many places that policy makers have been compelled to implement special training programs for the management of overdoses and the administration of the lifesaving antidote naloxone. One Ohio community experiencing a doubled number of overdoses requiring naloxone—and ambulances and medics to provide emergency services—even discussed, alarmingly, a “three strikes” rule, withholding care after the third call to revive the same person (Honig, 2017).

One estimate suggested that the medical costs alone for each case of opioid misuse, dependence, and overdose are greater than $15,000 annually (Kirson et al., 2017), with indirect costs from lost wages and productivity pushing actual societal costs much higher. Nationally, with the accelerating pace of the epidemic, the overall costs to the nation have not yet been fully assessed, but the societal costs of prescription opioid misuse were estimated in 2013 at $78.5 billion, inclusive of costs for health care, criminal justice, and lost productivity (Florence et al., 2016). The human and economic consequences of the opioid epidemic are so striking that it is not surprising that the nation’s governors, with their 2016 Compact to Fight Opioid Addiction, positioned combating the opioid epidemic at the top of their states’ agendas.

WHAT HAS DRIVEN THE EPIDEMIC?

Prescribing

Many factors have intersected to drive the rate and reach of the opioid epidemic. Prescribing practices have played a substantial role, but those practices have been shaped, in turn, by circumstances ranging from medical issues—increases in chronic diseases, new surgical interventions, professional calls for better pain management—to the influence of market distortions, including misinterpretation of scientific data, introduction of new products, commercial marketing, and large quantities of unused opioids made easily accessible in the home.

In the 1980s, advocacy groups began raising awareness of inadequate pain treatment for people with cancer (Paice and Roenn, 2014), and the use of opioids for treatment of cancer-related pain soon increased. There were calls to introduce the notion of pain as a “fifth vital sign” (beyond the usual vital signs of body temperature, heart rate, respiratory rate, and blood pressure) that should be inquired about at every clinician-patient encounter. Pharmaceutical companies increased the development and marketing of new opioid products, with FDA approving nearly two dozen new products between 1990 and 2017 (FDA, 2017b). The Joint Commission initiated the requirement of pain assessments

in patients even during routine clinic visits and the organization of pain management educational programs for prescribers ( Joint Commission, 2016). As societal pressure increased, many more clinicians became primed for the need to effectively recognize, treat, and, if possible, eliminate pain.

Around the same time, a few observations in the scientific literature suggested that the addictive properties of opioids might have been overstated. A short letter to the editor of a prominent medical journal, for example, reported very low rates of addiction from opioid use among patients recorded in a 40,000-person hospital database (Portenoy and Foley, 1986; Porter and Jick, 1980). Despite the fact that these patients had not been receiving long-term opioids for chronic pain, widely published media reports at the time emphasized strong benefits and low risks from opioids for chronic pain management. Such reports resulted in a greater propensity to prescribe opioids by clinicians and aggressive marketing by pharmaceutical manufacturing companies. Before long, opioids were being aggressively marketed not just for cancer pain, but for treatment of chronic pain in general. With investments in the hundreds of millions of dollars (Van Zee, 2009), and little acknowledgment of side effects, marketing strategies from interested companies included pain-management and clinician speaker-training conferences, the dissemination of potentially misleading information about benefits and risks of opioids, and bonus systems to incentivize sales (Meier, 2007).

Recognition of the emerging crisis has now prompted the development of strong efforts to raise awareness among clinicians of the need for vigilance and counteraction, and these efforts are beginning to take some effect. While opioid prescriptions decreased by 18 percent from 2010 to 2015, prescribing rates today remain at least triple what they were in 1999 and quadruple the opioid prescription rates in Europe (Guy, 2017).

A related element contributing to the lag in recognition of and response to the opioid crisis is the stigma often associated with substance use disorders. There is a pervasive notion among many members of the public and even some clinicians that those who suffer from drug or alcohol dependence may be reaping the consequences of their own choices, and that these are character flaws. The science, however, indicates otherwise. Like any other chronic disease—such as diabetes, hypertension, and cancer—substance use disorder is the product of individual differences in the results of the interplay between biology, behavior, and environment, and requires sustained, multifaceted, and team-oriented treatment regimens. Adequately addressing these issues, individually or societally, requires not their conceptual and practical sequestration, but their integration into the established chronic disease management paradigm.