Opioid moderatism and the imperative of rapprochement in pain medicine

Abstract

Michael E Schatman,1,2 Alexis Vasciannie,3,4 Ronald J Kulich3,5 1Research and Network Development, Boston PainCare, Waltham, MA, USA; 2Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA; 3Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 4Department of Biological Sciences, Northeastern University, Boston, MA, USA; 5Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA   A brief history of the “prescription opioid crisis” Few would deny that the first decade of this millennium was marked by a “prescription opioid crisis” in the United States, characterized by overprescription and frank opiophilia. Although many have attempted to blame this crisis on a single cause, more thoughtful analysis has yielded numerous contributors to the onset and maintenance of the abuse crisis.1 Schatman,2,3 among others, has posited that health insurance carriers’ decision to discontinue coverage of interdisciplinary pain management programs left physicians without the most effective means of treating chronic pain, resulting in the consequence of turning to increased opioid prescribing. Dasgupta et al1 recently suggested that the pharmaceutical industry responded to this void by propagating not only long-acting opioids but forms that were ultra-rapid-acting, including dissolving strips and nasal sprays. They also noted that safety issues associated with non-opioid pain medications such as non-steroidal anti-inflammatory drugs and acetaminophen may have further fueled opioid prescribing. Perhaps the aggressive and fraudulent marketing of OxyContin as “nonaddictive” has been considered the primary culprit in the prescription opioid crisis,4 although other questionable industry behaviors such as kickback schemes,5 lucrative compensation for speaking as an incentive to prescribe,6 and promotion of off-label use7 have also been implicated as contributing to the prescription opioid conflict. In the late 1990s patient advocates began to encourage the assessment of pain as the “fifth vital sign”, and those most vehemently against opioids have gone so far as to suggest that pharmaceutical industry lobbying was responsible for the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) advocacy for the institution of such.8 JCAHO’s proclamation has been indicted as creating a culture resulting in a marked increase in opioid prescription.9 Other causes to which the prescription opioid crisis has been attributed include unscrupulous physicians operating “pill mills”,10 unrealistic expectations of patients regarding complete relief of pain,11 state medical boards curtailing restrictions on prescribing opioids for noncancer pain,12 the Affordable Care Act’s provision requiring hospitals’ provision of patient satisfaction surveys that included satisfaction regarding pain relief,13 increased availability of prescription opioids without a prescription over the internet,14 and providers’ failures to adequately identify and monitor misuse and overuse.15 This list is far from exhaustive, with a recent assessment16 reporting that “The root causes of the modern opioid crisis are complex and traceable to at least 30 or more factors” (p. 943).

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