The Opioid Crisis—A Wicked Problem

“All across the United States, individuals, families, communities, and health care providers are struggling to cope with the impacts of the opioid crisis,” wrote US Surgeon General Jerome Adams in a recent Spotlight on Opioids. “The use of illegal opioids such as heroin—a highly addictive drug that has no accepted medical use in the United States—and the misuse of prescription opioid pain relievers can have serious negative health effects.”

In his presentation as part of the  Williamsburg Place Lecture Series, the medical director of the Farley Center, Jonathan C. Lee gave an overview of the ongoing epidemic which he categorized as a “wicked problem.”

Such a problem is difficult to describe fully. Dr. Lee offered a definition used by James Olver, an associate professor of business at William & Mary. Wicked problems arise from “complex systems with components that interact in poorly understood and unpredictable ways.” Interventions into such a system “produce downstream consequences that cannot be known in advance and cannot be undone while changing one element changes dynamics of the entire system.” Lee likened this kind of conundrum to “trying to control chaos.”

How Did We Get Here?

Dr. Lee presented a brief recap of the origin of the crisis. An infamous starting point was the one-paragraph letter published in the New England Journal of Medicine in 1980 suggesting a low risk of addiction when opioids were prescribed for chronic pain, even though no evidence for that claim was provided by the correspondents. In 1996, the American Pain Society introduced pain as the “fifth vital sign,” although pain—unlike the other vital signs—cannot be objectively measured.

This paved the way for an avalanche of prescriptions for opioid pain relievers. For years, Purdue Pharma—the maker of Oxycontin—vigorously promoted the idea that the use of prescription opioids involved little risk for patients.

The reality turned out to be very different. “From 1999 to 2017, almost 218,000 people died in the United States from overdoses related to prescription opioids,” according to the Centers for Disease and Prevention. “Overdose deaths involving prescription opioids were five times higher in 2017 than in 1999.” Lawsuits followed. In 2007, Purdue Frederick Co. and three individuals pleaded guilty to charges of misbranding OxyContin and paid more than $634 million in penalties.

Currently, about 115 people die from an opioid overdose each day in the United States. Even life expectancy has been declining in the last few years in a nation ravaged by escalating drug and suicide crises.

Fatal drug overdoses are now the most common reason for “unnatural death” in Virginia, having surpassed motor vehicle accidents and gun-related deaths, explained Lee. Like other states, Virginia implemented measures to fight the epidemic—with limited results.

In 2006, the Prescription Monitoring Program and the Virginia Board of Medicine started giving presentations on the proper prescribing of opioids. The governor formed a task force in 2014 and the General Assembly passed a law in 2016, requiring two hours of continuing education on controlled substances.

But a “wicked” problem is not easily defeated. “After we started to reduce prescription opioids there has been an escalation of fentanyl, heroin, and other illicit drugs. Fatal drug overdoses have continued to increase,” Lee said. Clearly, addiction is more complicated than having access to addictive substances.  

What Then Is Addiction?

Dr. Lee likes the definition provided by the National Institute on Drug Abuse (NIDA): “Addiction occurs when a person cannot control the impulse to use drugs even when there are negative consequences.” It is a chronic brain disease: “Behavioral changes are accompanied by changes in brain functioning, especially in the brain’s natural inhibition and reward centers.”

American Society of Addiction Medicine describes in as a primary, chronic disease of the brain with biological, psychological, social, and spiritual manifestations. Its main features are

  • Inability to consistently abstain
  • Impairment of behavioral control
  • Craving
  • Diminished insight into significant problems with behavior and relationships
  • Dysfunctional emotional responses
  • Cycles of relapse and remission
  • Progressive in nature

During his presentation, Lee explained various treatment methods such as 12-Step facilitation and medication-assisted treatment, using FDA-approved medications such as buprenorphine and methadone. Dr. Lee finished with a case discussion and explained various available screening methods to detect substance misuse.

The talk concluded with a quote from the former US Surgeon General Vivek Murthy: “We must stop treating addiction as a moral failing, and start seeing it for what it is: a chronic disease that must be treated with urgency and compassion.”