Doctor education, not youth drug prevention, is key to reversing opioid crisis

Over-prescribing still drives opioid addiction in Kentucky

Photo credit: National Cancer Institute on Unsplash

Earlier this week, Kentucky’s attorney general teamed up with universities across the state to launch part of his “Better Without It” youth anti-opioid campaign.

Educating youths about the dangers of opioids is useful, but data suggest focusing on youths is not the most efficacious way to curb opioid deaths and addiction – educating doctors is.

Statistics suggest that unlike with other substances, such as nicotine or alcohol, most opioid addiction begins in adulthood, not youth, and is predicated on prescription drugs, not street drugs including heroin and most forms of fentanyl.

Legal gateways to addiction

In 2023, federal data show physicians in our state alone wrote 58.3 prescriptions for opioids per every 100 Kentuckians. That’s prescriptions, not pills, so depending upon how many pills were in each bottle and for how many refills, we could be talking about tens of thousands of pills per every 100 residents of the state. 

And that’s even though the rate of opioid addiction in Kentucky is trending lower. State statistics from 2023 indicate that 1,984 Kentuckians, 571 of which were between the ages of 35 and 44, lost their lives to opioids, a decrease of nearly 10% from 2022.

Although the state reports that more than three-quarters of Kentucky opioid deaths in 2023 were due to fentanyl, it’s helpful to remember that one dose of fentanyl is deadlier than other forms of opiates. It is prescription pain pills that still fuel the opioid crisis, for a number of reasons.

The National Institute on Drug Abuse reports that eight out of 10 of heroin users tried prescription pills first, but because heroin is cheaper and easier to obtain than prescription opioids, users often interchange them.

Additionally, the Substance Abuse and Mental Health Services Administration reports that in 2023, nearly half of the nearly 9 million persons in the US, 12 years or older, who misused opioids, did so with a prescription drug. More than 39% used a prescription pill taken from a friend or relative.

Not youth-driven

Notably, however, was that 7.5 million people who misused opioids according to the same federal report, were 26 years or older. Misuse in young adults 18 to 25 years numbered 846,000 people, while in youths aged 12 to 17 years, there were 574,000 who misused opioids. 

And it’s from doctors these pills are emanating.

Surgery is the primary point where pain pills enter our communities and do harm. Federal statistics published in 2021 show that there were upwards of 14 million operating room procedures in 2018 in the US. Because standard of care pain management relies on opioids, that means millions of patients were given opioids post-op.

Many of these pills end up leading to addiction for the patient, or they end up diverted to others who, when they can no longer access the pills, turn to illicit drug supplies, including heroin and fentanyl.

Opioids are standard of care

With so much evidence that any benefits of prescription opioids are far outweighed by their risks, why do doctors still prescribe opioids when there is overwhelming evidence that they pose more risks than benefits in most cases outside of pain management for cancer?

“Part of the problem is what happens in med school,” Bret Alvis, MD, associate chief of anesthesiology and critical care medicine at Vanderbilt University Medical Center in Nashville, told The Edge in a phone interview. 

“When I was in med school, I was taught that pain management was opioid-based. When I started my training as an anesthesiologist, the first few years, we were heavy into using opioids,” Alvis said. “We were taught that people waking up from surgery should be relatively sedated and comfortable using opioids. It is still a new idea that we were teaching things the wrong way, by being heavy-handed with our opioids. But, to use opioids is just not evidence-based.”

Taught by Pharma

If opioids for pain management are not evidence-based, then why do doctors still prescribe them so heavily?

Because, as Alvis points out, doctors do what they are taught to do – and with good reason since what they learn in medical school is how to follow proven procedures for the best patient outcomes. 

But when they have been taught procedures by persons with no patient experience, no concern for the Hippocratic oath, and no code of ethics, they become vulnerable to learning behaviors that make an end-run around their better judgment, ultimately resulting in systemic harm, especially when the watchdog agencies doctors look to for guidelines, like the US Food and Drug Administration, fail at their job.

That is what happened when, without much evidence, the FDA approved extended-release oxycodone for indications beyond cancer pain in 1995. The decision was based on scant evidence provided by Purdue Pharma to justify broadening the approval of opioids for a range of indications, from back pain to dental surgery.

To date, federal policy maintains the opioids are the standard of care for pretty much all pain.

“While the FDA on the whole gets much more right than they get wrong in the approval process for prescription opioids, our findings suggest that over time the agency missed important opportunities to strengthen the regulation of opioid products,” G. Caleb Alexander, MD, an internist and epidemiologist, as well as a professor of medicine at the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, Md., said in 2020 about an investigation he co-authored into the evidence the FDA has used to endorse opioid prescribing outside of non-cancer pain management. 

Alexander has been at the forefront of combating the opioid crisis, and as an ad hoc member of the FDA’s Drug Safety and Risk Management Advisory Committee, has been a vocal critic of the role the Agency has played in it.

Once opioid manufacturers had the imprimatur of the FDA to push pain pills, doctors became unwitting targets of a multi-million dollar re-education campaign designed to make them unlearn what previous to 1995, they’d been taught in medical school, namely that opioid addiction is not only real, but real deadly.

Free food and psy-ops

A review in the American Journal of Medicine details how in 1996, an army of 600 pharmaceutical salespeople began descending upon physicians across the US, ones Purdue Pharma had researched and determined were most vulnerable to persuasion. 

