The desire to treat pain led to a devastating epidemic

America has a pain problem. About 100 million Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine. This might seem like an excessive number — roughly one-third of all Americans — but it includes everyone in the chronic pain spectrum, from the silent sufferer who deals with constant back pain to the patient who can no longer move because the pain all over her body is just too much.

As the blog Skeptical Scalpel notes, there isn’t a single medication that will relieve all pain for all patients. But there was a huge push in the 1990s and 2000s — through, for example, the federal government’s flawed “Pain as the Fifth Vital Sign” campaign — that doctors do something about pain, even when there wasn’t much that could be done.

This push allowed — as Keith Humphreys, an opioid and addiction expert at Stanford University, explained — pharmaceutical companies to take advantage of the pain problem: Despite the lack of evidence that opioid painkillers can treat chronic pain and evidence that these drugs are addictive and dangerous, pharmaceutical companies saw an opportunity for profit, and they marketed opioids to doctors as a safer way to treat pain than other medications.

Pharmaceutical companies’ claims were, of course, completely inaccurate, and Purdue Pharma, producer of the opioid OxyContin, would later pay hundreds of millions of dollars in fines for their false claims. Opioid painkillers carry a significant risk of addiction and overdose, especially for long-term users who build up a tolerance of the high and use more and more of the drug without building as much resistance for the respiratory effects that lead to overdose.

But many doctors, under pressure to treat pain more seriously, bought into the messaging from those decades and prescribed a ridiculous amount of painkillers to patients. In 2012, US physicians wrote 259 million prescriptions for opioid painkillers — enough to give a bottle of pills to every adult in the country. And these pills don’t just end up in patients’ hands, instead proliferating to black markets, landing in the hands of teens who rummaged through parents’ medicine cabinets, and so on.

Federal and state governments, aware of the problem, began going after doctors and pharmacists who provided painkillers too leniently, threatening them with incarceration and the loss of their medical licenses. Ideally, doctors will still be able to provide painkillers to patients who really need them — after, for example, evaluating whether the patient has a history of drug abuse. But doctors who weren’t conducting even such basic checks are being told — not just through the crackdown, but via health-care organizations and public education campaigns — to give more thought to their prescriptions.

Despite increased awareness and the crackdown, there are still signs of some doctors doing a lot of overprescribing. A Centers for Disease Control and Prevention report found that a small minority of prescribers are responsible for most opioid prescriptions, although there’s a lot of variation from state to state. For example, the top 1 percent of prescribers wrote one in four opioid prescriptions in Delaware, while the top 1 percent of prescribers wrote one in eight such prescriptions in Maine.

Still, the crackdown has appeared to stabilize the number of painkiller overdose deaths in the past few years, but it also led to a major downside: an increase in heroin abuse and deaths.

Painkiller-linked deaths have stabilized, but heroin-related deaths appear to be rising

When opioid addicts couldn’t fulfill their cravings with painkillers, many turned to an opioid that is, despite its status as an illegal substance, cheaper and more accessible than the legal medicine: heroin. So as painkiller overdoses leveled off at about 16,000 in recent years, heroin deaths skyrocketed from just over 3,000 in 2010 to more than 8,200 in 2013, according to CDC data. Though all heroin users didn’t necessarily start with painkillers, it’s the transition from painkillers to heroin, Humphreys and other experts say, that led to the recent dramatic spike in heroin abuse.

Heroin is even deadlier than opioid painkillers — it’s far more potent, and far more addictive. So even if a small number of painkiller users moved on to heroin, it would still, on a per-person basis, lead to far more deaths.

What’s worse, painkiller and heroin users tend to mix opioids with other substances — like alcohol and cocaine — that exacerbate the risk of an overdose. A 2003 study found roughly half of heroin-related deaths involved alcohol, and the CDC found that 31 percent of prescription painkiller-linked overdose deaths in 2011 were also linked to benzodiazepines, a legal anti-anxiety drug. So as people used painkillers and moved on to heroin, they continued using all these other substances that made their risk of overdose much, much higher — and it’s showing in the numbers.

That doesn’t mean cracking down on painkillers was a mistake. It appears to have slowed the rising number of painkiller deaths, and may have prevented doctors from prescribing the drugs to new generations of potential addicts. So the crackdown did lead to more heroin deaths, but it will hopefully prevent future populations of drug abuse, which could have suffered even more overdose deaths. That’s why, though they knew it could lead to a temporary spike in heroin use, state and federal agencies came down on painkillers.