Abstract
Introduction: The United States currently faces two opioid crises, an evolved crisis currently manifesting as widespread abuse of illicit opioids, and a crisis in pain management largely manufactured by the Centers for Disease Control and Prevention 2016 Guideline. Our goal in this paper is to identify root causes, trace the trajectory of forces unleashed over time, and define potential solutions to these crises.
Methods: Analytic review of the scientific, socioeconomic, and historical literature.
Results: The evolved crisis reflects a socioeconomic rift in American society that began in the 1970s and has resulted in disintegration of lives and rising levels of desperation, particularly among the under-educated, rendering them susceptible to the lure of illicit opioids. Present manifestations of that crisis reflect a complex series of events starting with a consensus in the late1990s that opioids were fully acceptable in the management of chronic noncancer pain. This was followed by vast opportunism by pill mills, drug distributors, and the manufacturers that supplied them; aggressive actions by state governments to rein in the pill mills; and ultimately, the development of an enormous black market in heroin and fentanyl. The manufactured crisis reflects intrusion into the medical care of patients in chronic pain by the Centers for Disease Control that had been politicized decades earlier and that, in 2016, issued a Guideline that reflected serious mis-construal of the causes of the opioid crisis. We trace this history and review the literature on treatment of addiction, including medically assisted therapy, treatment of depression, psychosocial interventions, 12-step programs, programs that seek to address the causes of desperation, supervised injection facilities, decriminalization, legalization, and the impact of the comprehensive approach taken by Portugal. We also analyze the problems affecting the Centers for Disease Control that led to the publication of its ill-advised 2016 Guideline.
Discussion: We conclude that many approaches currently being taken to treat addiction are well supported by scientific evidence but that the overall efficacy of treatment programs is not optimal and only a small fraction of all patients actually enter such programs. We also conclude that the Centers for Disease Control should have no future role in the regulation of patient care.