It’s expected that another 500,000 Americans will die over the next decade related to the opioid crisis, with additional social costs and with no evidence yet of validated, effective treatments in place despite reports and assurances. Inside medical healthcare systems, a Look forward, not back attitude prevails, and the Surgeon General pleaded Big pharma made us do it. But Big Pharma wasn’t in the exam rooms writing the opioid prescriptions for chronic pain , a condition known to be generally driven by emotional and mental states, not physical causes, and with non-medical treatments (Upcoming Post in SCIENCE: Chronic Pain: Research Says Find a Therapist). But would it make sense to trained medical professionals to trust drug manufacturers’ spin on research results for drug safety? Making excuses is no substitute for questioning and engaging in critical thought to understand the causes (“etiology”) of the opioid crisis and avoid repeating or continuing them.
We’ll see, below, that the Opioid Crisis did not emerge because correcting evidence became apparent or available only after evaluated, critically scrutinized, responsible clinical practices had already led to routine prescribing of opioid pain medications for centralized chronic pain.
Instead, it occurred in the face of those approaches being unsupported and without validation of safety or effectiveness from the beginning by all lines of available evidence and research, evidence longstanding prior to the runaway prescription of opioids. That’s an abdication of critical thought, accountability, and public responsibility that must be faced and become understood to avoid repeating.
To that point: let’s look at what happened and why, but first, let’s consider how healthcare systems are responding – with a medical fix – and ask whether we’ve learned anything from the opioid crisis, an epidemic caused by the unsupported and inappropriate use of a medical fix for an entirely non-medical problem.
The Response – Are We Learning?
In a rush to respond, manage the harm, and attempt to re-establish the appearance of competence and effectiveness in management of chronic pain, opioid use and related risks, the managed healthcare/medical industry has invested in a type of harm reduction strategy rebranded “Medication Assisted-Treatment”. In MAT the manufactured, prescription opioids methadone or buprenorphine (brand names Subutex, Suboxone) are dispensed and intended to provide the assisted part of Medication-Assisted Treatment, assisting by creating conditions for patients to basically feel and function better, in order to effectively access and benefit from the “treatment” part = effective (“evidence-based”) behavioral health therapies (the subject of multiple Upcoming Posts).
In medical settings opioid users are started on courses of the drugs, which provide a reduced level of the euphoric and sedative effect of opioids like heroin and at least relief from the highly distressing withdrawal symptoms – in intent and in theory. In theory, and in some clinical trials under non-natural conditions, but not reliably in practice, those effects minimize risks, stresses, and problems functioning in life related to use of illegal, “street” opioids and other drugs, promoting effective use of the treatment part of MAT. In the real world, under realistic community program conditions, things are different, and research results are disconfirming the idea that Suboxone and MAT are beneficial as currently designed and provided.
That focused and seemingly universal confidence in and reliance on harm reduction and MAT is embraced by the popular media and is managed in medical settings under medical, versus evidence-based behavioral treatment models, driven by the fictional and invalidated model of problem opioid use and substance use in general as a disease or medical condition. Predicting continued harm, MAT as currently implemented is driven by factors other than research and practices supported as effective by research for the actual treatment part of Medication-Assisted Treatment, because 1) research evidence for effectiveness of those presumed medication-based benefits is at best mixed,
with recent studies showing overall treatment failure and 2) the “treatment” part of MAT, (the behavioral health therapies required to address the compulsive drug use) currently consists of traditional treatments, or “treatment as usual” (TAU), established by decades of research to provide no benefit or harm (Upcoming Post: Why Addiction Treatment Doesn’t Work).
How did that happen? : decades of ineffective “rehab”; standard addiction treatment (TAU) without benefit, and a steadily worsening national substance use epidemic ?
And – Why haven’t we able to respond effectively, or even respond in ways that makes sense and predict beneficial results based on research available for decades? We have the answers, but they force us to do the nearly impossible: to challenge THE WAY THINGS ARE, the official, authoritative, accepted and enforced “knowledge”, doxa, about the very nature of substance use and its treatment – the focus of many Upcoming Posts at A Critical Discourse.
Taking apart and replacing that made-up, false and invalidated “knowledge” about substance use and its treatment will be critical in understanding the broader national substance use epidemic and other threats to public health.
SUMMARY: When buprenorphine (Subutex) substitution works, it can effectively provide a period of improved mood, thinking, and functioning in life that supports effective participation in the actual treatment part of MAT (evidence-based talk therapies for the conditions and stresses driving compulsive substance use, a focus of multiple Upcoming Posts) by motivated patients, with predicted benefit.
