Opioidology: An Unbiased View of Our Opioid Crisis for Clinicians

It was 2017, and I stood in the parking lot of our wild and wonderful state capital’s morgue during a CDC grant team visit while setting my eyes on one of the most horrific opioid crisis scenes that I’ll never get out of my head as extra refrigerated containers stood to accommodate the extra bodies from lives lost to drug overdoses.

An American dies every 7 minutes from a drug overdose (and countless nonfatal overdoses), every 4 minutes from an alcohol-related death, and every minute from a nicotine-related death.¹

Let all that percolate for a moment before reading onward.

The Story of Opioidology

I’m a glass-half-full type of guy, so that’s not a doom-and-gloom statement but rather the stark reality at the time. Then again, when a forest is decimated by fire, the regrowth can be astounding. Some of the clinical best practices and guidelines utilized around the world have their roots right here in Appalachia, such as the West Virginia Safe and Effective Management of Pain (SEMP) Guidelines.²

I typically refer to “Our Opioid Story” as opioidology, or the study of it all. Legal prescription medications. Illegal drugs. All of it. Especially the lost heartbeats and countless other touches to peoples’ lives. The first wave of our opioid crisis was driven by opioid misuse and diversion stemming from multiple factors such as pain scores (the infamous fifth vital sign) and pill mills providing oxycodone (OxyContin) and other controlled substances (while netting egregious sums of cash), among many other factors.

The second wave was dominated by illegal heroin, perpetuating the third wave of illegal fentanyl and its analogs (not the same fentanyl products utilized in every hospital). Unfortunately, there have always been drug overdose deaths, leading one to consider that there may always be drug overdose deaths. One must appreciate the health care vs illicit supply chains independently and with any potential overlap (diversion).

Looking more granularly into this opioid story, one of the fundamental shifts in the pain management realm was from opioidphobia (until around 1996) to opioidphilia (beginning of the 21st century) and back to opioidphobia (the last decade or so), as observed in our current landscape of decreased realistic access to prescription opioids for one reason or another.

The 1980s saw about 60 million opioid prescriptions in the US, which greatly increased around the turn of the century to peak at about 260 million opioid prescriptions in 2012, which by most recently available metrics has subsided to about 125 million opioid prescriptions in 2023 (Figure 1).³ Clinicians cannot return to peak opioid prescribing and dispensing habits, yet the question remains as to if clinicians should return to trough opioid prescribing/dispensing habits.

Opioid Use for Pain

As for pain, ouch! Most would agree that 8-out-of-10 pain is generally classified as “severe,” even though many would debate what would be an “8,” typically ripe for treatment with a prescription opioid (depending on the scenario, of course). Yet how easily and often are they offered today? As a follow-up to my time machine opening of this article, join me in recalling a personal experience at an urgent care clinic (for pesky poison ivy) and noticing a sign on the wall above the weigh-in scale: “No pain medications are prescribed in this clinic.” Not that folks with appreciable acute pain would head to an urgent care clinic, though, right?

Conversely, illegal pill mills aren’t exactly great for society, so every man, woman, and child doesn’t need a prescription opioid for a papercut either. In other words, pain sucks, and we need to address it safely and effectively, having our cake and eating it too, or that acute pain may amplify to centralized chronic pain haunting an individual for much, much longer. The secret sauce is in the details, though. The best practices in pain management are deployed to consistently provide patients safe, effective, and diverse pain management treatment plans.

Best Practices of Pain Management

Regardless of the Omnibus Budget Reconciliation Act of 1990⁴ or the federally mandated legal responsibilities placed on both prescribers and dispensers to ensure an appropriate diagnosis and scope of practice,⁵ one might reasonably ask whether the professional expectation should also include proactively offering patient counseling. This is not the infamous “Please sign here” nor even the “Do you have any questions?” scenario, but rather a “Provide information, then questions will prosper” situation. Building on this concept, opioid best practices span much further than patient counseling and can be organized into 3 broad categories: patient education, treatment selection, and adherence and diversion monitoring.

Clinicians should remind patients to store all medications, certainly not just controlled substances, in lockable safe boxes away from others and certainly away from the humidity and temperature fluctuations commonly found in bathrooms. Otherwise, children and pets may attain access, and if singling out locking up one’s oxycodone but not the lisinopril, there’s no more direct manner of educating someone as to the street value of the opioid.

Regarding medication disposal, the US Environmental Protection Agency recommends Drug Enforcement Administration drug take-back events or removing identifying information and mixing medications with undesirable substances before disposal while advising against flushing medications down the toilet.⁶ Conversely, the FDA generally agrees but also maintains a list of approximately 4 dozen controlled substances recommended for flushing.^7,8 One would hope for consistency among these federal-level recommendations; however, pharmacies can also register as authorized sites for controlled substance disposal.⁹

Treatment selection typically begins with establishing a diagnosis, which can be especially complicated in pain management. The Department of Defense and Veterans Pain Rating Scale (DVPRS) combines many of the best elements of traditional pain scales, including color coding, emotional faces, and numerical ratings.¹⁰ Notably, it incorporates 4 powerful questions assessing a patient’s activity, sleep, mood, and stress. Clinicians may not always be able to change a patient’s pain number, but improving even one of these functional domains represents a meaningful SMART goal.

