On August 1, recently passed Louisiana legislation regulating the prescription of opioid medication became effective law. While the new legislation is an important step, we physicians must do our part and educate our patients both about opioid risks and about non-narcotic treatment options.
But let’s back up and look at what caused this crisis in the first place.
The seeds of Louisiana’s current opioid epidemic were actually sown in the mid-1990s. Before then, most local physicians were concerned about the widespread use of opioids for chronic, non-cancer pain. They believed that these powerful agents were for severe acute pain (a bone fracture or kidney stone) or for end-of-life and cancer pain. They worried about patient addiction and about sanctions from federal and state authorities and so generally avoided the use of opioids for chronic pain.
In the mid-1990s, the consensus opinion regarding opioids suddenly reversed. In 1996, Purdue Pharma introduced OxyContin, a powerful opioid used mainly for cancer pain. Shortly thereafter, Purdue began an aggressive physician marketing strategy that promoted OxyContin for non-cancer pain despite a lack of evidence of its safety and efficacy. Their marketing strategy was, however, effective. By 2001, OxyContin prescriptions increased 1,800 percent and sales skyrocketed from $48 million to $1.1 billion. Large physician pain advocacy groups went along and opined that opioids were safe and effective for chronic, non-cancer pain.
However, an emerging opioid crisis quickly appeared in Louisiana and elsewhere. By 2007, the U.S. was consuming 99 percent of the world’s supply of hydrocodone, despite accounting for only 5 percent of the world’s population. By 2012, enough opioid prescriptions were written for every adult to have a bottle of pills. In 2013, drug overdose was the leading cause of accidental deaths, surpassing car accidents. For every death, there were many more prescription opioid overdoses, and even more reports of recreational misuse. In Louisiana, authorities started to prosecute healthcare providers who prescribed opioids recklessly. When the crackdown created difficulty for users to obtain prescription opioids, they turned to a widely available and cheaper option, heroin.
As concerning as opioid addiction and deaths were, evidence soon appeared that opioids might not even be effective for chronic pain. Opioids apparently cause “central hyperalgesia,” a condition in which a patient’s natural endorphin production decreases to a point where their pain paradoxically worsens with increasing doses.
Finally, in 2016, the CDC labeled prescription opioid abuse as an “epidemic.” And so, 20 years later, after countless lives were destroyed, officials finally acknowledged that erroneous medical consensus had essentially created a public health disaster — the opioid addiction epidemic.
In the late 1990s, when I was starting my own interventional pain practice in the Greater New Orleans area, I met with the Purdue Pharma representative and prescribed OxyContin to a few chronic pain patients. I quickly discovered a high incidence of misuse and addiction. I decided then that I would offer primarily non-narcotic pain alternatives. I found that not only did most of my patients want a non-opioid solution, but that I often was able to achieve effective pain relief using interventional strategies alone. While I realized that there were indications for opioids, intuition told me that their indiscriminate use would prove disastrous.
The development of evidence-based medicine and practice guidelines regarding opioids directly conflicted with my clinical experience. While standardization of care appeared a laudable goal, the fertile ground for catastrophic “group think” also developed. In 2003, early in the opioid epidemic, a dissenting group of interventional pain physicians outlined the hazards of opioids and called for state and national prescription monitoring programs. However, the majority of pain societies continued to insist that opioids were safe and effective despite overwhelming evidence to the contrary.
For the past 20 years, interventional pain specialist physicians have been effectively treating chronic pain conditions without opioids. Minimally invasive interventional strategies were largely ignored by the medical establishment. Failed medical consensus, fueled by pharmaceutical profits, led to the solitary application of opioid therapy and the denial of viable alternatives.
With the recently passed Louisiana legislation, we are reminded that only Louisiana healthcare providers, not national drug companies, prescribe opioids. Following our pledge to do no harm, we need to consider real non-narcotic alternatives and prescribe fewer opioids.
.jpg)
Patrick H. Waring, M.D., founder of the Pain Intervention Center in Metairie, is board certified in anesthesiology and pain medicine and also serves as a senior spine intervention society instructor. 