When it fails to support patient engagement in effective treatment and change, as the research indicates it generally does, MAT distracts resources and attention from critically needed, fundamental changes to substance use treatment models and methods, from critically needed reformation of the conceptualization of “addiction” itself.
So far, not good.
Medical Industry on the MAT response to the opioid crisis – But Look! Okay, never mind the “treatment” part for an entirely behavioral, psychosocial problem, we’re doing something, in medical clinics, with medicines! Always a good idea, right?
Sound familiar? Like what got us to the Opioid Crisis ? It should sound familiar, needs to be recognized as familiar, as MO of the Medical Industry – But Look. Okay, never mind the indicated “treatment” part for chronic pain, an entirely behavioral, psychogenic (generated by mental and emotional states) problem,
we’re doing something, in medical clinics, with medicine! We got this – prescribing opioid pain medications for common chronic pain, an entirely non-biomedical problem.
What Went Wrong?
But – How did that happen, and why are we avoiding that question?
From the beginning, well prior to explosion of runaway, widespread use of prescription opioids for centralized chronic pain, all lines of evidence pointed against and contraindicated their use. There was never support for their safe, effective use due to longstanding:
1) lack of research evidence for effectiveness long-term
2) evidence for the potential for hyperalgesia
3) established addictive potential of opioids
4) understanding of the psychogenic nature of centralized chronic pain
5) evidence for cognitive behavioral therapies (CBT) as the indicated treatment for chronic pain
[See text boxes linking sources to each point 1 – 5. (Numbers) in boxes link to online sources listed at bottom of post]
All relevant lines of evidence existed decades prior to emergence of runaway misuse of opioids and the current crisis.
The Opioid Crisis did not emerge because correcting evidence became apparent or available only after evaluated, critically scrutinized, responsible clinical practices had already led to routine prescribing of opioid pain medications for centralized chronic pain.
Instead, it occurred in the face of those approaches being unsupported and without validation of safety or effectiveness from the beginning by all lines of available evidence and research, evidence longstanding prior to the runaway prescription of opioids.
That can only be explained by an abdication, a failure of critical thought and critical discourse and of ethical reasoning and accountability, allowing the opioid crisis to be generated by other cultural forces, forces with the cultural capital (like status, authority, legitimization by the mass media) to create accepted, fake “knowledge” in the face of contradicting and invalidating evidence – made-up “knowledge” that protects status, power, interests.
Fundamentally the Opioid Crisis largely represents the predictable failure and harms of the unsupportable medicalization of common chronic pain, an entirely non-medical condition, without medical treatments, against all available evidence.
From all appearances, health care systems have not learned from the crisis and its underlying social and institutional dysfunctions, despite projections for 500,000 related deaths over the next decade. For example, chronic pain continues to be managed medically, with routine referrals to invalidated biophysical interventions despite lack of supporting evidence and at enormous costs.
There is also little evidence to believe that those errors, and the resulting costs continuing to accumulate, have begun to shift care systems or practices more generally toward long-established evidence-based practice (EBP) therapies evidenced as effective and predicting benefit for problem substance use, instead continuation of treatment as usual (TAU) without predicted benefit, provided by a multi-billion dollar medically-managed treatment industry.
More basically and predicting continuation of a national epidemic of problem substance use, human costs of the opioid crisis are not generating apparent insight or motivation for change in understanding of the very nature and effective treatment of substance use, despite the “disease” and “hijacked brain” medical models having been invalidated over past years and decades by all lines of evidence including: biology, neurobiology, epidemiology, logic, and the nature of substance dependence and relapse.
Failure to re-think problem opioid use, learn from the causes of the crisis, re-think problem substance use, or “addiction”, to align with decades of established research outcomes, and replace treatment as usual (TAU) with evidence-based practice (EBP), predicts continuation of harm and a continuing national substance use epidemic.
Numbered links to sources
1 – The high abuse and addictive potential of opioids including those prescribed for chronic pain is long-established
2 – generating a history of statutory control
3 – The 1970 Controlled Substances Act lists opioid drugs commonly prescribed
4 – Schedule II Substances are highly controlled as “drugs with a high potential for abuse”
See the Nation’s top medical authority blame pharmaceutical companies for medical professionals prescribing addictive drugs for chronic pain, a non-medical, non-physical condition, below: