Still a threatening opioid wave: it is time for the protagonist to step up!

Three years ago, the author discussed the current situation with opioid medication in Korea in an editorial in the Korean Journal of Pain regarding the opioid crisis in the United States [1]. What changes have occurred since then? A lot of things have happened in both the United States and Korea.

First of all, fentanyl, the ‘third wave’ is continuing and even growing stronger, and now mixtures with other drugs are spreading [2]. Fentanyl is killing more people despite strong government regulations. About 108,000 people died from drug overdoses in 2021, of which 71,000 died from fentanyl or fentanyl-related analogs. Illegal fentanyl overdose deaths accounted for 77% of teenage overdose deaths in 2021 [3]. The inflow of fentanyl from abroad is increasing in various forms.

Furthermore, the COVID-19 pandemic has made it harder to deal with the opioid crisis. Social distancing and isolation have made it more difficult to treat addiction, provide recovery services, and maintain mental health, and unemployment and economic poverty have created more drug addiction [2,4,5].

Recently, along with pharmaceutical companies, even the big pharmaceutical retail chains in the United States have agreed to pay $13.8 billion in a settlement to resolve thousands of lawsuits over their contributions to the opioid crisis. These include CVS, Walgreens, and Walmart. They attracted addicts by selling opioids at low prices and were punished for selling drugs recklessly without checking the suitability of the diagnosis and prescription drugs, or repeated prescriptions by doctors. Also, their branch offices did not share information about customers who were rejected while attempting to purchase drugs with problematic prescriptions. Also, a number of other lawsuits are currently underway [6,7].

In Korea, the illicit use of the fentanyl patch by adolescents has become a big social issue. They put the patch in aluminum foil and heat it to inhale the fumes. They have taken advantage of the laxity of some hospitals that prescribed fentanyl patches without checking past medical history or identification [8]. What is more surprising is that fentanyl patch prescriptions have recently been increasing in veterinary hospitals, although we don’t know the exact reason why [9]. Needless to say, there has been a surge in drug-related crime in recent years. There are a lot of articles saying that Korea is no longer a drug-free country.

So what do we do now? None of the problems raised in the previous article seem to have improved. Although some guidelines have been presented, there are many points to consider including whether they were made by administrative experts or by pain experts who prescribe opioids in the field. Fortunately, in the latest issue of the Korean Journal of Pain, Kim et al. [10] contributed an excellent review regarding the misuse of opioids. They addressed the opioid issue, including those that have been overlooked including opioid misuse in the perioperative period and by cancer survivors. Such opioid misuse is no longer treated as extraterritorial rights and should not be exonerated. The most important point in this literature is that it presents an opioid stewardship program for opioid use disorder (OUD). Just as the successful introduction of the antimicrobial stewardship program has made a lot of progress in the use of antibiotics, the opioid stewardship program must also be implemented to solve the current opioid problem. To this end, experts should take the initiative and actively present programs instead of waiting for implementation by government agencies. The government must also be strongly urged to introduce weapons to counter OUD, such as methadone, buprenorphine, and naltrexone ER which are still not available in Korea.

Now is the time for the experts, for the pain specialists. As previously mentioned, simply prescribing opioids is easy, but it is not the way to solve chronic pain. Of course, it is also improper to simply perform repeated interventional procedures. A pain physician should be proficient in all these multidisciplinary treatments, including moral support. Although it is a crisis situation, it is still relatively safe compared to the United States. It could be the last chance to prevent the worst. But, itʼs not too late. As a representative society of pain specialists, the Korean Pain Society should not be making mistakes, but should rather play a leading role in OUD prevention, diagnostics, and treatment.