are pharmaceutical companies and health insurers. Harriet Ryan and her colleagues place the blame more on pharmaceutical companies by describing their blatant false advertisement of opioids. They discussed how Purdue Pharma, a big name pharmaceutical company, not only lied about how addictive their drug Oxycontin was (Purdue Pharma claimed it was less addictive than it was in reality), but also falsely advertised the duration of pain relief Oxycontin would provide (Ryan, Harriet, et al.). The company assured 12 hours of pain relief when the drug only provided 8. Others like Joshua Aspril argue health insurers are the main contributor. He discusses how an average monthly supply of opioids will cost just 10 dollars (Aspril, Joshua, and JH Bloomberg School of Public Health). By covering such a large cost of the opioids, health insurers may be financially enabling addiction. While both factors undoubtedly make up a large piece of the epidemic, they simply do not match up to what doctors contribute. On top of the ripples physicians create in the epidemic as described above, they are the gatekeepers of the opioid crisis. This is because doctors are the ones who prescribe the opioids, consult with the patient and determine which ones should get the prescriptions. In a conducted survey, 46% of the public placed the blame for the opioid crisis on physicians for inappropriately prescribing opioids (Jones, Mark R., et al. 16).

Therefore, not only do doctors directly contribute to the opioid epidemic through incentive prescribing, faulty prescription methods, and inadequate addiction education, they also have a bigger role as the face of the epidemic - the factor that is in the spotlight and scrutinized by the public.

As doctors are perceived as the main factor in the furtherance of the opioid epidemic, a solution must be proposed to mitigate their negative effects. The most efficient solution would be to require physicians to have a pre-opioid prescription consultation with patients that breaks down the risks and effects of opioids as well as offering substitute, non-opioid drugs in appropriate situations. The consultation, which could reasonably take under ten minutes, fixes several large aspects of the negative effects doctors have on the crisis. The discussion requires doctors to spend more one-on-one time with the patients in which the conversation leans more toward informing patients and helping find the right prescription for them. To ensure that doctors would follow this protocol, the US Agency for Healthcare Research and Quality will make the discussion mandatory in their official guidelines. Through augmenting the doctor-patient interactions, there may be a reduction in opioid prescriptions as doctors begin to humanize their patients and better recognize their signs of opioid abuse. It can also decrease the overprescription of opioids because the requirement of listing substitute drugs increases the likelihood of the patient avoiding opioid prescriptions. Finally, the process of better informing the patient about opioids and the risks that come with them can help reduce the opioid epidemic as a whole. A more informed public will be less likely to develop an addiction since they are aware of the dangers of opioids and alternative steps they can take towards treatment. Tracy Harrison, a pediatric anesthesiologist at the Mayo Clinic, supports this type of solution. She acknowledges that the opioid epidemic is a problem that needs multiple levels of solutions, but better informing patients and encouraging nonopioid analgesics (weaker pain medications like ibuprofen and acetaminophen) are the first steps that need to be taken (Harrison).

Despite the opioid crisis being a complex web of factors that make it difficult to find an appropriate solution, defining doctors as the main contributor provides for a patient-oriented solution that will have a ripple-like reduction effect on the epidemic. The public can define doctors as the key root to the opioid epidemic due to several malpractices that many physicians partake in. The money and benefits doctors receive from pharmaceutical companies encourage them to prescribe certain opioids that may not be as effective as a competitor’s, perhaps even non-opioid, drug. Physicians also have faulty prescription methods in that overprescription and lack of use of drug monitoring programs allow for increased risk of patient addiction. In order to mitigate the negative effects of these faults, a pre-opioid prescription consultation in which doctors debrief the patients on opioid risks and alternative, non-opioid drugs must be put into action and regulated by the US Agency for Healthcare Research and Quality. Throughout the research and writing of this paper, one quote from my grandmother has resonated with me. ”I’m really scared, Sarah. I’m going to try and wean myself off of them slowly,” she told me. It was the only time she talked to me about her addiction struggle, and while I did not know it then, it was the last few moments with her before she fell into a heavy opioid addiction. Her desire to rid opioids out of her life inspired me to find the root cause of her - and so many others’- addiction. In the future, the situation that my grandmother was put in will hopefully be minimalized as both patients and doctors become better informed on the opioid crisis.