The Opioid Crisis – pt. 2

Last week I wrote about my experience of becoming physically addicted to Oxycodone earlier this year. That post was shared over 400 times on Facebook, and many people shared their own experiences with powerful opioid painkillers on my FB page. My guess is most people living in the US who are reading this know someone who shares my story, or knows someone who knows someone.

Last week the President of the United States declared the opioid crisis a national health emergency, although did not seek to appropriate any additional funds to deal with the emergency, as is typically done with health crises. The Center for Disease Control declared an opioid epidemic in 2011, and it has only gotten worse since then. Currently 142 Americans die EVERY DAY from an opioid overdose: that’s more than die from car crashes and gun homicides combined. Every three weeks, the US loses more citizens to opioid overdoses than died in the terrorist attacks on 9/11. Since 1999 the number of deaths has quadrupled. The increasing availability of fentanyl, which is up to 80 times more potent that morphine (most of which is produced in China, and often pressed into pill form that resembles Hydrocodone), is having a dramatic effect on overdose deaths. in 2015, 34% of opioid deaths in Kentucky were due to fentanyl: in 2016 that number rose to 47%. In 2013 there were 93 deaths in Ohio from fentanyl overdose: in 2014, that number more than quintupled to 514. Drug overdoses are now the leading cause of death among Americans under 50. The American Association of Addiction Medicine estimates that 2.5 million Americans have an opioid-use disorder, all of whom have a significantly increased risk of death by overdose. And with people turning to heroin, or crushing pills in order to inject the drug, we are also seeing a rise in the rate of HIV infection.

These numbers should shock us. The stereotypical image of someone who dies from a drug overdose for many of us is someone in a squalid apartment with a needle hanging out of their arm, perhaps with their dealer looking on unmoved. But now it is just as likely that that person is a stay at home mom in the suburbs who crushed what she thought was an OxyContin pill but instead ingested a lethal dose of fentanyl. Or who shot up heroin for the first time and died. Or it’s a miner in West Virginia living with chronic back pain who developed tolerance for the prescription he’s been taking for 3 years, and tried crushing it to remove the time release component in the hope of finding relief, but instead overdosed. Four out of five people who try heroin today started with prescription opioids. And if you live in Ohio, where in 2016 one in five people received a prescription for an opioid, your chance of using an illicit opioid is significantly higher than someone living pretty much anywhere else in the world.

How did we get here? The answer is unambiguous: the over-prescribing of opioid painkillers in the United States. In 2012, 259 million prescriptions for painkillers were written in the US – one for every adult. In Kentucky, 128 prescriptions were written for every 100 people. The US consumes 99% of the world’s supply of Hydrocodone, and 71% of the Oxycodone.  You’ve probably heard of so-called “pill mills” which have now just about been eradicated: the most infamous was in Kermit, West Virginia (population 400) where 9 million pills were shipped in a single year. Why is the situation so much worse in the US than other countries? The BBC has a helpful article, the main points of which can be summarized:

  • Insurance typically does not cover alternative treatment for pain (e.g. physical therapy): its preferred modality is medication, which is much cheaper
  • Advertising: only New Zealand and the United States permit advertising for prescription medication on TV. For that reason, patients in the US are much more likely to request a particular drug from their doctor. This obviously works, as advertising costs rose 64% from 2012-2016, when the industry spent $6.4 billion.
  • Gifts to doctors by pharmaceutical companies have a direct correlation with their prescribing company’s products
  • Most doctors have little training in pain management beyond medication, and with the effects that medication has on patients
  • We live in a culture of medication: 97% of doctors in the US treat acute pain with opioids: by contrast, in Japan, that number is 47%.

My own experience bears this out. Following surgery, my surgeon prescribed Oxycodone without saying anything about the risks associated with opioids. After I was hospitalized, I met with my surgeon weekly, and at the end of every meeting he asked me if I needed another prescription for pain meds. When I began to experience severe withdrawal symptoms he admitted he didn’t know much about that side of the drug, and referred me to a pain management specialist.

Ultimately, as this lengthy article in the New Yorker describes, this national emergency can be laid at the feet of one family-run company. Purdue Pharmaceuticals developed OxyContin (for “continuous release”) and released it in 1995. They began to market their product aggressively in 1996, sending out over 1,000 reps to doctor’s offices around the country. Their primary task: to downplay if not outright deny the addictive potential of this new drug. Within 5 years, OxyContin was generating a billion dollars a year for the Sackler family. Purdue marketed it’s benefit as continual pain relief from just two pills a day. Their 80mg and even 160mg pills meant people could get a solid 8 hours sleep without being woken by pain. A wonder drug indeed. But from the earliest days of testing, the company knew that not all, if even most people actually experienced 12 hours relief. “Prescribing a pill on a 12 hour schedule when, for many patients, it works for only eight is a recipe for withdrawal, addiction and abuse.” And that was exactly what unfolded.

Fast forward ten years, and in 2006 Purdue pleaded guilty to criminal charges of misbranding, acknowledging that it had marketed OxyContin “with the intent to defraud, or mislead.” Three company executives received probation and paid nearly $35 million in fines. Purdue paid an additional $600 million. But given the billions of dollars their product had already made, many critics saw this as an (expensive) slap on the wrist, given the level of misery their product has caused American families.

In 2015, the state of Kentucky brought a case against Purdue for deceptive marketing that had initially been filed in 2008. The trial was set to be held in Pike County, but Purdue sought to have it moved, believing they could not get a fair trial there. They financed a demographic study to bolster they claim, which only proved the case for the state: 29% of respondents reported that they or a family member knew someone who died from using OxyContin. Nearly half of the 1997 Pikesville High School football team had died of overdoses or were addicted to opioids. The judge in the case ruled it could not be moved, and Purdue settled for $24 million, without admitting liability. That amount is utterly incommensurate with Pike County’s need because of the epidemic they are experiencing. Currently ten other states are bringing cases against Purdue.

Purdue now acknowledges openly that patients will likely develop physical dependence (as I did) but they claim this is different from addiction. But if people find themselves unable to stop taking a drug for fear of crippling withdrawal, “at a certain point that might as well be addiction.” With the market shrinking in the US, Purdue are now turning their sights to the global market, which means, tragically, that the US may soon not be in a unique situation regarding our opioid epidemic.

But it’s not only Purdue. Another company has brought a new opioid painkiller to the market – Zohydro. When abused, it is up to 10 times stronger than any other version of Hydrocodone available, which begs the question, why on earth do we need this drug? And why did the FDA approve it, given the resistance from multiple medical organizations, and the current national emergency?

So, what is to be done? Clearly it begins with addressing the points the BBC article makes. And with providing long-term treatment for those suffering from opioid addiction. With no additional funds for any of this being requested by the current administration, where should we look? Perhaps to the companies that have made billions of dollars from the misery of their fellow citizens.

(Much of the statistical material in this post came from a lecture I attended recently given by Rich Wheeler, LPCC, who works in an in-patient drug treatment facility in Kentucky.)

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