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Medicine Interview Hot Topics: Opioid Crisis
Key Information
In 2018, 128 people in the US died every day after overdosing on opioid drugs. The term opioids includes a vast array of different drugs, including prescription painkillers, synthetic opioids like fentanyl, heroin, and prescription drugs that have become ‘party drugs’ like oxycontin. The breadth of the opioid epidemic has been labelled a national crisis, affecting as it does public health, social health, and the economy. The CDC estimated the total economic burden of just prescription opioid abuse - ignoring other domains like the recreational use of heroin - as $78.5 billion a year. That cost includes healthcare, courts and criminal law costs, loss of productivity, and treatment for addiction.
Statistics
Between 21% and 29% of patients prescribed opioid analgesics will go on to misuse them in some form, and between 8% and 12% will develop an opioid use disorder. Somewhere between four and six percent of those who misuse opioids will eventually move to using heroin.
80% of heroin addicts first misused prescription opioids.
2015 was the first year in which the average US life expectancy declined in the past 100 years - falling from 78.8 years in 2014 to 78.7 in 2015 - and onward to 78.5 in 2016 and 2017. This decline was directly linked to surging drug overdoses and suicides stemming from substance abuse problems - the opioid overdose rate increasing roughly sixfold from 1997-2017, and the overall drug overdose rate tripling.
How the Problem Developed
Doctors began to prescribe opioid analgesics with increasing frequency throughout the 1990s, leading to widespread misuse of the medications before it became clear just how addicted they were. Opioid overdose rates increased following increased prescriptions, with 47,000 US citizens dying from opioid overdoses in 2017 alone. However, the roots of the problem began in the 1980s, when pain became recognised as a problem that required adequate treatment, and US states began to pass pain treatment acts, which allowed physicians to aggressively treat pain with controlled substances. In 1995, the American Pain Society framed pain as a ‘vital sign’ that should be monitored, just as one monitors heart rate and blood pressure. Opioids were seen, around this time, as safer and less addictive than they previously had been and were prescribed for long term pain rather than short term issues - a use which they were largely inappropriate for in many instances.
The Situation Now, and the Future
Aiding the recognition of the opioid epidemic as a legitimate public health crisis are various related problems and disorders. Directly stemming from misuse come overdoses, and the increasing incidence of neonatal abstinence syndrome due to the abuse of opioids during pregnancy. Indirect problems include the spread of HIV/AIDS and Hepatitis C, through the sharing of needles. The US Department of Health and Human Services has therefore noted five priority areas that it seeks to treat or address. These are: improving the access to treatment and to recovery services, promoting the use of overdose-reversing drugs (notably naloxone), promoting better public health surveillance to strengthen our understanding of the problem and its scale, ensuring that research into pain and addiction has adequate support and investment, and advancing better practice in general for the management of pain. The National Institutes of Health (shortened to NIH) is the US’s primary research agency tasked with solving the opioid crisis through finding improved analgesic solutions, preventing misuse, and treating misuse and overdose. In April 2018, the HEAL initiative (Helping to End Addiction Long term) was launched, which is a trans-agency effort with the singular goal of developing and catalysing scientific solutions to the opioid epidemic.
Example Interview Questions
- Are you aware of the opioid epidemic?
- What caused the opioid epidemic here in the US?
- How might one go about trying to reverse the opioid epidemic?
- What factors have contributed to the scale of the opioid epidemic in the US?
- Why do you think that Europe has a far lesser problem with the misuse of opioid drugs?
- Why do you think that the death rate from opioids has increased so much in the last 20 years?
- What types of opioid drugs are most often abused?
- Why might someone legitimately be prescribed opioid drugs?
- Why might doctors feel a pressure to prescribe opioid analgesics to their patients?
How to answer questions on the opioid crisis
Be confident on the role of opioid drugs in healthcare, and try to have some statistics to hand that illustrate the scale of the epidemic. Have a clear answer on how the US can move forward and address this issue.
