By Simon Feng, MD

Opioids have acquired a terrible reputation as dangerous drugs, thanks to not one, but two opioid epidemics.

America’s first opioid epidemic began in the 19th century following the purification of morphine in 1804. Widespread military use during the Civil War, followed by aggressive postwar civilian marketing, contributed to widespread opioid use. Opioids were available not only from doctors but also as patent medicines, used for everything from menstrual cramps to insomnia, depression, “hysteria,” and even infantile colic.

The first opioid epidemic eventually led to the Harrison Narcotics Tax Act of 1914, which placed significant restrictions on morphine and other narcotics. The government recognized that unregulated use of morphine was problematic, but it did not conclude that morphine was an inherently unacceptable medication. Morphine remained widely used during both World Wars, the Korean War, and the Vietnam War. For generations, physicians around the world continued to prescribe opioids whenever they believed clinical benefits outweighed risks. Morphine remains on the World Health Organization’s list of essential medicines, a catalog of medications considered necessary to meet any country’s basic health care needs.

Yet today, opioids are viewed with extreme negativity, bordering on taboo. Physicians and other practitioners have become reluctant to prescribe them even in the face of compelling, legitimate clinical indications. Incredulously, I’ve had palliative care and cancer patients who were denied opioids.

How did important medications, considered essential for generations, become so stigmatized? Here is my perspective as a physician with four decades of clinical experience, who had a front-row seat to the unfolding of the modern opioid epidemic and its aftermath.

Before the current opioid epidemic, opioids were mainly prescribed by primary care doctors. However, as the opioid epidemic unfolded, most primary care providers became reluctant to prescribe them. Who would take over pain management?

Most fields of medicine have their specialists: cardiologists, neurologists, rheumatologists, and so forth. However, the emergence of pain management as a specialty was a fairly recent development. The first board certification examination in pain medicine was held in 1993, just before the advent of the modern opioid crisis. These early specialists were anesthesiologists whose expertise centered on perioperative pain (pain before, during, and after surgery). They had neither experience nor training in managing the complexities of chronic pain. These doctors were procedure-oriented interventionists who approached pain only as unwelcome neural signals to interrupt. They are largely unconcerned with social, emotional, functional, or mental health dimensions of suffering.

Yet as primary care backed away from opioid prescribing, interventional pain physicians became the de facto authorities in chronic pain management, eventually gaining a near-monopoly on the field. Their unchallenged authority gave them disproportionate influence over the narrative on opioids as well as how insurance companies, governments, and regulatory bodies governed access to opioid prescriptions.

Over time, I observed interventional pain doctors moving away from opioid prescribing. I suspect they came to realize that patients without access to opioids were more likely to accept epidural steroid injections, radiofrequency ablation, spinal cord stimulation, and other procedures.

Pain management is lucrative for hospitals, generating substantial revenue from imaging, procedures, facility fees, physical therapy, medical devices, and the like. Spine surgeries represent another major source of revenue for hospitals. Meanwhile, device manufacturers made billions from selling equipment for interventional procedures, including MRIs, C-arms, catheters, ablation equipment, spinal cord stimulators, pain pumps, and surgical hardware.

An entire ecosystem arose around the treatment of chronic pain that profits strongly from, even demands, the suppression of opioid prescriptions. I am not suggesting that there was any formal conspiracy among interventional pain physicians, hospitals, surgeons, and biotech companies. No conspiracy is necessary. It is enough for each party to respond rationally to their own financial interests, to realize that suppressing opioids was good for business. If patients could get medications to help manage their pain, how many would still choose injections, invasive procedures, or surgeries?

Was the addictive nature of opioids the actual proximate cause of the opioid epidemic? We must distinguish between the inherent risks of opioids and the circumstances that produced the modern opioid epidemic. The epidemic was not the inevitable consequence of opioids being prescribed. It began with deceptive pharmaceutical marketing, aggressively promoting overprescribing. Inadequate safeguards, greed, and a health care system ill-equipped to respond allowed the rise of the criminal pill-mill industry. Both the first and second opioid epidemics had the same underlying cause: the unscrupulous and unbridled pursuit of profits. Opioids are merely the scapegoats.

The problem wasn’t simply that opioids are addictive. It’s also how access to them was manipulated to profit Big Pharma and pill mills. Appropriate opioid use was overrun by inappropriate use. If opioids are inherently too addictive to prescribe, why were there no comparable prescription opioid epidemics throughout most of the 20th century, despite decades of widespread use?

Opioid prescribing in the United States peaked in 2011. Yet fatal opioid overdoses would surge over 300 percent over subsequent years, even as prescription rates fell precipitously. The illicit drug supply, particularly illicitly manufactured fentanyl, now plays the dominant role in opioid-related deaths with prescription opioids playing a minor, ever-diminishing role. Nevertheless, clinicians continue to be pressured against prescribing opioids due to “unacceptable” risks of addiction.

Opioids certainly carry significant risks including dependence, addiction, and fatal overdoses. As an addiction specialist, I’m all too familiar with the horrors of addiction. But don’t make opioids out to be the bogeyman. Opioids should never be prescribed casually without carefully balancing risks and benefits. Yet I believe, with proper safeguards, opioids have legitimate and necessary roles in chronic pain management.

Some readers may be appalled that I would argue for reconsidering access to opioids. We have been indoctrinated for years that opioids do not work for chronic pain and that the risks are simply too great. I will challenge both these propositions in a future article and examine the evidence on the safety and effectiveness of opioids vis-à-vis interventional procedures.

I welcome opposing comments and critiques on this complicated topic. Patients deserve genuine medical discourse rather than dogma from either side.

Simon Feng is a family physician and addiction medicine specialist in Indiana, where he serves as medical director of two opioid treatment programs and runs an independent clinic managing chronic pain patients on opioids as well as outpatient addiction. He is affiliated with Valle Vista Health Systems.

He graduated from medical school in Vancouver, Canada, and practiced family medicine for three decades. His career took him from a rural mining town in the Canadian Rockies to urban Toronto and suburban Indiana, and his clinical experience ranges from delivering babies to nursing homes, urban ERs, and office-based practice.

When pharmaceutical companies began aggressively promoting opioids in the 1990s, he became concerned about the consequences and developed protocols to monitor opioid use and misuse. Colleagues began referring their opioid patients to him, which led to his expertise in managing opioids. He subsequently pursued training in addiction medicine and is certified by the International Society of Addiction Medicine.