Q&A: Fentanyl, Opiophobia Concurrently Contribute to Ongoing Opioid Crisis

Despite many reported improvements and a national focus to curb the US opioid crisis, the epidemic is still ongoing, fueled by illicit fentanyl and community-wide stigmas regarding opioid use circulating across the country.

“An international panel of pain specialists including physicians and health policy scholars met to discuss the impact of fear of opioids on the clinical use of these strong analgesics,” wrote authors of study data published in the Journal of Pain & Palliative Care Pharmacotherapy.¹ “Recognizing potential risk from opioids, the panel members concluded that irrational fear of the drugs often impedes their appropriate use. The need for education among clinicians was recognized, and the panel concluded that while progress has been made, much remains to be done to correct unfounded fears and misconceptions that impede provision of opioid analgesia when it is indicated.”

This phenomenon of providers or patients fearing the use of opioids is known as opiophobia. According to pain management expert Mark Garofoli, PharmD, BCGP, CPE, CTTS, clinical associate professor at West Virginia University School of Pharmacy, opiophobia is a key driver in the persistent opioid epidemic today.

Garofoli recently joined Drug Topics to explore current issues stemming from the opioid epidemic. With his expertise on pain medications, as well as his residency in West Virginia, known as ground zero of the opioid crisis,² Garofoli described how opiophobia and fentanyl are contributing to the crisis despite significant efforts from a variety of stakeholders in the health care sector.

Hear from a pharmacist who has seen the impacts of the opioid crisis in real-time, from Mexico’s role in allowing fentanyl to enter the US³ to US health care providers' sentiments on the issue.

READ MORE: Patient-Centered Care Balances Pain and Addiction Concerns

Drug Topics: From a pain management expert's viewpoint, what is the most crucial difference between the current, fentanyl-driven wave of the crisis and the earlier phases across the country?

Mark Garofoli, PharmD, BCGP, CPE, CTTS: The first wave of our opioid crisis was driven by opioid misuse and diversion, which fueled the second wave dominated by illegal heroin, perpetuating the third wave of illegal fentanyl and its analogues. Of note, fentanyl is still utilized in just about every hospital on this planet in emergency, nonelective, and elective surgeries every single minute of every day.

But that’s the legal version, not what is haphazardly synthesized in illegal labs. Concurrently, one of the fundamental shifts in the pain management realm was from opiophilia to opiophobia, leading to our current landscape of decreased realistic access to prescription opioids for one reason or another.

Drug Topics: What national strategies have proved most effective against the overall opioid crisis, and how have those strategies evolved up until now?

Garofoli: I often hear, “We’re not going to arrest ourselves out of this,” or “Enough fentanyl [has been] seized to kill every American.” Although those efforts must certainly continue, they are not a panacea. After all, cartels are logistics experts, not medicinal experts. When kilos of fentanyl are seized by the authorities, the dose may be enough to kill every American, yet every American does not have access to that specific drug supply. Rather, [the fentanyl] would need to be transported to them.

Our most recent US "drug czar,” Rahul Gupta, MD, MPH, FACP, MBA, came from West Virginia and deployed a calculated data-driven approach to the “war on drugs” unlike any other, yielding actual results. Those results involved saved lives [and] an avoidance of lost heartbeats. West Virginia, “ground zero” [of the opioid epidemic], could be portrayed as the best of times, and the worst of times, depending on the timeline. We recently saw the largest percentage drop in lives lost to drug overdoses ever, a trend that absolutely needs to continue.

READ MORE: Pain Management Resource Center

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REFERENCES

1. Bennett DS, Carr DB. Opiophobia as a barrier to the treatment of pain. J Pain Palliat Care Pharmacother. 2002;16(1):105-109.

2. Mullins C. A public health emergency: West Virginia’s efforts to curb the opioid crisis. West Virginia Department of Health and Human Resources. January 14, 2020. Accessed November 7, 2025. https://www.congress.gov/116/meeting/house/110367/witnesses/HHRG-116-IF02-Wstate-MullinsC-20200114.pdf

3. Seelke CR, Senger SB. Illicit fentanyl and Mexico’s role. Library of Congress. August 26, 2025. Accessed November 7, 2025. https://www.congress.gov/crs-product/IF10400