Opioid Abuse is a Behavioral and Social Systems Problem

Opioid Abuse is a Behavioral and Social Systems Problem

Opioid Abuse has rapidly become a public health epidemic.  The CDC reports that while the amount of overall pain that patients report has not changed, the amount of prescription opioids sold in the U.S. has quadrupled since 1999.  Deaths from opioid overdose increased 200% between 2000 and 2014, and opioids are the leading cause of drug overdose in this country.

Last week, the CDC reported on the likelihood of long-term use based on initial prescribing patterns in over one million commercially insured, opioid-naïve, cancer-free adults.  They showed that the probability of chronic use rises rapidly after just three days of dosing, and increases most substantially after 5 days and after 1 month of use. Receiving a refill or being prescribed a longer-acting opioid also increased the chances of long-term use.  Although other factors could be responsible for these relationships, short-term prescribing of opioids (< 6-7 days) could reduce the chances of unintended chronic use by half.

The prescribing of opioids is a behavior that occurs in social context.  Influenced by medication marketing and cultural norms, patients often expect their healthcare provider to relieve their pain immediately, not help them manage it.  Via negative reinforcement, healthcare providers, even well-intentioned ones, learn that it is easier to prescribe pain meds than to counsel patients in how to manage their pain.

Relatively simple social and behavioral change techniques can have a significant impact on the preventing opioid abuse.  For example, giving surgeons clear guidance on how much pain medication should be prescribed post-operatively can cut opioid prescribing in half.  In Ohio, opioid prescribing and overdose deaths reduced substantially following the initiation of a program with pharmacists including public health messaging, promotion of responsible opioid use, and improved prescription drug monitoring.  Based on the CDC report on the potential benefits of short-term prescribing, choice architecture principles from behavioral economics could be used to encourage short-term prescribing of opioids while increasing the burden on both physician and patient to choose refills or prescribing for longer than a week.

Unfortunately, not all pain is acute, and chronic pain remains difficult to manage.  Psychosocial interventions including cognitive restructuring and relaxation have produced modest improvements in chronic pain and are an important component of chronic pain management.   And among those who become addicted to opioids and heroin, behavioral interventions play an important role.  The Substance Abuse and Mental Health Services Administration’s Medication Assisted Treatment combines behavior therapy and medications to treat substance use disorders.

There remains much to learn to prevent and treat opioid abuse and better manage both acute and chronic pain, and the NIH continues to support research that address these public health issues. For instance, OBSSR participates in the NIH Pain Consortium, established to enhance pain research and promote collaboration at the NIH, and this year’s annual NIH Pain Consortium Symposium focuses on multidisciplinary strategies for pain (May 31-June 1, Bethesda, MD).  This multidisciplinary focus highlights that medication prescribing is a behavior influenced by a variety of social processes and systems.  Integrating behavioral and social sciences into comprehensive efforts to change prescribing patterns, prevent and treat opioid and heroin abuse, and better manage both acute and chronic pain is clearly needed.  We will make considerably more progress in the opioid abuse epidemic when we acknowledge that a problem caused predominately by prescribing cannot be solved only by more or different prescribing.