From 1999-2019, nearly 500,000 Americans died from an overdose involving any opioid, including prescription medications and illicit substances (CDC). The opioid overdose epidemic is often described as occurring in three distinct waves, which reflect the primary driver in opioid overdose deaths in that time period. Although the crisis has changed over time, its modern roots can be traced back to the overprescription and misapplication of opioid medications in the 1990s.

During the first wave of the crisis, the U.S. medical community was rethinking the way that pain was treated. As part of broader efforts to improve pain care, the FDA approved OxyContin to treat moderate to severe pain in 1995. Despite positive intentions, this decision stemmed from misrepresentations of OxyContin as “less than 1% addictive”. This false claim was heavily marketed, and in turn created a widespread belief that opioids were safe for long term use. Opioid prescriptions were written in record numbers, fueled by pharmaceutical companies’ assertion that these drugs were a low-risk solution for a wide range of medical issues. OxyContin, originally intended for moderate to severe pain, was misprescribed to treat even headaches or toothaches (Jones, et. al). This over-reliance on opioids exposed more patients to medications that posed a risk for tolerance, dependence, or use disorder.

Pain was, and it still is, widely misunderstood. Education and research in relation to pain management and prescription application is lacking. David Julius, chair of physiology at the University of California, San Francisco School of Medicine, says, “We use ‘pain’ as one word, but I think it reflects a panoply of different disorders.” Pain has long been treated with a limited array of drugs that don’t necessarily distinguish one type of pain from another. By the early 2000’s pain was categorized as a “fifth vital sign” (VA.gov), though this designation was removed only three years later due to concerns about the impact of overprescribing. New standards encouraged hospitals to have patients rate their pain on a 10-point scale to give clinicians quantitative information on which to base treatment decisions. The rethinking of pain management led to new concepts such as “pseudoaddiction”, the idea that addictive behaviors could be seen as undertreated pain, with the solution being to prescribe more opioids (Greene and Chambers). These initiatives to redefine pain were heavily supported by pharmaceutical manufacturers, as they could be used to promote their opioid products.

It is widely acknowledged that opioids can still be very effective in stabilizing people after injury and surgery. These medications can also be beneficial in providing relief for cancer, end-of-life care, and palliative patients (CDC). The most important element of managing both chronic pain and potential use disorders is building engaged and informed patient-provider relationships. Health professionals continue to learn about the risks involved with the prescription of opioids, and the safest practices when considering treatment options for their patients. The CDC created a guide for clinicians in 2016 that “addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use” (CDC). It is these types of documents that will help patients experiencing pain receive educated and informed care, while recognizing the risks involved with the use of opioids.