Prescription opioid narcotic (painkiller) is a national epidemic in the US primarily initiated by uncontrolled prescribing of US physicians, the source of 99% of all prescription painkillers in the country. The US uses 80% of all prescription opioid pain killers in the world even though we are less than 5% of the world's population. We also use more than 95% of all hydrocodone in the world. Compared to Europe, the US doctors prescribe 450% as much per capita compared to European doctors with no difference in demonstrated pain control. In fact, there are several studies that have shown long term opioid (prescription painkillers) have no effect on pain from many sources, including low back pain. The confusion by US doctors began with incorrectly assuming chronic pain was simply an extension of acute pain.  Opioids for acute pain do help short term whereas for chronic pain (pain existing continuously for > 3 months), there is little evidence of effectiveness. With long term prescribing of opioids, tolerance develops, and the patient has to continue using opioids to avoid withdrawal symptoms (one of which is temporarily worsened pain). The chemical dependency on prescription painkillers prescribed long term by doctors is no different an effect on the body than use of heroin to avoid withdrawal- prescription painkillers and heroin act exactly the same places in the body to cause addiction. Doctors have created millions of people in the US addicted to opioids but the patients do not know it- they believe they need the opioids to treat their pain when in fact, they are using the opioids to avoid the effects of withdrawal from the painkillers including transiently worsening pain.

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     The country has 1200% per year as many prescription drug deaths now compared to 1990 and the amount prescribed has increased 7 fold during that timeframe. Now we have many studies demonstrating that over 120mg morphine equivalents per day (known as MED) the death rate increases by 400-1000%. This is equal to 80mg oxycodone per day or a 50mcg/hr patch of fentanyl. We also know that high dose compared to lower dose opioids actually increase chronic pain instead of reducing it (opioid induced hyperalgesia), and leads to a much higher incidence of substance abuse and addiction. However some doctors in the area including pain clinic doctors and their nurse practitioners, continue to prescribe very high doses of opioid narcotics despite the increased risks of addiction, overdose and death. Shockingly, one pain clinic in the region actually has a drugs for injections trade going on- you either accept the expensive spine injections or otherwise narcotic painkillers will be cut off. This type of practice keeps patients on high doses of opioid narcotics in order to feed their injection business that generates 10-20 times the amount of money compared to an office visit. Other doctors in the area naively continue prescribing very high dose opioids up to 1000mg MED per day without justification and contrary to the standards of care or patient safety concerns. 

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      Much of the cause of the prescription opioid epidemic was because doctors incorrectly believed chronic pain (a neurobiological disease) is simply an extension of acute pain (a tissue injury).  They failed to take into account what was happening with dopamine release into the brain and reinforcement of dosing.  Addiction can take place with as little as 2 weeks of continuous opioid use- not uncommon after surgery in the US where the surgeons prescribe out of their own convenience, far too many pain medications.  Some patients take the entire amount of pain medication allotted, not because it was needed, but because it was prescribed.  Overall, about 2/3 of the pain meds prescribed do not get used, and sit on the shelf for theft by household teenagers or their friends.  The average age kids begin using prescription opioids is age 14.  Other causes of the prescription epidemic range from drug company advertising of the drugs as safe and even non-addictive when pain exists (of course this is non-sense but the manufacturers in the 1990s and early 2000s could say whatever they wanted).  The Federation of State Medical Boards made the situation much worse by declairing physicians could be disciplined for not prescribing enough opioids to those in pain, and several organizations developed guidelines or policies that encouraged the use of opioids including the American Pain Society, JCAHO, VA hospitals, hospital adoption of pain as the "5th vital sign" when in fact it is not a sign at all, American Pain Foundation, American Academy of Pain Medicine, American Geriatrics Society, etc.  

     The idea in the late 1990s was that increasing pain simply required an escalation of dosage.  The medications themselves that had only been used in cancer pain previously in high doses, was now being used in chronic pain patients.  It was not uncommon to find patients taking 80mg Oxycontin three times a day (equivalent to 500mg morphine or 50 Vicodin 10mg per day).  The addiction of millions of patients by doctors to painkillers resulted in escalation of deaths but doctors were not putting two and two together, believing that the deaths were due to only drug addicts taking more than prescribed.  It did not dawn on doctors that they had created the addicts in the first place that required continuously escalating dosages, and if they could not get this, they faked injuries or illnesses in order to get other doctors to prescribe even more opioids.  Until late in the decade ending in 2010, most states did not have prescription monitoring programs to keep patients from filling scripts from several doctors at multiple pharmacies.  Most doctors did not do urine drug screens, instead believing the patients when they said they were compliant with the opioid usage.  Doctors created the addiction yet were naive about the behavior of addicts, continuing to supply them with ever escalating dosages of drugs, some over 1000mg morphine equivalents per day. Until the death toll in states became high enough, doctors had no constraints on prescribing opioids, since medical boards were rarely taking action against well meaning (but naive) doctors.  Finally a wave of regulations by the states, federal government, state medical boards, and actions by the county governments and prosecutors, and action by the states attorney generals finally stopped the escalation of amount of opioid being prescribed with 2014 being the first time the opioid prescribing levels dropped, although the death toll in 2014 was higher than in 2013.  It is expected eventually the number of deaths from prescription painkillers will begin to decrease as doctors are jailed or lose their medical license for inappropriate prescribing of these medications.  However, the addicted population of millions turns to heroin instead, or freely interchanges heroin and prescription opioids.  Fully 80% of those using heroin begain by using prescription opioids.