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An opioid epidemic is what happens when pain is treated only with pills

OxyContin pills at a pharmacy in Montpelier, Vt. (Toby Talbot/AP)

Too many opioids. Not enough opioids. Behold the opioid paradox.

The United States is in the midst of a massive opioid epidemic, as The Washington Post and other news organizations have documented extensively. In 2015, more than 33,000 people died from overdoses of opioids, meaning prescription painkillers, heroin, fentanyl or any combination. That easily keeps pace here with fatal motor vehicle accidents and gun-related deaths.

Certain states have been particularly affected. The Charleston Gazette just reported that opioid wholesalers shipped 780 million oxycodone and hydrocodone pills into West Virginia over a six-year period — enough for 433 pills for every person in the state. Meanwhile, 1,728 West Virginians died from overdoses of those two drugs.

One-third of long-term users are hooked on prescription opioids, Post poll shows

But there’s another side to the story. Opioids can be an effective treatment for chronic pain, and too many people around the world have limited access to them.

“We view pain relief as a human rights issue,” Kathleen Foley, a neurologist at Memorial Sloan Kettering Cancer Center, said at a Princeton symposium on pain and opioids this month. Historically, she said, pain has been under-treated, and she is concerned that the opioid epidemic “has stigmatized all patients with pain.”

Even in this country, some patients may be denied opioids because doctors are not convinced their described pain is real or fear the pills will be diverted to the illegal market. Keith Wailoo, a Princeton historian of medicine and health policy, who also spoke at the symposium, calls it a “pain gap” and says it is why African Americans with sickle cell disease, for example, have reported trouble getting prescription painkillers. “Think of it as a pain gap between the haves and the have-nots, along lines of class and race,” Wailoo wrote in the Daily Beast.

The United States also has a pain epidemic, with some 100 million Americans in chronic pain day in, day out. Partly that’s the consequence of sedentary lifestyles and obesity and the associated lower-back pain. But a lot of times manual labor and injuries from it are to blame.

The Post and the Kaiser Family Foundation conducted a poll this fall in which a third of long-term prescription opioid users reported being addicted or physically dependent. That’s a huge percentage. When doctors began prescribing opioids more liberally in the 1990s, they thought only a small fraction of patients would become addicted. We know otherwise today.

But the same poll showed that a large percentage of opioid users think these pills have improved their lives. Fully 68 percent say the drugs’ painkilling benefits outweigh their addiction dangers. See Emily Guskin’s report on that aspect of the results.

So it’s a conundrum. These pills are useful — but also dangerous. Doctors need to be prudent and first make sure there’s not an acceptable alternative. Tom Frieden, the head of the Centers for Disease Control and Prevention, said as much this week in an op-ed:

“There are safer drugs and treatment approaches that can control pain as well or better than opioids for the vast majority of patients. We must reduce the number of Americans exposed to opioids for the first time, especially for conditions where the risks of opioids outweigh the benefits.”

How can a doctor know when opioids are right and when they’re wrong? The CDC issued new guidelines this year. But there are other players in this game: private insurance companies, Medicare, Medicaid, Veterans Affairs and so on. That's the reimbursement system, and it's skewed toward pills.

Grant Baldwin, head of the CDC’s Division of Unintentional Injury Prevention, said at Princeton that the medical system needs to do more to reimburse non-opioid treatments, including physical therapy and counseling. Wailoo echoed that sentiment and said the emphasis on cost containment in health care has led to an over-reliance on pills.

“The reimbursement system looks favorably on drugs as prompt fixes for acute problems and looks askance at the kind of long-term, multidisciplinary care,” Wailoo said later in an interview.

He noted that the opioid epidemic has ravaged rural populations that generally voted for Donald Trump and GOP candidates who have vowed to repeal the Affordable Care Act. No matter what they do on the health-care law, he said, Republicans should be motivated to solve the opioid crisis.

“This is their constituency. These are their people,” he said.

 Read more:

Our series, "Unnatural Causes: Sick and dying in small-town America"

The lonely road of staying clean

Orphaned by the opioid epidemic