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Confessions of an American Opium-Prescriber

Thousands of Americans have died from opioid overdoses after receiving medical treatment for pain or addiction. However, new clinical dilemmas often confront prescribers who try to protect patients through reducing doses or substituting safer medicines.

The title of this article originates in the 1821 drug memoir of Thomas De Quincey, who at age nineteen (in 1804) became addicted to Laudanum, a preparation of opium dissolved in alcohol prescribed for rheumatic pain. In his Confessions of an English Opium-Eater, he wrote, “Oh, heavens! what a revulsion! what an upheaving, from its lowest depths, of inner spirit! what an apocalypse of the world within me!” (33). Although De Quincey began his opium habit to relieve pain, drug-induced euphoria transformed him into a recreational user. As he fell into addiction, he began to suffer cycles of intolerable intoxication and physical misery, particularly stomach agony.

This article evaluates the current opioid overdose crisis in the United States through the eyes of a physician. This epidemic has become so severe in recent years that it has led to a decrease in average life expectancy. It has produced more annual fatalities than those attributed to suicide or homicide, to recent wars, or to epidemics involving infectious agents. In 2019, the number of opioid-related fatalities will likely reach 50,000, the same as the number of AIDS-related deaths in the peak year of that epidemic in 1995. During the past fifteen years, more than 200,000 Americans have died of opioid overdoses. About one-fifth of this group once suffered from chronic pain (and most likely addiction complications) that doctors usually treat in office settings. Statistical evidence shows that since 2012 there has been a slow but steady decline in opioid prescription, explained partly by doctors resisting the pressure of patient demands for relief of pain (CDC 2017). Psychiatrists were hopeful that this trend and the recent success of skilled intervention applied to groups of vulnerable persons signaled an end to this crisis, but the national overdose death toll has not declined during this period, probably because of large increases in heroin and fentanyl use (Madras 2017).

I must confess that my own efforts have been bedeviled by unexpected thorny limitations and complications. We physicians were not fully aware of the new problems created by broad solutions and failed to sufficiently recognize the individual vulnerabilities of unique patients. This article explores the misunderstanding.

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