We Are Guilty

While most of 2020 has been focused on the Chinese invader—the coronavirus—a deadlier epidemic has been killing Americans over the past decade. From 1999 through 2017, almost 400,000 people have died in the United States from an opioid overdose (including oxycodone, hydrocodone, and Norco, to name a few).³ Opioids are powerful, naturally occurring painkillers that can also be synthesized cheaply. On average, 130 Americans die every day from an opioid overdose. Unfortunately, opioids have become far too easily available to the American public; Americans consume 99.7% of the world’s hydrocodone supply.⁸

Part of the problem with pain killers in the United States is the expectation that life’s tragedies can be experienced pain-free. Injuries, accidents, and illnesses are to be treated with an array of pills that render life’s burdens innocuous. The American public is inundated with commercial marketing that claims 100% effectiveness against every sort of human malady.

Consequently, when Americans undergo surgical procedures for musculoskeletal problems, the expectation is to experience minimal to no pain. Unfortunately, clinicians are then caught in a predicament that requires extensive use of pain medicine, often leading to overprescription of painkillers. The abundance of painkillers created by this overprescription provides a scenario that can lead to excess opioid use, dependence, and consequent addiction by patients and those with access to the patient’s medication.

The systematic review by Sheth et al¹¹ in this issue of Sports Health, titled “Opioid Use After Common Sports Medicine Procedures: A Systematic Review,” is shocking and an indictment of those performing arthroscopic knee, shoulder, and hip surgery. These common orthopaedic procedures, such as hip arthroscopy, which has seen a 25-fold increase in the past 10 years, result in the need for postoperative pain medication.¹³ Eight studies in this review showed that for the 816 patients included, between 31% and 64% of the prescribed opioids went unused after surgery. This excess is providing the opportunity for the elicit nonmedical use that has exploded in the United States. Complicating these factors is the report that 64% of these patients were unaware of what to do with their excess medication. Information and directions on proper disposal of narcotics was also not provided by the clinicians dispensing them. Regrettably, sports medicine physicians are not alone in this narcotic quagmire; other orthopaedic specialties have fallen into the same unfortunate situation.^4,6,7

Having recently undergone surgical procedures myself, I can understand how easy it is for these dangerous situations to develop. Caring physicians do not want their patients to suffer, and yet there is very little time available for the surgical team to educate patients on pain expectations and management. Patients are often anxious about the level of postoperative pain, having heard daunting stories from friends or relatives. In order to avoid being inundated by repeat calls for pain medication, the postoperative surgical team tends to prescribe more pain medicine than is actually necessary. Personally, when I was taking the opioids after surgery, I could feel the pain but it didn’t bother me. I was in an altered, insulated state of mind. Therefore, I can understand why some troubled individuals, suffering from many of life’s emotional and physical difficulties, would prefer to be in an altered state of mind.

The eventual result of this lifestyle alternative to treating the anxieties and dilemmas of life led to 70,237 drug overdoses in 2017 alone, with 47,600 (67.8%) involving opioids.¹⁰ From 2016 to 2017, the synthetic opioid overdose death rate increased by 45%.¹⁰ Some areas of the United States have been hit much harder than others. West Virginia, Ohio, Pennsylvania, and the District of Columbia have the highest rates of death related to drug overdose.¹⁰ This geographic localization of the opioid epidemic begs for an explanation. Recent reports have suggested that economic distress is the underlying culprit,⁵ with poverty, trauma, availability, and pain creating “the perfect storm.”⁵ Looking back to the 1990s, it is understandable how this nightmare began. In the 1990s, approximately 33% of the adult American population was supposedly affected in some way by chronic pain.⁹ Tragically, this led to a concerted effort by the federal government and drug companies to expand the use of opioids.² As the legitimate medical use of pain killers expanded, so did the oversupply, which produced the elicit nonmedical usage. A survey in 2013 found that 74% of opioid abusers obtained their pills from a doctor or from someone else who got them from a physician.¹² To satisfy this growing demand in the United States, Walgreen’s bought 13 billion oxycodone and hydrocodone pills between 2006 and 2012.¹ With this abundant supply, it is no wonder that much of it found its way to nonmedical use.

Now that the opioid crisis has been recognized, there has been much discussion about who is to blame. The pharmaceutical companies that reaped tremendous profits appear to have minimized the addictive nature of these medicines. Class action lawsuits and billion-dollar settlements have ensued, leaving these companies bankrupt. On the clinical side, physicians must recognize the depth of this tragedy and adjust their treatment protocols. Many of us have witnessed the abuse of the pain killers we have prescribed and are aware of the potentially tragic results. Attempting to eliminate all of life’s painful episodes, whether they be surgical, physical, or emotional, is not rational. Perhaps it is time for us physicians to consider a new approach.

—Edward M. Wojtys, MD
Editor-in-Chief