Last week I introduced you all to a friend of mine whose son has been struggling with heroin addiction for 12 years. It began with a car crash that caused traumatic brain injury. He began using heroin after taking opioid pain relievers as directed by his physicians. His story is not atypical as 79 percent of heroin users first abused opioid pain relievers.
The discussion that followed in the comments brought to the surface the other stakeholders that must be included in any discussion of opioid analgesics—the patients to whom the drugs were sold in the first place. Before the widespread use of opioid analgesics, patients with chronic pain were treated with non-opioid medications and various other therapies dependent upon the cause of the pain. Sadly, these treatments did not always provide the relief that patients needed and, frankly, deserved, so the introduction of an opioid analgesic that was marketed in the early 1990s as safe and less addictive than prior versions was a boon to them. As well as for the doctors who had struggled unsuccessfully to alleviate their pain.
In case you missed this diary, by CathyM, that was in the Community Spotlight earlier this year, you might want to give it a read to get some idea of what hoops our modern medical practice puts patients through when they seek pain relief. And this diary that CathyM wrote for the KosAbility Group is also worth the few moments of your time that it would take to read. Go ahead, I’ll wait.
Between 2000 and 2014, deaths from automobile accidents decreased, from 41,945 to 32,675 according to the National Highway Traffic Safety Administration (NHTSA). Deaths from firearms have increased over the same time span, from 28,663 in 2000 to 33,599 in 2014. But deaths from overdoses of prescribed drugs, opioid analgesics and heroin have skyrocketed.
In 2014, 47,055 people died from drug poisoning, according to the Centers for Disease Control and Prevention (CDC). Unintentional overdoses account for the majority of those deaths, 82 percent. Suicides were 12 percent and the rest were of undetermined intent. Of those 47,055 deaths, the deaths of 18,893 people involved opioid analgesics and most of those (65 percent) were due to opioid analgesics such as hydrocodone, morphine, and oxycodone. Opioid analgesics and heroin combined to make up over 60 percent of all drug-poisoning deaths in 2014.
As disturbing as that is, more disturbing is the rate of increase between 2000 and 2014. Heroin death rates have increased by 439 percent. Opioid analgesic death rates have gone up by 369 percent. Below is what a chart, showing what it would look like if the increase in gun deaths were growing as fast as deaths from opioid analgesics and heroin.
If gun deaths had climbed as quickly as deaths from the misuse of opioids, there would have been 122,964 deaths in 2014. If they grew at the same pace that deaths from heroin are growing, there would have been 154,493 deaths from firearms in 2014. The trend is similar to that of the HIV epidemic of the late 1980s and early 90s.
A recent Drug Enforcement Agency (DEA) report revealed that more than half of non-medical users of opioids obtained them from family members or friends for free. An additional 14.6 percent either bought them or took them from a friend or relative. Most of the friends and relatives got their supply from a single doctor.
I would think it unlikely that anyone suffering from moderate to severe chronic pain would willingly give up the only medicine that helps them survive so that a friend or a relative could get high. Which leaves, as a source, those patients who are prescribed unnecessary opioids. And whose actions make the lives of those in chronic pain, who desperately need the relief provided by opioids, that much more difficult.
Not all who use opioid analgesics will develop a dependency, but the rate of those who do is also skyrocketing. According to CNN, a recent study by FAIR Health revealed a 3,000 percent increase in medical services for privately insured patients diagnosed with opioid dependency.
The researchers used de-identified claims data from insurers representing 150 million patients, looking for diagnosis codes related to opioid dependency and abuse, adverse effects of heroin use, and problems caused by the misuse or abuse of other types of opiates.
...
The report found that the number of such services rendered to patients with a dependency diagnosis went from about 217,000 in 2007 to about 7 million in 2014.
