Psychiatry and the Opioid Overdose Crisis

For the third year in a row, the Centers for Disease Control and Prevention reported an unprecedented decline in life expectancy for the United States, a decline attributable mainly to drug overdose deaths and suicides (1, 2). Drug overdoses have continued to rise and are now estimated to account for 70,237 deaths in 2017 (3, 4). Adults 25–64 years old were the largest group affected, with the age 55–64 cohort manifesting a sixfold rise in death rate since 1999, yet individuals from all age ranges are contributing to the upward spiraling death rate. Death rates vary by states, with 20 states and the District of Columbia reporting drug overdose death rates that are higher than the national rate (21.7 per 100,000), eight states reporting rates comparable with the national rate, and 22 states exhibiting lower rates. Of the 70,237 deaths, approximately 49,000 were related to opioids, with methamphetamine and cocaine implicated in the majority of other deaths. Among opioid overdoses, fentanyl deaths rose precipitously since 2013, and fentanyl now accounts for more opioid deaths than prescription opioids, heroin, or methadone.

The first iatrogenic opioid crisis in the United States began in the mid-19th century and faded early in the 20th century. In the 19th century, persons with iatrogenic opioid and “street heroin” opioid use disorder were perceived by physicians as distinct populations, with different sources of opioids, with different reasons for use and for developing addiction. These boundaries have become unraveled in the current crisis, as persons increasingly transition from prescription opioids to heroin or fentanyl (5, 6); as treatment for opioid addiction becomes standardized; and as those affected increasingly are from economically advantaged or disadvantaged groups, in urban or rural settings, and from a broadening range of ethnic and racial groups.

The root causes of the modern opioid crisis are complex and traceable to at least 30 factors (B.K. Madras, National Drug Early Warning System Webinar, Jan. 10, 2018; https://ndews.umd.edu/resources/opioid-commission-summary-and-lessons-learned). A prime driver has been the health care system. Pressure on medical practitioners to resort to opioids for managing chronic pain led to a nation awash with prescription opioids, from both legitimately prescribed and diverted prescription sources. An initial catalyst was a letter to the editor of the New England Journal of Medicine in 1980, with the title “Addiction Rare in Patients Treated with Narcotics” (7). The authors of this five-sentence letter scrutinized the records of hospitalized patients and concluded that opioid addiction was rare, even though they provided no information regarding doses, duration of opioid treatment, opioid consumption postdischarge, long-term follow-up, or criteria for addiction. The letter garnered an unusual 600, mostly affirmative, citations (8). Six years later, another and inadequately powered study concluded that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse” (9, p. 1). These reports abetted aggressive advocacy for chronic pain management with opioids (9–11) by patients with chronic pain and by professional pain societies (12, 13). Critically, it empowered the opioid pharmaceutical industry to sponsor thousands of “educational” events for prescribers on the safety of opioids to treat chronic pain (14). In response to the pain movement, the Department of Veterans Affairs and then the Joint Commission designated pain as the “fifth vital sign” (15). Administrators and regulatory bodies pressured physicians to raise patient satisfaction scores primarily by addressing pain with opioids. In a recent survey of emergency department physicians, 71% reported a perceived pressure to prescribe opioid analgesics to avoid administrative and regulatory criticism, and 98% felt that patient satisfaction scores are excessively relied on by reimbursement providers to evaluate management of their patients. The physician requirement to address pain as the “fifth vital sign” (16)—reimbursement metrics based on patient satisfaction—may have inadvertently created a peculiar American environment conducive to opioid prescribing and exploitation by prescription opioid misusers (17). The erosion of opiophobia among health care providers, coupled with pressure from pain patients and the pharmaceutical industry, led to a >300% increase in opioid prescriptions. Conscientious physicians and detractors who issued cautionary statements and guidelines were essentially ignored, while advocates were given center stage (18). The vast excess of unused and unneeded opioids was heavily diverted for nonmedical use (as stated in the annual reports of the National Survey on Drug Use and Health [NSDUH; https://nsduhweb.rti.org/respweb/homepage.cfm] for 2006–2017).

The United States became awash with prescription opioids, a crisis unique to the country, as it ranks well above other “high-prescribing” nations on opioid-prescribing practices and prescription opioid deaths (19). A significant excess entered the system, as unused and unneeded opioids were diverted for nonmedical use. Excessive prescribing of opioids continues to this day, even though new opioid prescriptions are declining (20). Prescribing levels in 2015 were three times those of 1999, but trends are encouraging. Analysis of the NSDUH data indicate that nonmedical use of opioid analgesics declined from 48.4 per 1,000 persons between 2003 and 2005 to 43.3 per 1,000 persons between 2012 and 2014. In contrast, increases in abuse or dependence were observed during the same time interval (6.0 to 7.5 per 1,000 persons) (21). The prevalence of prescription opioid use disorder among users of nonmedical prescription opioids during this time period significantly increased among 18- to 34-year-olds but stayed relatively stable for 12- to 17-year-olds (22). Counterbalancing this movement is déjà vu, with the current evidence once again questioning the safety and efficacy of prescription opioids for chronic pain: (1) Treatment with opioids was shown to be not superior to treatment with nonopioid medications for improving moderate to severe chronic back pain or hip or knee osteoarthritis pain and pain-related function over 12 months, with findings not supportive of opioid therapy initiation (23); and (2) a meta-analysis of 96 randomized clinical trials and 26,169 patients with chronic noncancer pain showed that the use of opioids (compared with placebo but not with other analgesics) was associated with small reductions in pain (−0.69 cm on a 10-cm scale) and small improvements in physical functioning (2.04 of 100 points) (24). Accordingly, opioids may provide benefit for chronic noncancer pain, but the magnitude is likely to be small and the potential for adverse events high.