Interview Questions & Example Answers
Are you aware of the opioid epidemic?
I am aware of the scale of the opioid epidemic in the US. I know that in 2018, 128 people died every day, on average, after overdosing on opioid drugs. These will include both prescription painkillers like morphine, synthetic opioids like fentanyl, heroin, and prescription drugs that have crossed over into the realm of ‘party drugs’ like oxycontin. The CDC estimates that prescription opioid abuse costs the national economy almost 80 billion dollars a year - ignoring the additional burden of the recreational use of heroin. More than 21% of those who are prescribed opioid analgesics will go on to misuse them in some form.
What caused the opioid epidemic here in the US?
The problem began in the 1980s, when pain became a recognised issue that required adequate treatment, leading to states across the US passing pain treatment acts, allowing the aggressive treatment of pain with controlled substances. In 1995, the American Pain Society would label pain as a ‘vital sign’ that needed to be monitored and controlled, much as one does for heart rate or blood pressure. When doctors began to prescribe increased amounts of opioid analgesia throughout the 1990s, opioid overdose rates increased directly following the increase in prescriptions. The opioids were frequently prescribed for long term pain, which they were often inappropriate for, being highly addictive.
How might one go about trying to reverse the opioid epidemic?
The US Department of Health and Human Services has already instigated a plan to deal with this issue. It covers five principal areas, which are as follows. Firstly, improve the access to treatment and recovery services. Then, promote the use of overdose reversing drugs like naloxone, and promote better public health surveillance to help us better understand the epidemic itself. Additionally, we should invest in research on pain management, and thus advance better practice for the management of pain. The National Institutes of Health is responsible primarily for solving the opioid crisis, and focuses on new and improved analgesics, the prevention of misuse, and how to treat overdose.
What factors have contributed to the scale of the opioid epidemic in the US?
I believe that the opioid epidemic in the US is a public health issue that has been developing for some time, and stems from policymaking and actions that were taken from as early as the 1980s. Notably, the USA recognised pain as a problem that needed medical treatment in the 80s, paving the way for doctors to begin aggressively treating pain with controlled substances - chiefly opioids. Doctors, armed with both a relatively poor knowledge of the addictiveness and safety profile of opioids compared to today and a need to contend with each other in a private healthcare system, would feel that they had to begin prescribing opioids in ever higher amounts, as patients began to expect access to the drugs.
Why do you think that Europe has a far lesser problem with the misuse of opioid drugs?
As well as poor policy-making and questionable science that gained notoriety throughout the 1980s and 1990s, leading to pain being seen as a vital sign and opioids as not being addictive, we should also consider the role of doctors in the US vs doctors in the EU and UK. Most insurance companies won’t pay for anything but a prescription - meaning that in the US’ private healthcare system, a doctor who examines a patient with lower back pain won’t be able to bill for that service - but will be able to bill for prescribing analgesia. Drug companies are also able to court doctors with gifts and meals, which in turn leads to a direct increase in the prescription rates of their drugs. Lastly, the US is the only country in the world - besides New Zealand - that allows prescription drugs to be advertised on TV, leading to patients being far more likely to become interested in them.
Why do you think that the death rate from opioids has increased so much in the last 20 years?
I believe that a combination of factors are at play. Overall, it appears that the US itself has developed an unhealthy attitude to pain and analgesia over the past quarter of a century or so. I believe that this initially stemmed from policymaking (pain becoming a vital sign in the 1990s, and the Joint Commission establishing standards for pain assessment and treatment in 2001) and poor training of doctors, who were barely taught about analgesia as part of their basic training. These factors in turn, backed by insurance companies and the pharmaceutical industry’s influences, led to the US itself shifting toward an attitude that pain should be eliminated through the use of drugs, rather than that it might be controlled or dealt with in other ways. As patients come to expect that their pains will be eliminated, and doctors must pander to them in a private healthcare system, we in turn face a perfect storm that has built up over a period of time.
