How did the opioid epidemic get so bad?

March 29th, 2016  |  Source: Boston Globe

Doctors are partly to blame, but so is a culture that demands zero pain after medical treatment.

In a recent survey, a third of Americans blamed doctors for our country’s relentless opioid epidemic. I get it. Doctors (myself included) aren’t in a position to defend our prescribing practices — not with Massachusetts losing an estimated 1,173 people to overdoses in 2014, and 1,104 through just the first nine months of last year. While Massachusetts is responding to these deaths with a serious multifaceted approach, including last month’s breakthrough legislation limiting opioid prescriptions, our medical community needs to work hard to bring our culture up to speed with Governor Charlie Baker’s new law.

Overprescribing opioids is something we’ve gotten used to doing. To be fair, the origins of the epidemic aren’t due to the behavior of bad-apple doctors, who are rare. The majority are well-intentioned prescribers caught in a web of entangling interests spun over the past two decades. When the powerful narcotic OxyContin was first made available in the mid-90s, all that doctors heard from sweeping educational campaigns (many driven by pharmaceutical industry marketing) was that they were undertreating pain.

I’m ashamed that it took seeing deaths on the news every day in Massachusetts to force me to reconsider how I practice. Now, instead of jumping to opioids, I first try ibuprofen, or its relatives Toradol and intravenous Tylenol. Obviously I’m not alone.

In trials across the country, hospitals are trying new strategies to reduce opioid prescriptions. Peter Smulowitz is the president for the Massachusetts College of Emergency Physicians and associate chief of the emergency department at Beth Israel Deaconess in Plymouth, a town in the hot zone of opioid-related deaths. He’s running a study comparing prescription patterns of providers in the emergency department — if he sees doctors prescribing more opioids than average, Smulowitz’s team reaches out to them. “Providers are often surprised at their behavior, since it’s become their norm,” he says.

Over the first few months of Smulowitz’s study, total prescriptions of opioids in his emergency room dropped almost 25 percent. His ongoing study — among others — is a good start for how doctors can fight the epidemic. Medical and dental schools around the state, such as those at Boston University and Tufts, are now making the prevention and treatment of opioid addiction integral to their curriculums. Baker’s new legislation, alongside new guidelines from the Centers for Disease Control and Prevention, gives doctors a framework to reshape how we prescribe.

Still, we have more work to do. The state’s prescription drug monitoring program, a system doctors can use to track patients at risk for opioid addiction, isn’t used very often by physicians, many of whom find its interface cumbersome, according to a recent study. And while we shouldn’t fear opioids, since they remain appropriate for specific situations, they are too easy to administer broadly in a culture where pain remains unacceptable.

We need to look for new solutions to pain. Massage, meditation, behavioral therapy, placebo studies, and multidisciplinary pain teams need to become a part of routine medical care. Patients can help — by asking their physicians if these options are available. Here’s the biggest challenge: As a society, we need to start accepting that a measure of pain is a normal part of the course of illness.

It took doctors 20 years to help create this epidemic — but if we wake up to changing how we treat pain, we can more quickly contain its toll.


> 37% of survey respondents say drug users are “mainly responsible”

> 34% say doctors

> 10% say pharmaceutical companies

Source: March 2016 national poll by STAT and the Harvard T.H. Chan School of Public Health

Dr. Sushrut Jangi is an internist and instructor in medicine at Beth Israel Deaconess Medical Center. 



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