Every day there is something in the media on prescription opioids. For good reason, the problem is real—overdose deaths, selling them, and addiction. It all comes from the Vicodin, Oxycontin, and Fentanyl physicians prescribe.
OxyContin tablets crushed into powder
for insufflation (snorting). Notice the
tablets at the top with the coating removed.
By 51fifty at the English language
Wikipedia, CC BY-SA 3.0
Where’d this problem come from? When I was in medical school, we never had to deal with this. Opioids simply were not prescribed for chronic pain, at least not for patients without advanced cancer. Further, I work with many physicians from countries outside the U.S., and they are as astounded as I have been by the demands of patients for opioids—and for the plentiful amounts that we U.S. physicians prescribe. This problem does not occur in their home countries, where it is more like what it was like in this country in the 1970s and 1980s. An interesting statistic is that 5% of the world population (the U.S.) consumes 75% of the world’s drugs. How did this come about?
Through an unfortunate combination of circumstances beginning in the 1990s, the first event was that pharmaceutical houses saw chronic pain as a lucrative market. They developed new narcotic medications, with oxycodone (Oxycontin) being the prototype, to replace the old standby morphine because it was generic and produced no significant income. Drug company sponsored research supposedly demonstrated benefits to patients from the new drugs. This led the companies to advise physicians, via expensive marketing efforts, that addiction and adverse effects were non-existent with the new opioids, highlighting the difference from old morphine preparations. Wrong on both counts! All later, more rigorous studies revealed no long-term benefits whatsoever—and multitudes of serious problems with misuse and addiction and side effects and overdoses.
Oxycodone 10mg, “OC”
CC0 1.0 Universal (CC0 1.0)
In parallel, a well-intentioned effort further fostered prescription opioid use. Medicine was encouraged by pain societies and others to add a “fifth vital sign”—pain. This was in addition to the four vital signs we check with every patient (temperature, pulse, respirations, blood pressure), so pain would be evaluated every time the other four were. Wholesale adoption followed which greatly magnified patients’ and the medical and nursing professions’ attention to even the slightest amount of pain. The idea was that patients should not suffer any pain. Indeed, very erudite professors have told me just that. To show how pernicious this view has become, hospitals often waken patients to see if they have pain, and, if present, request that narcotics be started or increased. One of the commonest calls our residents get at night is to increase patients’ narcotics doses because they’re in pain and can’t sleep.
Neither cause of the opioid epidemic has moderated. Pharmaceutical houses continue to promote ever-evolving, newer and newer narcotic preparations—all addictive, many even more potent— and the medical/nursing professions continue hell-bent to prevent all suffering, notwithstanding that they actually are causing suffering by their liberal prescription policies.
Now let’s be specific about the downside. From august groups like the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies and the National Survey on Drug Use and Health, we learn the magnitude of the problem that resulted. More than one-third of the entire U.S. adult population in 2015 reported use of a prescription opioid. While some people who use opioids don’t misuse them, greater than 11 million U.S. citizens do each year. Misuse means use for purposes other than prescribed, such as for recreation (get “high”), to satisfy an addiction, to give to someone else, or even to sell (they are worth a lot on the street). All told, at some point in their lives, 52 million adults have used prescription drugs for non-medical reasons; most of these drugs are opioids but tranquilizers (benzodiazepines) and stimulants (amphetamines) are misused as well.
Here’s the real kicker: there are approximately 18,000 (all unnecessary) deaths yearly from prescription opioid overdoses. Especially worrisome, about one-half of teenagers believe that prescription drugs are safer than street drugs. Still worse, over half of prescription drug users get them free from a friend or relative. It is no surprise, then, that something like one-fourth to one-third of patients taking opioids for at least 6 months misuse them—as their physicians continue to refill their prescriptions.
So how can we address this problem? Physicians, who many now consider the country’s biggest drug dealers, prescribe them for no good reason. But, don’t blame them. Patients apply lots of pressure. It’s not the patients fault either, physicians prescribed them and made many addicted.
Here’s a big part of the answer, medicine itself is responsible, and it must address the root cause if things are to improve. Physicians are not trained in mental health and addiction medicine. Yet, there has been little, if any, change in formal training in over 100 years. The solution is obvious: train the people who provide the care. Although this crisis worsens, medicine still has not changed. With over $3,000,000,000,000 spent yearly on health care, patients deserve better.
Copyright Robert C. Smith 2018