As for mental health screenings, the succinct PHQ-2 asks 2 questions regarding the frequency of having little interest or pleasure in doing things and feeling down, depressed, or hopeless. If the PHQ-2 identifies risk, clinicians can administer the PHQ-9 to further evaluate whether referral to a mental health professional is warranted.¹¹ Additionally, opioid risk screening tools should be utilized for all patients being considered for or already receiving opioid therapy. Numerous validated tools are readily available, which are distinguished in 2 manners, including whether they are being conducted by a health care professional or the patient themselves and whether the patient is opioid-experienced or opioid-naïve.¹²

With respect to drug interaction screenings, let’s discuss the infamous opioid and benzodiazepine interaction. If someone has both a pulse and a health care professional license, they understand that combining opioids and benzodiazepines carries inherent risks of sedation and respiratory depression. The challenge arises when inheriting a patient already receiving both medications, as action is necessary regardless of how long the combination has been in place. When tapering is agreed upon, it should generally occur gradually unless immediate safety concerns exist. Rapid opioid tapers can produce serious negative consequences, and rapid benzodiazepine tapers may result in fatal seizures. Action is necessary, but clinicians should “start low and go slow,” ideally with collaboration among multiple health care professionals.

All patients and caregivers—if not all of society—need education regarding opioid antagonist administration. Opioid mu antagonists used in overdose situations include nalmefene and naloxone, available in both injectable and intranasal formulations. Nalmefene demonstrates a longer half-life and stronger mu receptor affinity than naloxone, which may represent either advantages or limitations depending on the clinical scenario. However, most opioid antagonist products currently available are naloxone formulations distributed through prescriptions, OTC availability, or harm reduction programs. Perhaps every pharmacist who directly and immediately saved someone’s life by administering naloxone or indirectly educating someone on how to do so should have their name engraved somewhere on our National Mall—near the American Pharmacists Association headquarters—like so many other heroes. Regardless, tomorrow the sun will rise, and another pharmacist will save yet another life; it’s what we do.

Drug Monitoring

Urine drug monitoring, an umbrella term encompassing both urine drug screening and urine drug testing, remains an important tool for monitoring medication adherence and detecting illicit substance use. Urine drug screenings are generally lower-cost, qualitative examinations often referred to as presumptive testing. Urine drug tests are higher-cost, quantitative examinations commonly referred to as confirmatory testing.

Prescription drug monitoring programs are valuable tools for monitoring medication adherence and reducing drug diversion, though they are not a panacea for preventing substance misuse or diversion. Health care professionals continually encounter situations requiring balance between diversion prevention and ensuring appropriate patient care. The National Opioid Settlement documents some of the most granular “controlled substance red flags” to date while clearly stating that the presence of a red flag alone does not automatically justify refusing to dispense a medication. Rather, red flags should be appropriately mitigated and documented regardless of whether dispensing ultimately occurs.¹³

Conclusion

It is vitally important to recognize that some patients in recovery also experience chronic pain and eventually or unfortunately will experience acute pain, and that pain frequently requires treatment beyond the medications for opioid use disorder already being utilized. If one bucket of water sufficiently waters a small garden, that same bucket may no longer suffice once the garden grows larger. It is that simple; don’t overcomplicate things. From there come the pharmacologic considerations, including increasing buprenorphine dosages or adding lipophilic opioids such as hydromorphone or fentanyl when clinically appropriate.

There remains a tremendous amount of work ahead, not just for health care professionals but rather society. Yet, when reading this article as a health care professional, especially as a pharmacist, this is our call to action to save and improve lives within our “opioid story” to stop the perpetuation of unpleasant and tragic endings and rather to ensure impact for more positive outcomes. The story may never end, nor should the audience.

REFERENCES

1. NIDA. Drug Overdose Deaths: Facts and Figures. National Institute on Drug Abuse website. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates. August 21, 2024 Accessed May 8, 2026.

2. SEMP. Accessed May 11, 2026. www.sempguidelines.org.

3. Pain Guy Podcast. Accessed May 11, 2026. https://painguy.us/pod

4. Omnibus Budget Reconciliation Act of 1990. S.3209. (1990).

5. Title 21. § 1306.04 Purpose of issue of prescription. Available at: https://www.ecfr.gov/current/title-21/chapter-II/part-1306/subject-group-ECFR1eb5bb3a23fddd0/section-1306.04 Accessed August 2023.

6. EPA. Household Medication Disposal. Accessed May 11, 2026. https://www.epa.gov/hwgenerators/collecting-and-disposing-unwanted-medicines

7. FDA. Where and How to Dispose of Unused Medicines. Updated April 16, 2025. Accessed May 11, 2026. https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm#steps

8. FDA. Safe Disposal of Medicines. Updated October 31, 2024. Accessed May 11, 2026. https://www.fda.gov/drugs/buying-using-medicine-safely/safe-disposal-medicines

9. DEA Diversion Control Division. Accessed May 11, 2026. https://www.deadiversion.usdoj.gov/

10. Defense and Veterans Pain Rating Scale. Accessed May 11, 2026. https://www.va.gov/PAINMANAGEMENT/docs/DVPRS_2slides_and_references.pdf

11, PHQ-9 (Patient Health Questionnaire-9). Accessed May 11, 2026. https://www.mdcalc.com/phq-9-patient-health-questionnaire-9

12. Garofoli M. What types of risk screening tests are available to clinicians prescribing opioid therapy?. Pract Pain Manag. 2018;18(8).

13. National Opioid Settlement. Accessed May 11, 2026. https://nationalopioidsettlement.com/