What types of opioid drugs are most often abused?
The most commonly abused opioids include naturally derived products like morphine and codeine, which are made from the poppy plant. Heroin is an illegal recreational drug that is synthesised from morphine. Semi-synthetic opioids like hydrocodone and oxycodone are manufactured in laboratories using a combination of man-made and natural ingredients. Fentanyl is an entirely synthetic opioid and is 100x more powerful than morphine. Fentanyl can therefore be lethal in very small doses, which in turn has led to increased deaths from overdose as it has been produced illegally and often substituted for other drugs. Methadone is also fully synthetic, and commonly used for recovering heroin addicts, as a substitute.
Why might someone legitimately be prescribed opioid drugs?
Opioid drugs are prescribed primarily for pain. They may be prescribed for mild or moderate pain (in the case of codeine or tramadol), moderate to moderately severe pain (hydrocodone and oxycodone) or moderate to severe pain. They may also be prescribed for around the clock analgesia for moderate to severe pain, which will involve fentanyl, methadone, oxycodone, or hydromorphone. Opioids may also be used for the treatment of breakthrough pain in tolerant cancer patients, which involves buccal or sublingual fentanyl products - the patient must already be receiving, and be tolerant to, round the clock therapy for underlying persistent cancer pain.
Why might doctors feel a pressure to prescribe opioid analgesics to their patients?
Doctors in the US are largely dictated to by the needs and processes of the private healthcare system in which they work. With patients able to rate them, and these ratings in turn affecting their future practice and incomes, they must feel a pressure to give the patients what they want - which, fuelled by adverts and a national increased reliance on painkillers, will often be opioid analgesia. Additionally, pharmaceutical companies will court doctors and give them gifts if they are able to prescribe their products, leading to increased rates of prescription. Finally, the doctors often will be unable to claim from insurance companies unless they prescribe a patient medication, with something like a physical examination or advice-giving not easily being claimed back against an insurance company - whereas prescribing an opioid can be claimed against insurance quickly and easily.
Are you aware of the opioid epidemic?
I am aware of the scale of the opioid epidemic in the US. I know that in 2018, 128 people died every day, on average, after overdosing on opioid drugs. These will include both prescription painkillers like morphine, synthetic opioids like fentanyl, heroin, and prescription drugs that have crossed over into the realm of ‘party drugs’ like oxycontin. The CDC estimates that prescription opioid abuse costs the national economy almost 80 billion dollars a year - ignoring the additional burden of the recreational use of heroin. More than 21% of those who are prescribed opioid analgesics will go on to misuse them in some form.
What caused the opioid epidemic here in the US?
The problem began in the 1980s, when pain became a recognised issue that required adequate treatment, leading to states across the US passing pain treatment acts, allowing the aggressive treatment of pain with controlled substances. In 1995, the American Pain Society would label pain as a ‘vital sign’ that needed to be monitored and controlled, much as one does for heart rate or blood pressure. When doctors began to prescribe increased amounts of opioid analgesia throughout the 1990s, opioid overdose rates increased directly following the increase in prescriptions. The opioids were frequently prescribed for long term pain, which they were often inappropriate for, being highly addictive.
How might one go about trying to reverse the opioid epidemic?
The US Department of Health and Human Services has already instigated a plan to deal with this issue. It covers five principal areas, which are as follows. Firstly, improve the access to treatment and recovery services. Then, promote the use of overdose reversing drugs like naloxone, and promote better public health surveillance to help us better understand the epidemic itself. Additionally, we should invest in research on pain management, and thus advance better practice for the management of pain. The National Institutes of Health is responsible primarily for solving the opioid crisis, and focuses on new and improved analgesics, the prevention of misuse, and how to treat overdose.
What factors have contributed to the scale of the opioid epidemic in the US?
