Over the past two decades, as the prevalence of chronic pain and health care costs have
exploded, an opioid epidemic with adverse consequences has escalated. Efforts to increase
opioid use and a campaign touting the alleged undertreatment of pain continue to be
significant factors in the escalation. Many arguments in favor of opioids are based solely on
traditions, expert opinion, practical experience and uncontrolled anecdotal observations.
Over the past 20 years, the liberalization of laws governing the prescribing of opioids for
the treatment of chronic non-cancer pain by the state medical boards has led to dramatic
increases in opioid use. This has evolved into the present stage, with the introduction
of new pain management standards by the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO) in 2000, an increased awareness of the right to pain
relief, the support of various organizations supporting the use of opioids in large doses,
and finally, aggressive marketing by the pharmaceutical industry. These positions are based
on unsound science and blatant misinformation, and accompanied by the dangerous
assumptions that opioids are highly effective and safe, and devoid of adverse events when
prescribed by physicians.
Results of the 2010 National Survey on Drug Use and Health (NSDUH) showed that an
estimated 22.6 million, or 8.9% of Americans, aged 12 or older, were current or past
month illicit drug users, The survey showed that just behind the 7 million people who had
used marijuana, 5.1 million had used pain relievers. It has also been shown that only one
in 6 or 17.3% of users of non-therapeutic opioids indicated that they received the drugs
through a prescription from one doctor.
The escalating use of therapeutic opioids shows hydrocodone topping all prescriptions
with 136.7 million prescriptions in 2011, with all narcotic analgesics exceeding 238 million
prescriptions. It has also been illustrated that opioid analgesics are now responsible for
more deaths than the number of deaths from both suicide and motor vehicle crashes, or
deaths from cocaine and heroin combined. A significant relationship exists between sales
of opioid pain relievers and deaths. The majority of deaths (60%) occur in patients when
they are given prescriptions based on prescribing guidelines by medical boards, with 20%
of deaths in low dose opioid therapy of 100 mg of morphine equivalent dose or less per
day and 40% in those receiving morphine of over 100 mg per day. In comparison, 40%
of deaths occur in individuals abusing the drugs obtained through multiple prescriptions,
doctor shopping, and drug diversion.
The purpose of this comprehensive review is to describe various aspects of crisis of opioid
use in the United States. The obstacles that must be surmounted are primarily inappropriate
prescribing patterns, which are largely based on a lack of knowledge, perceived safety, and
inaccurate belief of undertreatment of pain.
Key words: Opioid abuse, opioid misuse, nonmedical use of psychotherapeutic drugs,
nonmedical use of opioids, National Survey on Drug Use and Health, opioid guidelines.
