We learned Thursday that Prince died of an opioid overdose—specifically from fentanyl, a synthetic opioid often prescribed to people who have built up a tolerance to oral opioids. (Fentanyl is more potent than powerful drugs like OxyContin and is most commonly administered via a patch.) While the toxicology report has not yet been made public—and may never be—it’s possible that Prince, who had a reputation for living substance-free but also suffered from debilitating hip and knee pain, got his drugs from his doctor, not a dealer. Why would the legendary recording artist have been prescribed a drug that put his life at risk?
There’s no question that opioids are effective at managing certain types of pain. But American medicine has become far too reliant on the potentially dangerous drugs for the wrong reasons. About 15 years ago, hospital watchdog groups grew concerned that physicians were not taking pain management seriously enough. The solution to this perceived epidemic of pain in the early 2000s was opioids. These strong painkillers became the drug of choice as ibuprofen (the active ingredient in Advil, Motrin, and similar products) had fallen out of favor thanks to overblown concerns about the risks of internal bleeding.
Around the same time, pharmaceutical companies noticed a now infamous study from 1986 suggesting that opioids were less addictive than previously thought. The author of that paper has since publicly recanted its conclusions, calling the sample size of 38 individuals too small. But pharmaceutical companies used this small, now roundly debunked study to convince professional medical organizations, and eventually hospital regulators, that it was safe to give opioids to more patients. Since the early 1990s, the annual number of opioid prescriptions has tripled. Opioid overdose deaths have quadrupled. Today, Americans consume 80 percent of the world’s (legal) opioids, despite accounting for less than 5 percent of the world population.
There’s no single villain in this story. Our dangerous embrace of opioids was the result of the entire medical establishment—including governmental, nonprofit, and pharmaceutical organizations—searching for an answer to the problem of pain. That problem is real: Managing pain, specifically chronic pain, is an essential part of any doctor’s practice. It is terrible to see people suffer and whenever possible and prudent, pain should be treated. And some of the players in this story were driven by real concern for patients’ quality of life. But others, specifically the manufacturers, were driven by crasser motives: the realization that they could make a fortune by pushing for wider use of prescription opioids.
In the 1990s, the American Pain Society, a nonprofit organization of medical professionals with the stated goal of reducing pain-related suffering by advocating for changes in public policy, started pushing for pain to be treated as a “vital sign”—meaning that a person’s subjective assessment of their pain would be considered on even footing with heart rate, blood pressure, body temperature, and breathing rate, four of the most meaningful measurements in all of medicine. By the 2000s, many electronic medical records reported pain scores next to the patients’ objectively measured vital signs. Around the same time, the APS started advocating for a wider use of opioids even though they had previously expressed concern about the drugs’ safety.
In the years that followed, the federal government gave hospitals further incentive to make managing patient pain a paramount concern. Every time a hospital discharges a patient, the federal government asks them to survey the patient about their experience: Did nurses listen carefully to you? Did they respond to the call button quickly enough? In 2006, it also became mandatory to poll discharged patients about whether their pain had been adequately assessed and treated during their stay. The change was put in place by the Centers for Medicare and Medicaid Services acting on recommendations of the Joint Commission, the national nonprofit health care quality organization that accredits hospitals. The results of these surveys are posted online and they contribute substantially to how the Joint Commission ranks hospitals. The results of these surveys can affect whether or not a hospital is eligible for Medicaid reimbursements, so scoring poorly can affect a hospital’s bottom line. In 2012, the Affordable Care Act made this connection even more direct when it gave Medicare the ability to withhold a portion of hospital reimbursement if patient satisfaction scores were low.
Unsurprisingly, under this regime, the number of opioid prescriptions increased dramatically. Worried that their survey scores would be low for not treating pain aggressively enough (and under pressure to address this), doctors began liberally prescribing opioids. Data show that receiving opioids doesn’t change patient satisfaction, but doctors were convinced they did. A recent study found that 71 percent of doctors reported feeling “pressure to prescribe opioid analgesics to avoid administrative and regulatory criticism.” Over half specifically felt the Joint Commission patient satisfaction surveys had a harmful effect on prescribing practices.
One problem with putting so much emphasis on aggressively treating patient pain is that measuring pain accurately or uniformly is impossible. Typically, patients are asked to rank their pain on a zero to 10 scale. As any doctor will tell you, such rankings are frustratingly hard to parse: One patient may report a pain score of 10 while calmly eating a sandwich. Another might be writhing on a stretcher and report a pain score of 5. Which patient needs more aggressive pain control?
There’s also the question of expectations. We all want to live as comfortably as possible—but from a medical perspective, this is not always possible or prudent. For a patient in pain at the end of his or her life, the primary goal may well to be to find a way to live pain-free. This patient would likely benefit from opioids. But for an otherwise healthy patient with a back injury, the primary goal is not actually pain control but a return to a normal, functional life as soon as is safely possible. Opioids are almost certainly not the right course of action in this case; the short-term benefits are outweighed by the risks. For patients with consistent, chronic pain (what Prince is thought to have struggled with), the calculus may be trickier, but opioids are still a dangerous choice. Preliminary research conducted in rats suggests opioids may be more detrimental than they are beneficial—making pain last longer. “There’s no evidence that opioids work long term if taken on a daily basis,” says New York–based Dr. Andrew Kolodny, who serves as president of the Physicians for Responsible Opioid Prescribing. At best, chronic use may be safe in a very small number of cases.
