If we want to talk about the opioid epidemic as an actual epidemic, let’s use the same terms we use for communicable disease: Agent, Vector/Environment, Host. Virulence. Transmission. Immunity.
The media has done a great job of providing descriptive statistics of the epidemic. And recent oversight, both legislative and advisory, have attempted to focus on altering Vector (prescriber) behavior in the wake of apparent failed attempts to reduce Agent virulence. What seems to be lacking in the overall discussion though, in my opinion, is a focus on the Host. That is where eradication of epidemics has generally been more successful.
What is unique about modern chronic disease epidemics, contrasted to classic infectious disease epidemics, is the unique behavioral vulnerability of the Host. People have no problem adopting mosquito nets, fleeing plague-infested quarters of the city, or submitting to vaccination. And yet, they flock to Krispy Kreme, tobacco, and opioids despite the knowledge that these agents can destroy them. We are drawn like moths to a flame to that which we know to be harmful to us_—_if we deem short-term benefit to outweigh long-term cost (“delay discounting,” as Marc Lewis calls it. Check out his wonderful little book, The Biology of Desire).
The cultivation of what some have labeled “behavioral immunity” is essential if we are to overcome the opioid epidemic. After all, epidemics typically only end when a sufficient proportion of the populace is no longer at risk, typically via immunity.
Let’s stick with the tobacco analogy just another minute. Of course, comparing cigarettes with opioids is apples to oranges. Cigarettes are legalized, generally don’t kill you instantly by overdose, are not prescribed, etc. Nonetheless, apples and oranges are both fruit and obviously share similar characteristics. Similarly, both tobacco and opioids are highly addictive substances, unlike cholera or influenza. Both share a tremendous degree of appeal to those who use them to cope or find comfort in the face of suffering and distress, emotional or otherwise. Both cost the nation untold billions of dollars in healthcare costs, lost productivity, etc.
Yet, we have been able to make some headway in terms of reducing the public health burden from tobacco. Massive advertising campaigns as well as legal/regulatory limits on procurement, designated smoke-free zones, and even taxes, seem to have been very effective in turning the tide against cigarettes’ relentless assault. That problem has not gone away, but its advance has been checked.
In my patient population, nearly 50% smoke (nearly twice the national average.) At least as many patients sent my way use opioids regularly. Neither of these phenomena are uncommon in the chronic pain world. I can count on only one hand, however, those who adamantly maintain that cigarette smoking is beneficial to them and something they never desire to give up. The vast majority of people want to quit, make very good efforts, and even succeed if we as physicians assist them.
How do we accomplish that same popular mindset with opioids? Advertising campaigns will help. Legislation and oversight will help. But people are still people, and even if prescription opioids were eradicated, there will simply be a shift to illicits_—witness the resurgence of heroin—_or other drugs of choice.
Now we’re talking about vector behavior, but the interactions between vector and host are important, as in any epidemic. It has been noted frequently in the national dialogue that physicians are too busy to adequately help manage pain, and writing opioid prescriptions is quick and easy. I’m sorry, but that is a copout. (I certainly do not run a very efficient or profitable practice, much to the chagrin of my administrator, bookkeeper, and family.) Our entire clinical team engages every patient in a plethora of multimodal, biopsychosocial-spiritual efforts. These are not just buzzwords. We all need to be addressing our patients’ OSA, PTSD, PUFA-6 fatty acid issues, vitamin D deficiency, BMI and sedentariness, posture, etc. Their psychosocial and spiritual domains arguably comprise the most important arenas for intervention. I make efforts to stay abreast of the latest research and development in the area of opioid science and practice. I spend time_—a lot of time—_every visit with my patients who seek opioid therapy, counseling them and applying motivational enhancement techniques to dissuade them from the self-destructive pursuit of chronic opioid therapy. And we wean, baby, wean. We use Suboxone if we have to.
Not unlike the same efforts that caring physicians have made for decades with cigarettes. And the data have shown for at least a couple decades that simply applying physician counseling to the problem of cigarette addiction is well worth the time/investment.
So, to recap, we need to help our patients (and the public) develop behavioral immunity to opioids. (It wouldn’t hurt for us to regain the public’s trust_—a privilege, not right, that we have abdicated.) The point is, just as we provide artificial immunity to viruses and other microbes through the delivery of vaccines (as well as providing counseling regarding hand washing or avoiding contaminated water), it is incumbent upon us to take the time and make the effort to foster resistance to these pathogens—_as well as improved living conditions and health behaviors that obviate interactions between agent and host.
Heath McAnally, MD, MSPH, is a board-certified anesthesiologist, integrative pain physician and addictionologist who started and manages Northern Anesthesia & Pain Medicine. He is also a clinical instructor for the University of Washington School of Medicine, and the author of Opioid Dependence: A Clinical and Epidemiologic Approach.