I believe that the opioid epidemic in the US is a public health issue that has been developing for some time, and stems from policymaking and actions that were taken from as early as the 1980s. Notably, the USA recognised pain as a problem that needed medical treatment in the 80s, paving the way for doctors to begin aggressively treating pain with controlled substances - chiefly opioids. Doctors, armed with both a relatively poor knowledge of the addictiveness and safety profile of opioids compared to today and a need to contend with each other in a private healthcare system, would feel that they had to begin prescribing opioids in ever higher amounts, as patients began to expect access to the drugs.
Why do you think that Europe has a far lesser problem with the misuse of opioid drugs?
As well as poor policy-making and questionable science that gained notoriety throughout the 1980s and 1990s, leading to pain being seen as a vital sign and opioids as not being addictive, we should also consider the role of doctors in the US vs doctors in the EU and UK. Most insurance companies won’t pay for anything but a prescription - meaning that in the US’ private healthcare system, a doctor who examines a patient with lower back pain won’t be able to bill for that service - but will be able to bill for prescribing analgesia. Drug companies are also able to court doctors with gifts and meals, which in turn leads to a direct increase in the prescription rates of their drugs. Lastly, the US is the only country in the world - besides New Zealand - that allows prescription drugs to be advertised on TV, leading to patients being far more likely to become interested in them.
Why do you think that the death rate from opioids has increased so much in the last 20 years?
I believe that a combination of factors are at play. Overall, it appears that the US itself has developed an unhealthy attitude to pain and analgesia over the past quarter of a century or so. I believe that this initially stemmed from policymaking (pain becoming a vital sign in the 1990s, and the Joint Commission establishing standards for pain assessment and treatment in 2001) and poor training of doctors, who were barely taught about analgesia as part of their basic training. These factors in turn, backed by insurance companies and the pharmaceutical industry’s influences, led to the US itself shifting toward an attitude that pain should be eliminated through the use of drugs, rather than that it might be controlled or dealt with in other ways. As patients come to expect that their pains will be eliminated, and doctors must pander to them in a private healthcare system, we in turn face a perfect storm that has built up over a period of time.
What types of opioid drugs are most often abused?
The most commonly abused opioids include naturally derived products like morphine and codeine, which are made from the poppy plant. Heroin is an illegal recreational drug that is synthesised from morphine. Semi-synthetic opioids like hydrocodone and oxycodone are manufactured in laboratories using a combination of man-made and natural ingredients. Fentanyl is an entirely synthetic opioid and is 100x more powerful than morphine. Fentanyl can therefore be lethal in very small doses, which in turn has led to increased deaths from overdose as it has been produced illegally and often substituted for other drugs. Methadone is also fully synthetic, and commonly used for recovering heroin addicts, as a substitute.
Why might someone legitimately be prescribed opioid drugs?
Opioid drugs are prescribed primarily for pain. They may be prescribed for mild or moderate pain (in the case of codeine or tramadol), moderate to moderately severe pain (hydrocodone and oxycodone) or moderate to severe pain. They may also be prescribed for around the clock analgesia for moderate to severe pain, which will involve fentanyl, methadone, oxycodone, or hydromorphone. Opioids may also be used for the treatment of breakthrough pain in tolerant cancer patients, which involves buccal or sublingual fentanyl products - the patient must already be receiving, and be tolerant to, round the clock therapy for underlying persistent cancer pain.
Why might doctors feel a pressure to prescribe opioid analgesics to their patients?
Doctors in the US are largely dictated to by the needs and processes of the private healthcare system in which they work. With patients able to rate them, and these ratings in turn affecting their future practice and incomes, they must feel a pressure to give the patients what they want - which, fuelled by adverts and a national increased reliance on painkillers, will often be opioid analgesia. Additionally, pharmaceutical companies will court doctors and give them gifts if they are able to prescribe their products, leading to increased rates of prescription. Finally, the doctors often will be unable to claim from insurance companies unless they prescribe a patient medication, with something like a physical examination or advice-giving not easily being claimed back against an insurance company - whereas prescribing an opioid can be claimed against insurance quickly and easily.