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The Opinion Pages | OP-ED CONTRIBUTOR

The Opioid Epidemic We Failed to

Foresee
By DAVID A. KESSLER MAY 6, 2016
BEGINNING in the late 1990s, pharmaceutical companies selling high-dose
opioids seized upon a notion, based on flimsy scientific evidence, that regardless of
the length of treatment, patients would not become addicted to opioids.

It has proved to be one of the biggest mistakes in modern medicine.

An epidemic of prescription drug abuse has swept across the country as a

result, and one of the latest victims, according to The New York Times, may have
been Prince.

The paper reported that he had developed a problem with prescription

painkillers, and that just before his death, friends sought urgent medical help from
a California doctor who specializes in treating people addicted to pain medication.
Whether pain pills played a role in his death wont be known until the results of an
autopsy are released.

How did we get this so wrong?

The so-called proof that patients would not become addicted was based on a
limited number of patients. This was coupled with the idea that opioids should be
used for a broad range of indications including all types of moderate to severe
pain when, in fact, they dont work against all forms of chronic pain.

Equally dangerous was the notion that there was virtually no dose ceiling. The
mantra was: Prescribe until patients achieve pain relief. And then there was the
flawed concept of pseudoaddiction: If the patient comes in and is showing signs of
drug seeking, that doesnt mean the patient is actually addicted to opioids; it more
likely means that he or she just needs more opioids to control pain. So the first
response should be to prescribe more.

In turn, the Food and Drug Administration relied too heavily on doctors to
figure out how to appropriately prescribe these medicines. For many of them, a pill
was an expedient way to try to help their patients. Figures published by the Centers
for Disease Control and Prevention for the period 2008 to 2011 show that among
those who were at the highest risk of overdose, 27 percent used their own
prescriptions and another 49 percent either got or bought opioids from friends and
relatives. Only 15 percent bought them from a drug dealer.

Doctors, regulators and drug makers also mistakenly divided the world up into
those patients who had legitimate pain and who they believed would not become
addicted, and drug addicts. Moreover, they missed one fundamental: The more
opioids prescribed, the more opioid abuse there will be.

One thing that all experts agree on is that opioids have a role in cancer pain,
end-of-life palliation and some forms of acute pain. The question is whether we
make people with chronic pain better by treating them with opioids.

No doubt they sometimes work in the short term. And some pain experts
believe that there are patients who function well on moderate doses of opioids and
do not require more. But over time, the biology of opioids makes tolerance and
thus the need for higher and higher doses a reality for a considerable number of
patients who stay on the drug.

Continued opioids are needed to keep the physical withdrawal symptoms at

bay. Those withdrawal symptoms are associated with their own pain. Thus,
whatever pain that occurred at the beginning of treatment is replaced by the pain
that is generated by the drugs withdrawal symptoms.

Some patients will make heart-rending pleas that they cannot live without
their opioids. But we have failed to see this for what it is, the signature of
addiction: I need it. I cant get better or normal without it.
 Some experts believe that lower doses taken over a long period may be
appropriate in certain instances. But that requires careful monitoring on the part
of both the patient and the doctor. We need to recognize that there are many forms
of pain, and not all respond to opioids. All are real. Some are caused by tissue
injury, others by nerve injury. In a number of conditions, we can become
hypervigilant to signals in our body that keep us trapped in a vicious cycle of pain.
Certainly in those where we become keenly alert to the pain, treatment strategies
including cognitive behavioral therapy are more effective than opioids.

What we have learned with addictive substances is that how society perceives
them will predict how widely they will be used. For decades, cigarettes were made
out to be something that we wanted and would give us pleasure. Then that
perception changed as people came to understand that cigarettes actually were
deadly addictive products that had no place in a healthy life. Opioids are trickier
because they have some value in certain conditions. But we need to view them for
what they are: addictive and potentially deadly drugs.

David A. Kessler was the commissioner of the Food and Drug Administration from 1990
to 1997 and is the author of Capture: Unraveling the Mystery of Mental Suffering.

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A version of this op-ed appears in print on May 7, 2016, on page A19 of the New York edition with the
headline: The Epidemic We Failed to Foresee.

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