Ultimately the “opioid crisis” is not about opioids, it is about addiction and mental health and societal despair. In fact, the majority of drug overdose deaths are due to multiple substances, including alcohol and benzodiazepines, not just opioids. The real crisis we are facing in this country is a substance abuse problem, not an opioid abuse problem.

The hysteria around opioid use for chronic pain is wrong and not supported by the facts. Studies show that among people who are prescribed opioids, addiction is relatively uncommon. According to a brilliant article by Dr. Sally Satel, “the percentage of patients who become addicted after taking opioids for chronic pain is measured in the single digits; studies show an incidence from less than 1 percent to 8 percent.”

It is important here to clarify the difference between addiction and dependence. Because of how opioids affect the brain, anyone taking this type of medications regularly will develop physical dependence on them, meaning if the medications are stopped suddenly withdrawal symptoms may occur. Dependence is not the same as addiction. Addiction means abnormal behaviors around a medication, using it to change your mood or get high, and being unable to control your use of the medication.

Ultimately the “opioid crisis” is not about opioids, it is about addiction and mental health and societal despair. In fact, the majority of drug overdose deaths are due to multiple substances, including alcohol and benzodiazepines, not just opioids. The real crisis we are facing in this country is a “substance abuse” problem, not an opioid abuse problem.

In a powerful editorial in Pain Medicine News, Dr. James Choo, a Tennessee pain physician, says it perfectly: “The opioid crisis has caught the nation’s attention, but through the lens of opioids we focus on a narrow bandwidth and overlook the deeper problems… of addiction, trauma and polysubstance abuse.”

In fact, the policies to control one type of drug use often cause a flourishing of another type. As prescription opioids became harder to access, more people turned to stronger illicit fentanyl and heroin, which are much more likely to lead to deadly overdose. In fact, as this powerful graph shows, as prescriptions for opioids went down, rates of overdose deaths have gone up.

Clearly the current efforts to clamp down on opioid prescriptions are misguided. During prohibition when alcohol was illegal, people turned to homemade alcohols and toxic wood alcohol (methanol) that caused blindness and death. Our current “opioid crisis” looks a lot like a deadly game of whack-a-mole, as we chase after the current drugs of abuse, while not addressing the underlying demand for drugs.

According to Dr. Choo, the better question is why do addicts seek any drug? The answer is likely trauma, a societal affliction that most policymakers and the media are uncomfortable addressing. A study in the 1990s by the CDC and Kaiser Permanente found that the amount of trauma experienced in childhood was directly related to the risk of developing addictions. Some addiction experts now think that substance abuse may be a normal learned response to trauma, a form of compulsive comfort-seeking or self-soothing. Dr. Choo advocates changing the narrative from an “opioid-crisis” to a “trauma crisis” and “directing resources and attention to addressing what drives the demand for drugs, but this would take political and societal will, and it takes a long view to care—not a quick fix by any means.”

He is absolutely right. We cannot win by playing an eternal game of “whack-a-drug”, without addressing the underlying societal ills driving substance abuse and addiction. Responding to a substance abuse epidemic by taking opioids away from those in chronic pain simply creates an epidemic of undertreated chronic pain.

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