Drug overdoses are now one of the leading causes of injury death in the United States.
Opioid analgesics are highly addictive because they reduce pain, but they also change the chemical coding within the human brain. Over a period of time of taking an opioid, the brain stops releasing dopamine and/or endorphins, so patients then feel a need to continue to take these prescriptions just to feel normal. This is known as an opioid dependency, which can lead to addiction if not handled carefully.
This opioid epidemic began in the 1990’s when pharmaceutical companies “reassured” the medical community that patients would not become addicted to the opioid pain relievers they provided. Due to this notion, healthcare providers began to prescribe opioid prescriptions at a higher rate than before. This caused the opioid epidemic to rise quickly in the early 2000’s, and the number of deaths due to overdose only increase more and more each year. In 2018, there were an estimated of 68,557 drug overdose deaths. Of the 68,557 drug overdoses, an estimated 47,590 deaths involved opioids and 31, 897 involved synthetic opioids. These staggering numbers are only seen in the United States today. While other countries may deal with their own opioid epidemic, the United States is the only country to not have figured out an effective solution. Especially when compared to Portugal, who used to have the highest rate of opioid deaths in Western Europe, but now they have the lowest rate in the world. Their opioid death rate is 1/50th of America. Although the United States is far behind other countries in this issue, there has been recent movements in attempting to find a solution and to stop the stigma of addiction.
On October 9, 2019, Sesame street aired an episode with a new character, Karli, who is in foster care, because their mother was in recovery from being an opioid addict. Sesame street wanted to spread awareness about the epidemic, stop stigmas with opioid addiction, and to also provide support and comfort to children who are going through similar situations. In addition to this, there was “The Comprehensive Addiction and Recovery Act” (CARA) set in place in 2016, which primarily targeted teens, parents, and other caretakers, and aging populations to help prevent the abuse of analgesics and illicit opioids, in addition to promoting treatment and recovery for patients. And while this act covers a wide demographic, the common demographic for opioid abuse and overdoses are primarily men through the ages of 25 and 44 and are usually seen in micropolitan and fringe rural areas. The highest rates of death fell mostly on the eastern side of the United States in New Hampshire, West Virginia, Massachusetts, and Ohio. And while the majority of people pin the blame of opioid addiction on unscrupulous physicians, the real cause of opioid addiction is due to pharmaceutical companies providing misinformation to physicians, stigmas around addiction due to ignorance, and the difficulty to obtaining a prescription for patients who are in a serious need of one.
Mark Edmund Rose, the author of the article ‘Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts’, is a licensed psychologist and has also specialized in medical and bio-behavioral communications on a global level. His intended audience through this article is medical professionals who are either entering the field or those who have already been in the field. His purpose is to inform about the assumptions that are not true and provide what should be known instead.
Interestingly enough, the United States consumes 80% of the world’s opioid supply. While this is a severely high percentage, opioids still remain the most effective drug class for controlling severe pain, although they carry potential for adverse effects, misuse, and overdose. As mentioned in the previous article too, the overwhelming opioid death rate began to come into light in the early 2000’s, thus did widespread reactions in change of perceptions to prescriptions of opioid analgesics. And while the use of these prescriptions is broadly accepted in use for acute pain, cancer pain, and palliative/end-of-life care, there is a lot of controversy with prescription opioids being used to treat chronic noncancer pain, which turned into a polarized debate. Due to this, the Centers for Disease Control and Prevention (CDC) and media worked together to publish several reports focused on overuse of opioids for pain and related overdoses. They described analgesic opioids as, “an out of control hazard”. And they failed to note the plight of patients who were dealing with chronic pain and sought relief, and the sociomedical barriers to accessing pain control. This caused an increase in hardships for patients with chronic pain as there was a misperceived correlation between the patients and the rising numbers of deaths that were attributable to opioids. The CDC took advantage of this and set out on a one-sided informational propaganda on how opioid analgesic prescribing fueled the epidemic America was facing. These false portrayals promoted stigma and misperceptions of opioid analgesics in health care and lay populations, which caused far-reaching consequences. The CDC leadership even further publicized statements such as, “prescription opioids… are no less addictive that heroin”, have also amped up the stigmas around a medication that is a lifeline to people. Eventually, actions by the Drug Enforcement Administration (DEA), CDC, and media sensationalism intensified the barriers to appropriate access to opioid analgesics to patients with chronic pain. Due to this, there was multiple reports from 2012 to 2015 in the states: Georgia, Indiana, Massachusetts, Montana, Nevada, and Texas, who reported of an increase in physicians refusing to issue opioids prescriptions, patients facing withdrawal form their stable opioid regimens (regardless of their pain control), and even extending to patients with terminal illnesses and cancer pains and acute post-surgical pains. This action continued into pharmacies refusing to refill prescriptions for these patients and instead called them, “drug-seeking addicts” in front of other customers to witness. Patients felt criminalized by these hostile interactions and being unable to obtain their prescription medication, patients who were previously stable on their opioid regimens were forced into opioid withdrawal. These patients, desperate to ease the pains of their opioid withdrawal were forced to locate a pharmacy willing to fill their prescription, or later known as the “pharmacy crawl”. Due to this, there was an increase of these patients who had repeated emergency department visits in attempts to ease their pains, or, for some, suicide.