The problem is that opioids don’t just treat pain—they also carry several serious risks. They smother our chemical receptors, causing a wide variety of side effects. They cause euphoria and sedation, which can lead to abuse. They also cause respiratory depression. At high enough doses, opioids cause us to stop breathing altogether. They kill.
We have known this about opioids for decades—that’s why it took such a concerted effort to increase how frequently they were prescribed. The various stakeholders invested in increasing their use included the aforementioned Joint Commission and the American Pain Society, the Federation of State Medical Boards, and Purdue Pharmaceuticals, the producer of OxyContin, and one of the largest opioid producers.
Purdue, which only makes opioid-containing pain medications, employed dishonest and even illegal tactics to ensure the drugs’ spread. In 2007, Purdue agreed to pay $600 million in damages after pleading guilty to criminal charges over misrepresenting the drugs’ risk of addiction. Purdue circulated literature that claimed opioids were safe; that literature was created by doctors raking in consulting fees from the pharmaceutical companies making the drugs.
A turning point came in 1999, when the Joint Commission released a report recommending that we treat pain more aggressively and largely with opioids. The Joint Commission’s programs for complying with the new pain standards were funded by Purdue and took up the company’s position that opioids had been wrongly stigmatized as unsafe. “Some clinicians have inaccurate and exaggerated concerns about addiction, tolerance and risk of death,” the Joint Commission’s 1999 pain policy stated. “This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” The Commission downplayed the risks of the drugs while overemphasizing the perceived problem of untreated pain. Others followed the Commission’s lead. In 2000, the Veterans Administration revised its literature to list pain as the fifth vital sign. Hospital regulators bought in, too.
Doctors responded. Opioid prescriptions increased—and not just in cases where there is medical consensus that opioids are necessary (terminal cancer, exacerbations of sickle-cell anemia-induced pain, as well as some acute causes of pain such as broken bones and kidney stones). Patients started receiving opioid prescriptions when they got wisdom teeth removed. Between 2002 and 2012, total expenses for outpatient opioid prescriptions had increased 120 percent.
A decade later, doctors started to realize just how dangerous these prescribing practices were, and tried to reduce their reliance on the drugs. Surprisingly, the Joint Commission started hedging its rhetoric as well. A publication from 2011 explicitly referred to pain as the “fifth vital sign” while simultaneously acknowledging that, “unlike other physical indicators like blood pressure and temperature, pain cannot be quantitatively measured.”
In April, the Joint Commission published an article addressing what it calls “misconceptions” that stemmed from its 1999 recommendations for pain control. While the document calls for a more guarded approach to opioid use, it fails to acknowledge that its own pain management initiative may have played a role in the spike in prescriptions. Instead it says that the Commission “does not endorse pain as a vital sign, and this is not part of our standards,” a claim that is hard to square with its own published materials. Kolodny found the Joint Commission’s response to be “very defensive and almost dishonest.”
Now that we know how damaging widespread use of opioids can be, we need to readjust how we use these drugs, a task that would be easier if the groups that pushed for their overuse would admit their mistakes. The Centers for Disease Control and Prevention, at least, recently released a new “Guideline for Prescribing Opioids for Chronic Pain.” The document is promising, stating that “nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.” It also encourages doctors and patients to have more realistic discussions of risks and benefits, and to develop an exit strategy if opioids are in fact necessary. In March, the White House had 60 medical schools and over 150 nursing schools pledge to educate their students on the new CDC guidelines for safe opiate prescribing.
CDC officials are also finally attempting to limit pharmaceutical industry influence on pain medicine prescription. Leading by example, the CDC insisted that the expert opinions it relied on in developing its new pain management guideline come from experts without conflicts of interest with opioid-producing pharmaceutical companies. Unfortunately, what the CDC guideline lacks is regulatory power to enforce this for other regulatory bodies. Meanwhile, CMS and the Joint Commission continue to rate and reimburse hospitals based on patient perceptions of pain control. Congress is currently considering several laws related to opioid safety, one of which would remove pain assessment from the required patient satisfaction surveys.
So who killed Prince? No one person, company, or regulatory body can be blamed, especially when there are still so many questions around his death. But it seems likely that Prince died as a result of the wrong-headed approach to pain control that doctors had been cornered into adopting by regulators who were misguided at best and misled—by bad research and greedy drug companies—at worst. Until all parties take responsibility and unravel this opioid-heavy approach to pain, Prince won’t be the last person to die thanks to these irresponsible decisions.
This article was written after conversations with Dr. Debra Houry, Dr. Andrew Kolodny, Dr. Sergey Motov, Dr. Lewis Nelson, Dr. Jeanmarie Perrone, and Dr. Scott Weiner.
Disclaimer: The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.