Harry J. Gould, III, MD, PhD
On June 26, 2021, Johnson & Johnson confirmed that in 2020, as part of a $230M settlement with the State of New York, they discontinued promotion and distribution of opioid products in the State of New York. The settlement was made in response to efforts to mitigate the unprecedented overdose deaths associated with the excessive and often inappropriate use of opioid medications by reducing excess supply and encouraging activities such as improving the education of patients and clinicians to decrease demand. The goal of this strategy is to ensure coverage for patients in need while decreasing the deleterious effects of misuse, abuse and diversion on patients, families, and society as a whole.
Since 2012, the limitation of supply coupled with specific guidelines for prescribing opioids for managing chronic pain has resulted in a steady and significant reduction in the number of prescriptions being written for opioid medications and a similar leveling or decrease in opioid related overdose death. Unfortunately, despite additional mandatory training in the use of opioid medications, the implementation of risk evaluation and mitigation strategies (REMS) programs and the publication of guidelines for prescribing opioid medications for chronic pain to improve both physician and patient education, overdose deaths continue to occur at unacceptably high levels.
Part of the observed positive trend is likely due to the increase in physician reluctance for prescribing opioid medications, a reduction in initiating treatment with opioid medications and the initial prescribing of lower doses for shorter periods of time. These shifts in prescribing patterns consequently, reduce the risk of developing dependency and reinforcing negative behavior patterns that favor continued opioid use.
For the unfortunate victims of the “opioid crisis” who suffer with the burden of dependency and substance abuse disorder, a reduction in opioid availability in the absence of affordable direction and guidance to sobriety, is often perceived by the patient as an abandonment by the medical community accompanied by an unreasonable loss of analgesic coverage. This perception too frequently presents an untenable challenge for the patients who seek a “solution” by obtaining “relief” from alternate, unreliable, and deadly sources. Further mitigation of the untoward opioid related death rate is thus likely to require additional commitment to providing affordable support for evaluation, rehabilitation, and substance abuse counseling.
Although these early measures seem to be having or are likely to have a continuing mitigating effect, the fact that the current “opioid crisis” has been described as “the greatest healthcare crisis in U.S. history”, indicates that we are dealing with a problem of greater magnitude and complexity than anything that we have faced do date. The problem is unlikely to be amenable to “quick fix” remedies and is likely to require the identification and mitigation of “deep-seated”, heretofore unrecognized root-cause weaknesses that are not typically considered problematic.
That said, one might pose the question, “Why has the current “opioid crisis” reached the level that it has? Opioid use disorder has been a problem in the past.” For generations, opioid preparations have been known to affect changes in sensory and emotional perception and cognition and have been used by sections of society for recreation or to escape from the pressures of life. Might there be a greater need in the 21st century for a larger portion of the population to escape, from pressures related to more frequent failed life expectations, from the effects of technical discoveries that afford improvements in productivity and the means for immediate gratification and consequently, for the increased demands for the, now expected, immediate responses that such advances inherently imposed, to name a few. As we look into the future, a closer look at where we are in the evolution and demands of society may be increasingly important to consider in managing pain and may well be required if we hope for significant further progress in reversing the “opioid crisis.”