Opioid Crisis: The Medicalization of American Pain

• Of a rolling 12-month period ending April 2021, there were 100,306 drug overdose deaths in the US-making it the deadliest year of the opioid crisis. 
• The US is the largest consumer per capita of opioids. Opioids quickly became the center of pain management, but a complex paradigm in which it is prescribed for patient’s perceived and reported pain. 
• Physicians and pharmaceutical companies alike can be blamed for the over prescription of opioids, but it is time for change. Together strategies to combat the opioid crisis can be achieved with new technology, education, policy and change. 

2020 was the deadliest year of the opioid crisis in North America. We reached a milestone that you may have missed. A tragic, preventable benchmark littered with tales of sobering demise. For a rolling 12-month period ending April, 2021, there were 100,306 drug overdose deaths in the United States.  

A staggering 30% increase from the prior year and the first time Americans breached 100,000 deaths in any rolling 12-month period. How did we arrive at this tragic inflection point? 

The discussion surrounding the medicalization of ordinary Americans with mild pain continues Ad nauseam. Success in pain management is pivotal in how healthcare moves forward. But how did we get here? And how do other countries treat pain?

In short, pain management policies deliver pain medication in a safe and effective manner for pain perceived and reported by the patient and/or assessed by the practitioner. What are the keys here? Perceived and reported by the patient.  

Americans consume the vast majority of the world’s opioids. The United States is 3rd in per mg consumption at (398 mg/person). Preceded by Germany (480 mg/person), and Iceland (428 mg/person). But the United States is by far the largest overall consumer by aggregate at 131,340,000,000 milligrams per capita.  

Take a moment to ponder that number. It is astounding.  

Our children face a more terrifying number. The current lifetime odds of dying in an accidental opioid drug overdose are 1 in 67.  

That means in a high school class of four hundred, six students will die from a preventable opioid death. 

 Within three days, your body craves the euphoria that opioids produce. The trajectory of misuse is rapid and unforgiving.  

The Language of Pain

We have dumped pain management at the backdoor of American healthcare. Practitioners are desperate for insights on treating discomfort in a more effective way.

Discussions include how we change the language and prescription patterns across medical disciplines. And how we discuss the propagation of misinformation, and our insufficient understanding of pain. 

No one needs to suffer. For those with chronic pain, we need to set realistic goals around behavioral and optimal outcomes beyond the 0 to 10 pain score. We should engage in honest and open conversation that benefits the end user, the patient. Insufficient understanding of the pain experience has undermined treatment.  

The current medical establishment bears significant responsibility. Reframing the pain experience and avoiding induced suffering is a desired goal.

Well-intentioned practitioners seeking to decrease suffering have caused significant harm. The wish to have zero pain implies that being pain free is an attainable treatment goal, which has contributed to unrealistic expectations of pain relief.  

The difficulties abound with the subjective nature of pain. Language around pain is complex. Pain has emotional, physical, psychological, and social components. Every individual’s pain has a unique tie to the individual, and that is problematic in the current way we practice medicine.

Prof Chris Eccleston, director of the Centre for Pain Research at the University of Bath, describes humans as having an urge to communicate suffering. And pain, while being private, is a social experience alerting others to this suffering. 

100,000 Deaths During the Opioid Crisis

History has tied Dr. James Campbell to the genesis of this opioid crisis when he declared pain the fifth vital sign. With this, we focused on pain.

Are Americans suffering more than other countries? No.

One reason for the opioid epidemic is that the United States regulates opioid manufacturers and distributors with less rigor than many European countries and other developed nations.

In the United States, the pain landscape is a user-friendly environment for the manufacturers and deceptive promoters. In summary, America’s pain problem is unregulated, ill-defined, and over-distributed. It is no wonder we are in the throes of an opioid crisis.  

During my ED career, there was a defined prevalence drift where everyone was in persistent or chronic pain and narcotics were at the root of countless physician-patient and nurse-patient arguments. Patients flock to the emergency room seeking pain management.

In fact, chronic pain (CP) accounts for 10–16% of emergency department (ED) visits. These numbers are a contributing variable to ED overcrowding and adverse events.  

On the Horizon

Winning the opioid war is achievable. But we may need a shift from subjective measures to technology that supersede opioids. In development are systems that use immune biomarkers to diagnose pain states. These biomarkers show pain-related patterns of immune cells in the blood.  

In clinical trials are Nav1.8-blocking drugs, which have shown promise and placebo analgesia, another well-documented phenomenon.  

Beyond new modalities, we need honest conversation about the opioid culture. Ending the conflicts between the regulatory agencies and industry. We must meet innovation and transformation with reinforced regulation, post-marketing surveillance, and physician education. 

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