A presentation by Brian D Sites at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Brian D. Sites, M.D.
Professor of Anesthesiology
D-H/Geisel
The American
Prescription Opioid
Crisis

2. No Conflicts or
Disclosures

3. Special Thanks
• Mona Kotecha, MD who led our social
policy research

4. Objectives
• Define the origins of the liberal opioid
prescribing policies
• Summarize the crisis of diversion,
addiction, abuse
• Establish the connection between
escalating utilization and morbidity
• Display public health data regarding
efficacy of opioid therapy

5. “Could have been, would have
been, and should have been
are always undefeated.”
-Coach Jim Harbaugh

6. Pain, pre-90’s
• Painkillers are addictive!
• Newborns and the elderly don’t experience
as much pain
• Pain builds character
• Pain is part of the human experience
• Opioids are for cancer patients
• Pain is subjective, therefore questionable

7. Pain, 1990’s - present
• Painkillers are addictive!  No, they’re not
• Newborns and the elderly don’t experience as much pain 
Everyone has pain
• Pain builds character  Pain has no purpose
• Pain is part of the human experience  Suffering should
be avoided at all costs
• Opioids are for cancer patients  Opioids are suitable
for many people in pain
• Pain is subjective  Subjective reports should be
accepted at face value

9. Striking Statistics
• 100 million Americans have
chronic/acute pain
• 635 billion dollar price tag in treatment
and lost productive
• 80% of cancer pain patients report
under treatment of pain
Institute of Medicine

10. “I’m shocked and surprised at the
magnitude of the problem”
-Dr. Perry Fine, President of the American
Academy of Pain Medicine

11. Why improve pain
management?
• Improve activities of daily living
• Reduce disability
• Increase ability to have employment
• Improve wound healing and
postoperative recovery
American Pain Society

12. Promoting increased
pain treatment
1992 and beyond

13. • largest integrated
health system serving
8.3 million veterans
• Coined the phrase
(later trademarked by
APS)
• Enacted a national
strategy to ensure that
pain is routinely
assessed using a 0-to-
10 Numeric Rating
Scale (NRS).
Veteran’s Health
System

14. Cultural factors are critical

15. “The current system might just kill you. Many doctors,
in order to get high ratings (and a higher salary),
overprescribe and overtest, just to “satisfy” patients,
who probably aren’t qualified to judge their care. And
there’s a financial cost, as flawed survey methods and
the decisions they induce, produce billions more in
waste. It’s a case of good intentions gone badly awry–
and it’s only getting worse.”
Kai Falkenberg

16. Comments based on
Fenton et al
• If you had “High Satisfaction” with your
care compared to “Low Satisfaction:,
you had 26% increase in odds of death!
• Based on almost 60,000 patients from
the MEPS database.
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization,
Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411.

17. Social
Policy
Marketing
$$$$$$
Cultural
Factors
• IOM
• JCAHO
• Big Pharma
• Consumer-driven
healthcare
• Pill culture
Pills and more Pills

18. 5%
95%
USA World
80%
20%
Population Consumption of Opioids
Pain Physician
2008;11:S63-S8

21. 0
2
4
6
8
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Sales (kg)
Deaths
Abuse treatment
Year
Rate
(per10,000
people)
Adapted from Drug Enforcement Agency. National Vital Statistics. Available at:
http://www.cdc.gov/vitalsigns/painkilleroverdoses/. (Accessed September 17, 2013).
More deaths than from:
HOMICIDES or CAR CRASHES!!!

22. Did financial conflicts of
interest inform the anti-pain
campaign?

23. • “Network of national organizations and
researchers with financial connections to the
makers of narcotic painkillers…helped create a
body of dubious information favoring opioids
that can be found in prescribing guidelines,
patient literature, position statements, books
and doctor education courses.”

24. Who funds PAIN research?

25. Who DOESN’T fund PAIN
research?

26. Are opioid users
getting healthier?
• No data supporting any improvements
in meaningful outcome metrics such as
reductions in chronic pain, hospital re-
admissions, death, etc

27. From CDC: accessed 2016

28. This paper documents a marked
increase in the all-cause mortality of
middle-aged white non-Hispanic men
and women in the United States between
1999 and 2013. This change reversed
decades of progress in mortality and was
unique to the United States

29. Health and disability 2000-2010
Year Year
Opioid users No opioids
Remember, anticipated improvement in these
areas was the intellectual foundation for the
liberalization of opioid prescribing policies

30. Key basic tenants are
wrong
Slide from Dr. Andrew Kolodny, Physicians for Responsibility Opioid Prescribing, November 2012, at
http://www.slideshare.net/grouphealth/the-opioid-analgesic-epidemic-how-it-happened#btnNext
In medical school we were taught DON’T WORRY
about addiction if opioids are being given for pain

31. Slide from Dr. Andrew Kolodny, Physicians for Responsibility Opioid Prescribing, November 2012, at
http://www.slideshare.net/grouphealth/the-opioid-analgesic-epidemic-how-it-happened#btnNext
“Although there were 11,882 patients who
received at least one narcotic preparation,
there were only four cases of reasonably well
documented addiction in patients who had no
history of addiction”

32. Conclusions
• Social Policy Changes dramatically
increased opioid prescribing in the US
• This increase in utilization and
expenditures is correlated to epidemic
levels of morbidity and mortality
• There are likely serious conflicts of
interest
• Opioid users on a public health level
are not getting healthier
• It is time to re-think our pain policies