The current crisis is more lethal than it was at the onset of the problem, because fentanyl and its analogs have replaced prescription opioids as a primary cause of opioid overdose deaths (25). Fentanyl is lethal at vanishingly low doses (26); its high potency makes even distribution of fentanyl powder/crystals within “fillers” difficult. Fentanyl can catalyze respiratory depression rapidly, often long before first responders become aware, are alerted or can react. Counterfeit pill presses disguise fentanyl in pills marketed on the street as prescription opioids, or sedatives, and counterfeit powders sold as cocaine can be lethal to users who have not developed tolerance to opioids (26). Strategies to end the opioid crisis are grounded in these realities but are bolstered by the advent of large-scale data analytics, evidence-based pharmaceutical treatments, early detection, and lessons learned from the previous crisis (27).

In 2017, an unprecedented action was taken by President Donald J. Trump. He signed an executive order on March 29, 2017, establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis, tasked with providing guidance on reversing the crisis. Chaired by Governor Chris Christie (New Jersey), the six-member Commission included Governor Charlie Baker (Massachusetts), Governor Roy Cooper (North Carolina), former Congressman Patrick Kennedy (Rhode Island), Attorney General Pam Bondi (Florida), and the first author of this article (Massachusetts). An interim report requested that the president declare the opioid crisis a public health emergency under federal law, which he did. Charged with coordinating and developing the final report, the first author of the present article developed a perspective that informs the focus of this article. We explored the root causes of the current crisis both to devise strategies to reverse-engineer reversible factors and to provide a blueprint to prevent the same errors from recurring. Strategies include, for example, improving the following: scrutiny from the Food and Drug Administration of opioid abuse liability and mandatory reporting of addiction as an adverse event; medical education in opioid prescribing, pain management, and the diagnosis and treatment of substance use disorders; guidelines for opioid prescribing that are informed by pharmacoepidemiological analyses; information flow of patients’ opioid prescriptions, substance use disorder, and overdose chronicles among physicians, treatment centers, emergency departments, first responders, medical examiners, and pharmacies; removal of unwarranted institutional, professional, legal, patient, insurance, and financial pressure on physicians to address pain aggressively with opioids; removal of barriers such as health care insurers’ prior authorization approval for pain management alternatives, pharmacotherapeutics, and addiction treatment; enforcement of compliance with mental health and addiction treatment parity laws; quality of addiction treatment services, with provisions of pharmacotherapies and mental health care; and responsiveness to overdoses. The 56 recommendations of the President’s Commission report were grounded in the reality of past errors and current weaknesses in management of pain, in addiction treatment, and in reimbursement systems and represent advanced strategies for prevention, treatment, rescue, recovery support, research, improved data analytics, and accountability (28). With a focus on the quality of treatment services and recovery homes, the report calls for implementing high standards of care for treatment. Specialists in addiction medicine and addiction psychiatry are best positioned to develop and implement high-quality care. Advanced data analytics to strengthen data collection, integration, and real-time surveillance of the opioid crisis at the national, state, local, and tribal levels are embedded throughout the report. The report also calls for scientific research as a key component in mitigating the opioid crisis. The development of analgesics with limited or no abuse liability, antagonists to reverse newly emerging high-potency opioid agonists while mitigating withdrawal symptoms, and new pharmacotherapies to treat opioid addiction are listed as attainable goals. New technologies are mentioned, including wearable devices that sense respiratory depression to alert the user, devices that automatically inject naloxone when blood oxygenation levels are dangerously low, and devices that wirelessly report a looming crisis to a first responder. Also included are apps for wireless electronic devices (e.g., phones, watches, and virtual reality devices) to function as behavioral coaches, to reduce pain, or to increase compliance, among others. On October 24, 2018, President Trump signed sweeping legislation to address the nation’s opioid crisis, the SUPPORT for Patients and Communities Act, which was shaped to an extent by the President’s Commission report.

Multiple weaknesses exist in our current system of care that can be addressed by the practice of psychiatry. The following recommendations were partly inspired by two recently published articles (27, 29).

Dr. Madras is supported by National Institute on Drug Abuse grant DA042178.