Originally Posted by
Sensei
There seems to be a fair amount of misinformation when it comes to this topic. Here is the Cliff Notes version of where we’ve been and where we are at.
1) Prior to the mid-80’s, it was exceedingly rare for opiates to be prescribed on a long term for non-cancer pain. During that time, a small cadre of physicians were employed by the pharmaceutical industry to reshape the lay and medical community’s opinions of opioids in preparation for several drugs that would enter the market within a decade.
2) In the late 80’s, this cadre of doctors published a few cases series of patients who received relatively short duration of opiate therapy without apparent consequences. Keep in mind that case series are some of the lowest forms of scientific evidence and there were no randomized trials looking at long term safety. However, these poor quality studies were cited by these doctors who were being employed by Pharma as evidence that the standard of care had shifted, and that opiates were safe for long term use in chronic, non-cancer pain. MS Contin was released in 1987 as the first oral long-acting opiate agent.
3) By the early 90s, a massive amount of money was pouring into professional societies (really shadow entities of the pharmaceutical industry) that were petitioning regulatory bodies such as Center for Medicare Services and the Joint Commission that accredits hospitals to become more aggressive with treating all forms of pain with opiates. Hence pain became a vital sign, doctors were sued and disciplined for not treating pain with opiates, and the medical system was primed for what was about to happen next.
4) In 1995 OxyContin was approved and within 2 years was one of the top 2 or 3 most prescribed medications in America.
5) By the early 2000s, portions of the medical community started to realize there might be a problem. Although OxyContin was thought to have low abuse potential, reports of it being injected were starting to crop up. Moreover, certain pharmacies were distributing massive amounts of the drug to relatively small populations. The manufacturer, Purdue Pharma, was aware of the irregularities and suppressed the information.
6) In 2010, a new, less abuse prone form of OxyContin was approved. Unfortunately, several other abuse-prone opiates were released (I.e. Opana). As for distribution, states without any controlled substance monitoring such as FL saw pill mill pain clinics flourish along I95. In the parking lots were license plates from OH, TN, WV, etc. Also at this time we were noticing a massive increase in opiate-related overdoses, opiate-complicated births, and mental health issues.
7) By 2014, everyone in the medical community knew there was a problem. Deaths from overdoses were at 60,000 and America was still seeing more and more total morphine equivalents being prescribed.
8) Between 2015 and present time we have seen a paradigm shift. Several studies were published including the first randomized trial of opiates vs. non-opiates for chronic pain. Known as the SPACE Trial, opiates were no more effective than non-opiates at controlling chronic pain and were associated with more adverse events - so much for patients “needing” opiates. Other studies showed that a course beyond just 5 days of opiate therapy was associated with future chronic opioid use and dependence, and most surgical patients need just 7-10 of opioid meds to control their symptoms.
9) By 2016, most states had significantly tightened their oversight of opiate prescribing. The cartels stepped in and began to fill the void with cheap heroin and fentanyl. A recent survey of heroin addicts showed that 70% began their road to opiate addiction with a prescription.
So, this was a system wide failure of the pharmaceutical industry, medical profession, federal and state regulatory bodies, and general public. It is good that the pharmaceutical industry is being held to account. Now it’s time to continue looking at outlier prescribers and hold them to account if they cannot show proper accounting and precautions. Finally, a complete overhaul of CMS and Joint Commission needs to be undertaken and scrutinized on how core measures and practice guidelines are developed and applied to the industry.
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