In 1736, Ben Franklin famously advised Philadelphians that preventing fires is better than fighting them. Mr. Franklin’s advice is just as applicable today in addressing America’s opioid crisis. Billions of opioid settlement dollars are being distributed to every state, and a portion of those funds should be allocated to preventing opioid addictions, not just buying fire extinguishers (Narcan) and fighting fires (medication-assisted therapy or substance use disorder treatment). Preventing opioid addiction requires a deeper understanding of how America became an outlier in opioid consumption and recognizing the match that sparks our opioid fires.
America’s widespread use of opioids is exceptional, and studies show that we prescribe alarmingly high amounts compared to other countries. We are 4.6% of the world’s population, but we consume 80% of the world’s opioids. In the late ’90s, clever marketing by the opioid manufacturer Purdue Pharma convinced America’s physicians and patients that opioids were the best treatment for acute and chronic pain and that longer-duration opioids were not addictive. By the early 2000s, the American Pain Society and the Veterans Administration bought in.
So did the Joint Commission, a peer-review organization that reviews the quality and oversees accreditation of health care facilities. It advanced the idea, now retracted, that subjective pain scores should be measured on a 0-10 scale and treated as the “fifth vital sign.” These developments encouraged, and essentially mandated, the widespread use of opioids by U.S. doctors, nurses, and hospitals.
Current evidence shows that opioid prescriptions are the wellspring of our addiction crisis. Nearly 75% of heroin users report having been introduced to opioids through prescription medications. For them, and most Americans, a doctor provides the pill that can trigger opioid addiction. After acute care, like surgery, an injury, or a dental procedure, Americans typically are sent home with an opioid prescription.
Unfortunately, according to the CDC, after only 5 days of opioid use, our bodies start developing opioid dependence. If we try to stop taking these medications, we feel unwell, jittery, crampy, sweaty, and we can’t sleep. We continue taking these medicines to prevent those symptoms and then become addicted.
America is awash in opioids that sit in virtually every medicine cabinet. Numerous studies show that Americans have a 10% chance of remaining on opioids after elective surgery. That number approaches 20% for women undergoing a mastectomy for cancer. Surgery alone accounts for nearly 3 million new opioid addicts per year. Given these statistics, it should not surprise us that, in labor-intensive jobs where injuries are common, roughly 25% of workers are on opioids while on the job.
If unnecessary opioid prescriptions are the source of the problem, then an effective prevention strategy is needed. This is the thinking behind recent legislative efforts like the Non-Opioid Directive, now law in 7 states, which provides for an advanced directive that lets patients refuse opioids when receiving care. This law is widely backed by organized labor, and it has been proposed federally. A 2019 study from the University of Michigan and IBM Watson showed that one opioid prescription after any surgery increased costs by 50% for all payers. This included Medicare and Medicaid, which significantly impact Federal and State budgets. Imagine the savings that could be realized by simply preventing these pills from inappropriately entering our society.
The U.S.’ opioid settlement is 50 billion dollars over 18 years. Most of these funds have been earmarked for Narcan, medication-assisted therapy, and substance use disorder treatment. None of these interventions address the source of the problem. The CDC has shown that the per-patient annual cost of substance use disorder treatment is $15,640. Treating just our 3 million new opioid-dependent surgical patients each year would be $47 billion, quickly overwhelming the settlement funds.
A more cost-effective strategy would include addressing the problem’s source. The rest of the world has this right, and Americans can learn about and embrace how other high-functioning societies manage pain. America’s physicians can be trained in multimodal pain management and avoiding unnecessary opioid prescriptions. Patients can be educated on the dangers of opioids and how to change their expectations.
Ben Franklin was right 287 years ago, and he is right today about our opioid crisis; an ounce of prevention is worth more than a pound of cure.
Matt McCord is an anesthesiologist. Brian Klepper is a health care executive. This article was originally published in HEALTH CARE un-covered.
