Long before there was such a thing as a "drug czar," more than 100 years ago, the US government had something called an Opium Commissioner.
US Opium Commissioner Hamilton Wright, MD, a physician and pathologist, was appointed to that post by President Theodore Roosevelt in 1908, and in February 1909 he attended the International Opium Commission in Shanghai, China. He served at the follow-on conference at The Hague in 1911.
Commissioner Wright reported that, "Of all the nations of the world, the United States consumes the most habit-forming drugs per capita, even more than the Chinese."1 He called opium the "most pernicious drug known to humanity and the US, a fiend."1
Today, the United States still experiences more than 70,000 deaths from drug overdose per year, with more than 67% of these attributable to opioids.2
As the number of opioid prescriptions has risen to more than 225 million annually, physician overprescribing is usually identified as a major cause of the current opioid crisis. For example, one surgical study reported that more than 90% of patients undergoing elective procedures at 3 academic medical centers were prescribed an opioid postoperatively, and 77% of those patients had leftover drugs.3 Also, some 75% of individuals who use heroin describe their first opioid of abuse as a prescription drug.4
A recent viewpoint by Chidgey et al5 argues this general belief, rather emphasizing misinformation and outside pressure from pharmaceutical companies and accrediting bodies, such as The Joint Commission (TJC, but under its earlier and longer name, the Joint Commission on the Accreditation of Healthcare Organizations) and the American Pain Society (APS, which dissolved in June 2019). TJC and the APS had designated pain the fifth vital sign.5 With that designation as a validation, oxycontin and other opioids, once prescribed for pain from malignant conditions, were then marketed as good treatment for pain. From 1996 to 2000, sales of oxycontin rose from $48 million to $1.1 billion annually.
TJC released new pain management standards: pain control was a patient's right, and suffering was identified as a gap in clinician education and training. An aggressive approach to pain assessment was advocated with quantitative measures such as the 10-point scale.
Responsibility for pain management was placed on health care organizations, with demand for treatment until pain was appropriately addressed. No longer was pain an unavoidable part of life. Rather, it was unacceptable.
Although concerned about creating addicts, physicians were assured by TJC and the National Pharmaceutical Council in a published statement that, "in general, patients in pain do not become addicted to opioids" and clinical concern about opioids "sometimes reflects a lack of understanding of the risk of addiction with therapeutic drug use."6
Supporting data came from a single paragraph letter, describing a retrospective review of a database of 11,882 patients that indicated only 4 patients became slightly addicted, and only 1 was considered to have major addiction.7 Purdue Pharma and many others used this article repeatedly.
Opioids became the perceived gold standard for pain control. Patients were asked by the Centers for Medicare & Medicaid Services how often staff had done everything possible to manage their pain. Reimbursement of services was tied in. Consequences of suffering from persistent pain due to "medical mismanagement" were considerable.
But pain is very difficult to quantify, despite our best efforts. Although pain signals can be modulated by ancillary methods, ultimately, health care workers are asked to quantify perceptions.
Thus, in this quandary, physicians became unwitting accomplices in the opioid crisis. Multifaceted approaches from governing bodies to pharmaceutical agencies to health care workers must work together to develop standards that reflect the complexity of pain treatment. Nonopioid treatment options, including mental health services, must be recognized. Realistic expectations for recovery, reducing surgical stress, and promoting a rapid return to normal function must be emphasized. Pain should not be taken simply as the "fifth vital sign."
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