Reframing the Prevention Strategies of the Opioid Crisis: Focusing on Prescription Opioids, Fentanyl, and Heroin Epidemic
Laxmaiah Manchikanti, MD, Jaya Sanapati, MD, Ramsin M. Benyamin, MD, Sairam Atluri, MD, Alan D. Kaye, MD, PhD, and Joshua A. Hirsch, MD
The opioid epidemic has been called the most consequential preventable public health problem in the United States”. Though there is wide recognition of the role of prescription opioids in the epidemic, evidence has shown that heroin and synthetic opioids contribute to the majority of opioid overdose deaths.
This manuscript, featured in the July/August issue of Pain Physician, describes the escalation of opioid use in the United States, discussing the roles played by drug manufacturers and distributors, liberalization by the DEA, the Food and Drug Administration (FDA), licensure boards and legislatures, poor science, and misuse of evidence-based medicine.
Data on opioid overdose deaths shows
- 42,000 deaths in 2016
- synthetic opioids other than methadone were responsible for over 20,000
- heroin for over 15,000
- natural and semi-synthetic opioids responsible for over 14,000
- Fentanyl deaths increased 520% from 2009 to 2016
- Heroin deaths increased 533% from 2000 to 2016
- Prescription opioid deaths increased by 18% overall between 2009 and 2016.
The Drug Enforcement Administration (DEA) mandated reductions in opioid production by 25% in 2017 and 20% in 2018. The number of prescriptions for opioids declined significantly from 252 million in 2013 to 196 million in 2017.
This manuscript describes a 3-tier approach presented to Congress.
- Tier 1 includes an aggressive education campaign geared toward the public, physicians, and patients.
- Tier 2 includes facilitation of easier access to non-opioid techniques and the establishment of a National All Schedules Prescription Electronic Reporting Act (NASPER).
- Tier 3 focuses on making buprenorphine more available for chronic pain management as well as for medication-assisted treatment.
Implementing this legislative and clinical framework requires a broader understanding of the socioeconomic vulnerabilities that often precede substance use disorders. The authors emphasize that the opioid epidemic operates symbiotically with other behavioral health crises, meaning that prevention strategies cannot focus solely on pharmacy dispensing logs. Recognizing the holistic environment of the patient is essential for the proposed education campaigns to resonate effectively across different demographic groups.
To support Tier 1’s aggressive education initiatives, public health officials are increasingly relying on advanced surveillance dashboards to map community-level distress. These predictive models analyze a wide spectrum of socio-behavioral indicators to anticipate where the next wave of illicit fentanyl or heroin use might emerge. By identifying specific markers of psychological and financial vulnerability, outreach can be deployed preemptively rather than reactively.
This expanded tracking framework incorporates alternative digital and economic signals into traditional epidemiological models. Researchers now routinely cross-reference regional prescription volumes with localized behavioral metrics, ranging from surges in short-term loan applications to active user traffic on betting websites, which often function as early indicators of overlapping addiction or financial desperation. Integrating these varied datasets allows state health departments to allocate their limited intervention resources with much higher precision.
Once these high-risk communities are accurately mapped, the structural reforms outlined in Tier 2 must be actualized to provide viable alternatives to opioid therapy. Facilitating easier access to non-opioid pain management techniques, such as physical therapy, interventional procedures, and cognitive behavioral therapy, reduces the initial exposure rate. Simultaneously, the robust implementation of NASPER ensures that clinical providers have immediate, interstate data regarding a patient’s controlled substance history.
Ultimately, the comprehensive strategy culminates in Tier 3’s mandate to reform medication-assisted treatment protocols. By making buprenorphine more accessible for both chronic pain management and addiction recovery, the medical community can bridge the gap between initial dependence and sustainable rehabilitation. Reframing the prevention narrative around these interconnected tiers provides a scientifically grounded pathway out of the current public health emergency.
Click Here to read the Article in Pain Physician Journal 2018: 21:309-326