This article is not meant to minimize the dangers of opioids, whether prescribed or obtained illicitly. All opioids have a risk of addiction and overdose that is undeniable. In my work at a drug and alcohol treatment center, I see everyday the life-threatening danger of opioid addiction. While prescription opioids are to blame for some opioid overdose deaths, according to the CDC it is the ready access to illicitly manufactured fentanyl that is the primary driver behind the rising rate of opioid overdose deaths. Fentanyl is a synthetic opioid that is 50 times stronger than heroin, and due to its potency it is very easy to accidentally overdose on fentanyl.
Until we have better tools to manage pain, I believe opioids still need to remain one of the pain management options available to those in chronic pain. In many ways the hysteria around opioid use for chronic pain is misguided. Studies show that among people who are prescribed opioids, addiction is relatively uncommon.
According to a brilliant article by Dr. Sally Satel, “the percentage of patients who become addicted after taking opioids for chronic pain is measured in the single digits; studies show an incidence from less than 1 percent to 8 percent".
It is important here to clarify the difference between addiction and dependence. Because of how opioids affect the brain, anyone taking this type of medications regularly will develop physical dependence on them, meaning if the medications are stopped suddenly withdrawal symptoms may occur. Dependence is not the same as addiction. Addiction means abnormal behaviors around a medication, using it to change your mood or get high, and being unable to control your use of the medication. And addiction to substances or behaviors (like gambling or sex) are much more likely in people experiencing poverty, trauma or mental health issues. Ultimately the “opioid crisis” is not really about opioids, it is about addiction and mental health and societal despair driving suffering people to abuse mood-altering addictive substances like opioids.
In a powerful editorial in Pain Medicine News, Dr. James Choo says it perfectly: “The opioid crisis has caught the nation’s attention, but through the lens of opioids we focus on a narrow bandwidth and overlook the deeper problems… of addiction, trauma and polysubstance abuse.”
In fact, the policies to control one type of drug use often cause a flourishing of another type. As prescription opioids became harder to access, more people turned to stronger illicit fentanyl and heroin, which are much more likely to lead to deadly overdose. In fact, as this powerful graph shows, as prescriptions for opioids went down, rates of overdose deaths have gone up.
Clearly the current efforts to clamp down on all opioid prescriptions are misguided. During prohibition when alcohol was illegal, people turned to homemade alcohols and toxic wood alcohol (methanol) that caused blindness and death. Our current “opioid crisis” looks a lot like a deadly game of whack-a-mole, as we chase after the current drugs of abuse, while not addressing the underlying demand for drugs.
Trauma and Addiction
According to Dr. Choo, the better question is why do addicts seek any drug? The answer is likely trauma, a societal affliction that most policymakers and the media are uncomfortable addressing. A study in the 1990s by the CDC and Kaiser Permanente found that the amount of trauma experienced in childhood was directly related to the risk of developing addictions. Some addiction experts now think that substance abuse may be a normal learned response to trauma, a form of compulsive comfort-seeking or self-soothing. Dr. Choo advocates changing the narrative from an “opioid-crisis” to a “trauma crisis” and “directing resources and attention to addressing what drives the demand for drugs, but this would take political and societal will, and it takes a long view to care—not a quick fix by any means.”
He is absolutely right. We cannot win by playing an eternal game of “whack-a-drug”, without addressing the underlying societal ills driving substance abuse and addiction. Responding to a substance abuse epidemic by taking prescription opioids away from those in chronic pain simply creates another epidemic of undertreated chronic pain.