Special article
How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis

https://doi.org/10.1016/j.mayocp.2017.12.020Get rights and content

Abstract

The opioid crisis that exists today developed over the past 30 years. The reasons for this are many. Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Following the publication of a short letter to the editor in a major medical journal declaring that those with chronic pain who received opioids rarely became addicted, prescriber attitude toward opioid use changed. Opioids were no longer reserved for treatment of acute pain or terminal pain conditions but now were used to treat any pain condition. Governing agencies began to evaluate doctors and hospitals on their control of patients' pain. Ultimately, reimbursement became tied to patients' perception of pain control. As a result, increasing amounts of opioids were prescribed, which led to dependence. When this occurred, patients sought more in the form of opioid prescriptions from providers or from illegal sources. Illegal, unregulated sources of opioids are now a factor in the increasing death rate from opioid overdoses. Stopping the opioid crisis will require the engagement of all, including health care providers, hospitals, the pharmaceutical industry, and federal and state government agencies.

Section snippets

Addressing Chronic Pain

In the past, opioid medications were prescribed primarily for acute pain due to injury or surgery or severe pain related to cancer or a terminal illness. Physicians were reluctant to prescribe opioids for other conditions because there was no evidence to support wider prescribing practices, and there was a concern for addiction. In addition, physicians feared investigation and state board disciplinary action if they did prescribe opioids more liberally.14, 15, 16 In 1980, a 1-paragraph letter

Monitoring Pain

The impetus for more aggressive pain treatment came from numerous studies published in the 1990s indicating that cancer and noncancer pain were ineffectively treated. In 1998, a study examining a national database of elderly patients in a nursing home with cancer found that pain was prevalent and often untreated.29 Another study of more than 1000 outpatients with metastatic cancer treated between 1990 and 1991 reported that 42% did not receive adequate pain therapy.30 Inadequate pain therapy

Reimbursing for Patient Satisfaction

The Deficit Reduction Act of 2005 required hospitals to participate in the HCAHPS Survey by submitting the results of the survey as a part of the Inpatient Prospective Payment System. The hospitals that submitted patient satisfaction data received full annual payment; those that did not incurred a 2% penalty for nonsubmission.36 By 2010, the Patient Protection and Affordable Care Act of 2010 expanded the role of patient satisfaction as a payment incentive by including the HCAHPS Survey scores

Providing Larger Amounts and More Potent Painkillers

Pharmaceutical companies, medical governing agencies, insurance companies, and retail pharmacies also had good intentions of improving patient care and decreasing cost, but these intentions also indirectly contributed to the opioid crisis. Physicians and dentists wrote prescriptions for larger supplies of opioids after procedures to not only aggressively treat pain but also limit refill requests. Some retail pharmacies and insurance companies inadvertently contributed to the opioid problem by

Summary

Many good intentions leading to specific actions contributed to the opioid crisis. It began with underestimating the addictive potential of opioids in treating chronic pain and the advocacy of opioids to treat all pain issues. The implied message was that pain, which is part of the human condition, is a vital sign that should be treated similar to abrupt changes in temperature and blood pressure. Concurrently, pain control assessments included in patient satisfaction surveys became a measure of

Possible Next Steps

To address the opioid crisis, there are a number of groups attempting to set goals, guidelines, and regulations including the IOM, the Joint Commission, the Department of Health and Human Services, the CMS, the FDA, the Centers for Disease Control and Prevention, and other federal and state government agencies. In 2011, the IOM published “Relieving Pain in America,” which advocates for a multidisciplinary and multimodal approach to pain management, and includes emphasis on prevention, not just

Conclusion

Over the past 30 years, the intentions to address and control pain and to have patients directly involved in their care were well-meaning, but the measures taken to achieve these goals contributed to the opioid crisis. Pain is not an opioid-deficient condition but a human, multidimensional disorder often involving more than just physical pain. Because it encompasses emotional, social, and spiritual, as well as physical components, it cannot be eliminated by a single drug. If we continue to

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    For editorial comment, see page 269

    Potential Competing Interests: The authors report no competing interests.

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