North Carolina Has an Opioid Problem, How Did We Get Here?

“We are often loathe to give liberal amounts of narcotics because the drug addiction itself may become a hideous spectacle.”

Those words were written by Warren Cole, MD, FACS, in 1956 for a book describing cancer pain treatment in the mid-20^th century. In Dr. Cole’s day, physicians were trained to prescribe pain medications sparingly, or even not at all. Doctors and patients alike were fearful of the dangers of prescription drug abuse and addiction – to the point where many people suffering from chronic pain had a very poor quality of life.   

Looking at pain differently 

Warren H. Cole, MD, FACS (1899-1990)

The generation of physicians who followed Dr. Cole started looking at pain differently. They voiced concerns about how pain impacted quality of life. Others in health care started considering the economic impact of pain, looking at issues like the loss of productivity that pain brings.

By the early 1980s, there was a real shift in thinking among the medical community. Some physicians were questioning the long-held belief that pain was preferable to the potential dangers of taking opioids. At that point, there was no library of published long-term data about how many people taking pain medicines were abusing opioids or becoming addicted. In fact, there were no comprehensive studies of opioid use for chronic pain at all.

The pendulum began to swing in the opposite direction from the Dr. Cole philosophy. Some smaller research studies seemed to indicate that cancer patients taking high doses of opioids weren’t becoming dependent on the drugs, giving the green light to physicians whose only interest was relieving their patients’ misery.

Multidisciplinary pain clinics began forming, featuring physicians trained in pain management, psychologists, physical therapists, and occupational therapists. By 1990, the American Pain Society launched an awareness campaign called “Pain, The Fifth Vital Sign,” advocating a change in medical philosophy around the use of opioids to treat chronic pain. Anyone who’s been to see a doctor in the last 25 years is familiar with the “Are you having any pain today?” inquiry.

The rise of Oxycontin abuse 

A decade later, regulatory organizations like the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated pain assessments with the familiar numeric pain rating scale. The US Drug Enforcement Agency (DEA) announced it would reduce oversight of physicians who had high rates of opioid prescribing.

And then came Oxycontin, a brand-name extended-release version of oxycodone. If you could point to one single medicine that’s most responsible for today’s opioid epidemic, it would probably be Oxycontin. Purdue Pharmaceutical’s new opioid drug was hailed as a major breakthrough in the now specialized world of pain management, marketed as a long-lasting pain remedy – a full 12 hours of relief.

Oxycontin was aggressively marketed to all physicians, who were assured by the US Food and Drug Administration’s approval of Oxycontin’s 12-hour dosing. The marketing downplayed Oxycontin’s addiction risk, leaving physicians to believe the drug to be perfectly safe.

Since Oxycontin’s launch in 1995, tens of thousands of Americans have abused the drug, many eventually died from an overdose.

And that brings us to today, much wiser in the practice of prescribing opioids, but still struggling to help people with legitimate short-term and chronic pain problems without exposing them to the risk of addiction or overdose. 

The rise of pain management as a specialty coincided with the launch of my own medical career. I became interested in pain management largely because relieving pain seemed to be the most immediate form of medical care. For me, it all came down to a simple question: How can I help someone whose pain is limiting their life regain their functioning?

Today, after 11 years of treating acute and chronic pain patients, there are many more questions that drive me. And very few of them are simple questions: How can I help relieve pain without exposing patients to the threat of addiction? How can I prevent patients from abusing and diverting opioids? How can I contribute to a broader movement to reduce opioid abuse and dependence?

These questions drive me forward. As a pain management specialist, I have an obligation to help solve the opioid epidemic that my field unwittingly enabled.

I was a child back in the 1980s when opioids gained new popularity among prescribing doctors. I didn’t have a hand in creating the problem. But I have a duty to help solve it.

Blue making it better 

In my role as a medical director at Blue Cross NC, I have a platform to help create policies that will allow people who truly need opioid pain medicines to get the help they need while keeping those pills out of the hands of people who shouldn’t have them.

North Carolina is a place where I feel like I can have a meaningful impact. Our state has a higher rate of opioid use disorder – a pattern of opioid use that causes significant impairment or distress – than most others.

According to the Blue Cross and Blue Shield Association’s most recent Health of America report, more than 8 of every 1,000 North Carolinians have a diagnosis of opioid use disorder versus a national average of less than 6. That difference may not seem like a lot, but it actually means our state’s rate of opioid use disorder is almost 40 percent higher than the rest of the national average.

I’m using my public voice – through sitting on committees, testifying in hearings, talking with reporters, writing blog posts – to ring the alarm bell on opioid addiction.

To get to our destination of a North Carolina where opioids are helping instead of hurting, it’s important to understand the history of how we got here. And to learn from that history. 

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