The Opioid Epidemic in America

We have recently been bombarded from the media and regulators about the opioid epidemic in America. A recent broadcast on National Public Radio reported the Centers for Disease Control data that 19000 people died from prescription opioid overdoses last year. ³

That works out to be more than 50 deaths per day in the United States. The United States makes up less than 5% of the world’s population, but consumes 80% of the global opioid supply and approximately 99% of hydrocodone. ¹

The American Pain Society (APS) introduced the phrase “Pain as the fifth vital sign” in 1996. ⁵ This initiative emphasized that pain assessment is as important as assessment of the standard 4 vital signs. This led to the Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards for pain assessment and management. This was the first step to the expansion of the use of prescription opioids. During the late 1980s and early 1990s, pain experts touted the benefits and safety of prescription opioids. Experts overstated the benefits of the drugs, while at the same time, glossed over the risks. The Federation of State Medical Boards reassured doctors in 1998 that they would not face regulatory action for prescribing even large amounts of narcotics, as long as it was in the course of medical treatment. The group asked state medical boards to punish physicians for the undertreatment of pain in 2004.

It was learned later that policy was developed by several people linked to the manufacturing of long-acting narcotics. These funded policy makers were funded with millions of dollars of support and consulting fees from the makers of the drugs. The Joint Commission published a guide sponsored by one of the largest makers of these drugs that stated that “some physicians have inaccurate and exaggerated concerns” about addiction, tolerance and risk of death. ⁴ American physicians responsibly followed these guidelines that came from their professional societies, JCAHO, and the Department of Veterans Affairs. It was these responsible practices that led to our current crisis.

Now that the truth has come forward, we are faced with an epidemic of monumental proportions. Many states have greatly restricted the ability of physicians to prescribe opioids. Many states have threatened mandatory training before allowing physicians to prescribe these now considered “dangerous” drugs. Forty-nine states have created a mandatory Prescription Database to track who is writing these prescriptions for whom. ²

David Ring, MD (chair of AAOS patient Safety Committee) has long been a champion for exploring strategies for the management of pain without the overuse of narcotic pain medications. By the time this publication comes to print, the AAOS Patient Safety Committee should have a very interesting toolkit available to use in your practice to assist you in developing a more modern approach to pain management and responsible use of potentially dangerous medications. I implore you to attend the Patient Safety presentations at the AAOS Annual Meeting to address this vexing problem. Be proactive in your practice. Learn how to use the multi-modal approach of regional anesthesia, cold therapy, nonsteroidal anti-inflammatory drugs, and other safe neuroleptic medications. Rather than simply saying “no” to the use of these medications, be judicious in their use and learn other methods to help your patients. This is going to be a valuable learning process for all of us. We value your comments on this challenging problem. Contact the FootForum at mpinzur@aofas.org.