To further enhance the severity of the situation, in addition to the stigmas and misconceptions of analgesic opioids increasing and causing damage to these patients, in 2014 the DEA rescheduled hydrocodone from CS III to CS II, which adversely affected patients with chronic pain who had previously benefited from this agent. As a result, these patients had their prescribed hydrocodone replaced by less effective analgesic opioids, and there was an increase of negative pharmacy interactions when filling a hydrocodone order. Henceforth, some patients began to turn to marijuana or borrow pain medications for pain management after the loss of hydrocodone access. Many patients missed work from the bans on refills and some experienced such severe pain that they experienced suicidal ideation.
Also, within the article the author mentions on how some experts in pain medicine commented that the 2016 CDC opioid prescribing guideline makes access to pain control, including opioid analgesic, increasingly difficult if not virtually for impossible for patients with pain to obtain. It continues on how a pioneer in pain research “observed that prolonged uncontrolled pain can destroy the quality of life, the will to live, and drive some patients to suicide, adverse psychological (impaired cognitive function, pathologic anxiety/depression, suicidal ideation, despair, hopelessness) and social/interpersonal (relationship disruption, loss of employment/financial ruin) outcomes”. In addition to this, the author included a breakdown of each symptom and how severe the consequences can be. For example, neurotoxicity is a chronic under controlled pain that is commonly associated with peripheral and the central nervous system (CNS). The effects of neurotoxicity include neuroinflammation, tissue destruction, and loss of CNS tissue mass and receptors, with resultant loss of opioid and other analgesic responses. Due to the loss of opioid and other analgesic responses, if a patient were able to obtain opioids, they would need a high dose to attain a modest analgesic response. The negative impact of chronic pain leads to a degraded quality of life is seen to be more severe than heart failure, renal failure, or major depression. It is even comparable with the quality of life of patients dying of cancer.
Furthermore, the negative attitudes of primary care and other clinicians towards patients with chronic pain who use illicit substances or misuse prescribed drugs are presumed to be for hedonistic pursuit. Yet the reality is more complex and these patients use these substances to alleviate poor controlled pain. This was the conclusion of a study that consisted of 600 adult primary care clinic patients who tested positive for illicit or nonprescribed prescription drugs. “Of these patients, 87% reported chronic pain (13% mild, 24% moderate, 50% severe); 74% reported impairment from pain (15% mild, 23% moderate, 36% severe); 51% of 576 patients who used illicit drugs (marijuana, heroin) did so to treat pain; 81% of 121 patients who misused prescription drugs did so to self-medicate pain; and 38% of 265 patients who reported past-three-month heavy drinking did so to control pain, as did 79% of 57 high-risk alcohol user”. As about on third of the study patients reported both severe pain and disabling impairment, it is also suggested that significant pain is a very prevalent factor in these patients with positive drug screenings. Although the sample size of this study is not very large, it still provides a very prominent fact that many opioid addicts are not indulging in such activities for hedonistic pursuit, but to manage their poorly controlled pain.
Equally, within the article the author notes how there was a miscorrelation between overall opioid prescribing and prescription opioid analgesic overdoses from the CDC. Often overlooked, beginning in 2012 through early 2017, the overall opioid prescribing rate was seen to have a multiyear decline. For example, Oxycodone was shown to have a steady decrease in prescribing, including a 39% decrease in a health plan that consisted of 31 million adult members from late 2009 to late 2012. In addition to this decrease in oxycodone prescriptions, nationwide data showed decreases in: 48% decrease in national poison center surveillance system mentions, 32% decrease in mentions in a national drug treatment system, 27% decrease in prescribing through the use of a claims database, a 50% decrease in doctor shopping, and there was a reported 65% decrease in fatal overdoses reported to the manufacturer. In correlation to this data, there is also a notable decrease in total oxycodone prescriptions decreased 29.7% from 2007 to 2011, which is an estimated of 8 million. In a parallel trend, there was a 28% in methadone prescriptions from 2010 to 2015. By the same token, the overall total of opioid analgesic prescriptions decreased by 4.5% from 2011 to 2014.
Despite these decreases in prescriptions, the CDC Injury Center’s data saying otherwise. The data they provided showed that there was still an increase in prescription opioid analgesic overdoses. During an FDA Advisory workshop in May 2016, there were questions directed at the CDC on how to interpret the multiyear decline in opioid analgesic prescribing, despite the CDC data saying otherwise. It was soon discovered that CDC’s data was a mix of fentanyl overdoses (of illicit origin) and prescription opioid analgesic overdoses recorded together in the early 2014. In response to this, in March 2016, a CDC Injury webpage stated that, “toxicology cannot distinguish illicit from diverted pharmaceutical fentanyl,” yet they also admitted that the 2014 spike in opioid analgesic overdoses were primarily driven by fentanyl, almost entirely illicit in origin. After this revision, only 14,000 of 47,055 opioid overdoses involved a prescription opioid analgesic.