In reviewing the report, it pays to keep in mind that the data are based on insurance claims for medical services, and not the actual services themselves. Medical service providers do not always accurately code services, and the higher profile that the epidemic has gained over the past couple of years could have increased the use of those claim codes to some extent. The report itself clarifies its use of the terms opioid dependence and opioid abuse:
In the period 2007-2014, opioid dependence rose by 3,203 percent (figure 1). Opioid abuse rose less sharply, by 317 percent. The two diagnoses are distinguishable according to DSM-IV criteria, with dependence considered the more severe condition.11 Dependence is characterized by such symptoms as tolerance (needing larger amounts to produce the same effect), withdrawal and repeated unsuccessful attempts to quit, whereas abuse is identified by such symptoms as continued use despite recurrent social problems caused or exacerbated by the substance. More recently, the DSM-5 has combined the categories of substance abuse and dependence into substance use disorder, measured on a continuum from mild to severe.12
Also on the increase is the number of babies born with neonatal abstinence syndrome (NAS), an illness that most often results from exposure to opioids in the womb. A report from the CDC shows an increase in the incidence of NAS of 383 percent between 2000 and 2012. The long-term effects are unknown, but the symptoms at birth include central nervous system problems, such as high-pitched crying, tremors and convulsions, gastrointestinal issues, and fevers. Symptoms can last up to five days and, if they require morphine or methadone, an additional period of three weeks will be needed to wean them off the drugs.
During the 1980s and the early ‘90s I suffered from chronic migraines. The visual auras would give me enough time to hope that the Cafergot (a nasty combination of ergotamine and caffeine) would work. Usually it didn’t. And when it did not stop the migraine, it made the symptoms worse, especially the nausea.
If it got bad enough, and if I was able to go to the emergency room, I would be given a shot of Demerol which would put me to sleep for 24 hours and guarantee a rebound headache the next day. I spent half my life in a quiet, dark room trying very hard not to throw up. Doctors refused to prescribe narcotic pain relievers in that era, at least Navy doctors refused, with one exception. On Christmas Eve, a senior emergency room doctor was on duty and he gave me a prescription for Fiorinal (aspirin, caffeine and codeine) to take after the Demerol wore off.
And then triptans came along and saved my life. The first one was Imitrex and was available only via an injection. They had a kit that a patient could use at home, and for the first time I thought I might be able to have a normal life. Eventually it came out in pill form which took a little longer to act, but was just as effective for me.
The Department of Defense soon decided that Imitrex was too expensive and so they started to restrict the dosage and the number of refills that were allowed. I remember the panic and then the anger that they would consider my pain to be of so little importance in their decision to restrict my access to the drug. Eventually, other manufacturers began producing triptans, the price went down and my access was restored.
Triptans aren’t subject to abuse, so I have never had to deal with the same barriers that pain patients do today, but I can relate to the concern that they must experience every time more negative information comes out about the drugs they need to function on a daily basis.
In March, the CDC issued new guidelines that are designed to provide help for primary care physicians in using opioid analgesics to treat chronic pain. As CathyM explains in KosAbility: Pain, the mind and the medical system:
the CDC admits that there are zero studies done4 on the long-term benefits of opioid pain medicine for chronic pain. None. Zero. [This is recently been confirmed to me by a doctor who specializes in pain, who says “the studies you’re looking for have not yet received funding.”] And yet they have created guidelines for long-term treatment of chronic pain that state there is no significantly increased benefit of opioids versus over-the-counter drugs like ibuprofen and Tylenol. There are half a dozen studies about the side effects of long-term opioid treatment of chronic pain (do you sense a bias?), but they admit that the quality of those studies is “low”. And now these guidelines are being put in place as rules by many state and corporate medical systems. How is this supposed to give us confidence in our medical treatment??
In July, President Obama signed the Comprehensive Addiction and Recovery Act of 2016. The act, known as CARA, was passed on a bipartisan basis, and expands the availability of naxolone to counteract opioid overdoses, improves prescription drug-monitoring programs to prevent doctor shopping, shifts resources toward treating incarcerated addicts, and prohibits the Department of Education from asking an applicant about past convictions for possession or sale of illegal drugs on its financial aid form. Although President Obama requested more than a billion dollars for the effort, the bill only provides $181 million.
“The bill is an important step forward but much remains on the table to address other factors,” said Beth Darnall, PhD, clinical associate professor in the Division of Pain Medicine at Stanford University and author of The Opioid-Free Pain Relief Kit and Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control Over Chronic Pain. “The bill addresses the end-stage of opioid misuse. To fully reduce opioid overprescribing it is critical to develop strategies that provide early treatment and preventive strategies focused on the main reason opioids are prescribed: pain.”