Over free donuts, lunches, and even more lavish fare, these sales reps, enticed by expensive perks like all-expenses-paid Hawaiian vacations and sports cars, leaned hard on doctors to believe the lie that opioids were not dangerous. 

Doctors were also given free trips to “exotic locations” where after sitting through presentations often given by non-medical personnel who explained why patients needed these pills, the doctors were given coupons for patients to use for a month’s free supply of opioids.

Meanwhile, even as the epidemic of opioid deaths and addictions were well underway, the review reports, Purdue and other pharmaceutical companies leveraged the American Pain Society’s “pain movement”, which began as an attempt to better manage cancer pain, and weaponized it against unsuspecting physicians. 

As such, Purdue and other pharmaceutical companies perpetrated a psy-ops on doctors, telling them that the unproven “Theory of Pseudo-Addiction” was a phenomenon whereby patients treated with opioids weren’t becoming addicted, they were still in pain. That is to say, a patient exhibiting signs of pseudo-addiction, which was actually real addiction, was the doctor’s fault for not prescribing enough pills!

Frightened into submission

Conveniently, doctors who might already have been questioning their prescribing habits thanks to the pharmaceutical industry’s fear-mongering, were more open to learning about prescribing opioids for common pain complaints, even if the data backing them were shoddy, and soon medical schools were teaching pain management via opioids.

“Contrary to what many clinicians have been led to believe, prescription opioids are neither safe nor terribly effective for many settings where they have been commonly used – especially for the treatment of chronic non-cancer pain,” Alexander told The Edge in an email.  

A study published in 2013, co-authored by Alexander essentially found that the push to use opioids was so great, other forms of pain management were overlooked in the treatment of patients who had what in medicine is known as “non-malignant pain”, essentially meaning their pain was not a symptom of a life-threatening condition.

Alexander told The Edge: “The paper made a big splash at the time and is still relevant because it raises important questions as to whether or not quality of care for pain has actually increased over time. Given the enormous harms associated with opioids, as well as their limited efficacy for chronic non-cancer pain, in fact the paper suggests that the answer is no, at least among this cohort, although many other studies have also of course, raised enormous concern about the overuse of prescription opioids.”

This is why, to battle opioid addiction without educating, perhaps re-educating, doctors, is to lose the fight.

Evidence for other solutions

For Alvis, during his residency at Vanderbilt, he began to notice that the opioids he used in his patients often led to poor outcomes. He began researching other analgesics and pain management protocols, only to discover that there were many, and that there was far more evidence supporting their efficacy than there ever had been for opioids. 

“There is more money behind the pharmaceutical solutions, so they are more emphasized,” Alvis said. 

Alvis has gone on to conduct his own studies of alternatives to opioids for pain after surgery and is a proponent of what are known as ERAS and APCS. 

ERAS stands for “enhanced recovery after surgery”. APCS is the acronym for “anesthesia perioperative care service”. Both focus on preparing the patient for surgery by ensuring they are well hydrated, have enough nutrients to help heal, and include strategies for getting ahead of post-surgical pain, among other prophylactic measures. 

One Alvis-authored study found that by implementing an opioid-free APCS in total knee replacement surgeries, hospital stays decreased by a day, and there was no increase in hospital re-admissions.

Resistence to change

Alvis is now an advocate for changing standards of care to put low to no opioid pain management practices ahead of opioids. He is the anesthesia advisor for Goldfinch Health, an Iowa-based company dedicated to improving surgical outcomes, in part through its Billion Pill Pledge, which asks surgeons and other physicians to find alternatives to opioids for their patients.

“We began working together because we had a mutual interest in reducing the frequency doctors prescribe opioids,” Alvis told The Edge.

Despite his passion for the evidence, Alvis says he frequently encounters resistance from the generation of physicians who were trained to think of opioids first. “The resistance is dogmatic, because it goes against what they have been trained to do,” he said. 

Focus on where the gate opens

Last year, the Kentucky Opioid Abatement Advisory Commission, which oversees the state’s share of the multi-million dollar Opioid Settlement with the pharmaceutical companies that largely created the opioid crisis, greenlighted Coleman’s request for 3.6 million dollars to implement his “Better Without It” campaign.

In the past, the Commission has favored some education/prevention programs, although the majority of them are prevention programs that seem to focus on the person suffering from the addiction.

Why not instead focus on the physicians mediating the crisis with their prescription pads, thus opening the gates to addiction in adulthood, simply because they have not been taught there is a better way?

In Tennessee, where opioid addiction and death statistics are even more tragic than Kentucky’s, there is Alvis’s non- to low-opioid surgery protocol program at Vanderbilt, as well as another at the Southern Tennessee Regional Health System in Lawrenceburg. Each have committed to not introducing opioids into their communities by way of prescribing them when there are alternatives.

Kentucky Attorney General Russell Coleman’s office is currently assessing proposals from those with various ideas for how to stem the tide of opioid addiction in order to recommend to the Commission what he believes is best in 2025.

An announcement is expected in March. 

Update: A portion of a sentence was missing from the original has been added: Conveniently, doctors who might already have been questioning their prescribing habits thanks to the pharmaceutical industry’s fear-mongering, were more open to learning about prescribing opioids for common pain complaints, even if the data backing them were shoddy, and soon medical schools were teaching pain management via opioids.