Every so often, we need a new “crisis” to overreact to, and waste human and financial capital on misguided remedies. The opioid epidemic is a poster child for scapegoating and misdirected efforts.
First, here is the pure fantasy you hear from the mainstream media and politicians:
“We have an epidemic of opioid addiction. The main culprits are pharmaceutical companies that made increasingly powerful pain relievers with no regard to addiction potential, all for the sake of increasing corporate profit. They worked hand-in-hand to prescribers to sell these drugs. The health care providers were not aware of the addictive potential of narcotics, and overprescribed them. As a consequence, these partners have created a huge population of addicts in our country. Once hooked on opioids, when the addicts can obtain no more prescriptions, they turn to even more dangerous drugs like heroin. Overdosage and death are the tragic result occurring more and more frequently.”
Now, here is the real story, based on facts and not demagoguery:
From the time we started studying the pharmacology of pain relievers, we providers learned about the addictive dangers of narcotic and non-narcotic drugs. If that were not enough, we are plagued throughout our professional careers by addicted patients trying every ploy imaginable to get pain reliever and tranquilizer prescriptions from us. The last thing in the world we need is a yearly government-mandated course warning us of the addictive potential of opium derivatives!
When I graduated with my doctorate in 1980, the strongest oral pain reliever was a narcotic named Meperidine. Knowing how addictive it could be, we rarely prescribed it. Nearly 40 years later, it and morphine are still probably the strongest pain killers on the market. There are second-tier non-narcotic alternatives like Toradol, but they don’t work for everybody. Some patients cannot take them. Many surgeries are so traumatic that narcotics are warranted for pain relief, at least for a short time. I had an open reduction of a fractured leg many years ago. Despite having a very high pain tolerance, I was so grateful to be dosed with opioid drugs. They really helped relieve my severe post-op pain!
Longer term pain management is a problem. What do you do for a terminal cancer patient in excruciating pain? Administering a narcotic, and having the effect wane after three or four hours is a bother. So timed-release Oxycodone was invented, trade name Oxycontin. The effectiveness of this compound was 12 hours, requiring less frequent dosing. Of course its maker promoted its drug to providers. Every pharmaceutical company advertises each new drug it spends money formulating, in order to make prescribers aware of the drug’s availability and potential uses!
No matter what drug is concocted, addicts can find a way to abuse it. So it was with Oxycontin. Addicts discovered they could crush the tablets and get one gigantic opioid rush over a short time. Was that the drug company’s fault?
Oxycontin’s maker, Perdue Pharmaceuticals, was not responsible for our opioid epidemic, and neither are any other narcotic manufacturers. Most prescribing doctors have not been irresponsible or negligent in prescribing them for appropriate uses.
So who are the real villains of the opioid epidemic that no news reporters or politicians want to talk about?
They might surprise you!
Something you may not have heard on the news is most opioid death and near-deaths are not caused by Hydrocodone and Oxycodone prescriptions filled at local drug stores. They are by Fentanyl-laced narcotics sold on the street by Mexican drug cartels and illegal Chinese online labs shipping by US mail!
Fentanyl is a synthetic narcotic 50 times more potent than heroin. It is far cheaper to produce than opioids. Packing a bigger punch than narcotics, and cheaper to produce as well, it is a natural that illegal drug vendors are incorporating Fentanyl in varying amounts in pills peddled to the US public. Given that no authority inspects these pills for content, it is inevitable that some contain lethal amount of Fentanyl. Add the fact that addicts are not methodical in any way about dosing themselves, and it is no surprise more deaths result.
This is important: opioid deaths are occurring principally by drugs manufactured for illegal distribution channels, NOT mainstream pharmacies.
But are not prescribers the ones who are responsible for addicting patient to start with, so they must continue to feed their habits with dangerous street drugs?
I have prescribed drugs for almost 40 years, and I’ve never made anyone an addict. Addiction potential is inherent in some individual brains. We prescribers can’t instill it. There are times we MUST prescribe narcotics, if only for short periods.
Medical insurers try to avoid surgeries that may reduce pain, because operations result in very costly insurance claims. Many medical benefit plans require chronic pain patients to go to pain clinics for an extended period before having surgery. Various things are tried in these pain clinics, but one is drug management of pain. Patients are often subjected to narcotic pain relief for extended periods. This is where patients with addictive tendencies may be hooked on opioids.
But let us suppose the patient makes it past the insurance roadblocks to surgery and is admitted to the hospital. Patient had traumatic surgery in years past were kept several days for supervised recovery. Pain meds were carefully titrated and tapered off during the hospital stay. There was no chance for opioid abuse when the nurse had to deliver each pain reliever!
Now, however, patients are often dismissed from the hospital the day after surgery- many times too soon- as a cost-saving measure. Patients are given oral pain meds to self-administer as needed. Anything can happen at home, as dosing is hit or miss. The patient may oversleep and be late on a dose. Finding himself in extreme pain, the patient may take two tablets at once in desperation. Tolerance to the narcotic is developed, which in turn causes the patient to self-administer higher doses more frequently. Addiction is more likely than in a controlled hospital environment.
To be honest, some “pill mills” exist where ethically compromised physicians can make a quick cash by prescribing large quantities of requested addictive drugs. We had one such outfit in my town. It is reprehensible that some prescribers stoop so low to make a quick buck, but they do. Authorities usually catch on to such rackets quickly, so such places go in an out of business fairly regularly. But patient-customers of pill mills are usually addicts before they even come there!
The unanswered question is why the USA has so many potential addicts compared to other countries? After treating hundreds of addicts over my career, I just don’t understand what makes them tick. One cause might be that our overly generous welfare system allows leisure time for non-productive people to pursue drug use. On the other hand, third world inhabitants must work or starve, leaving no time or money for illegal drug habits. Another reason may be that too many Americans have empty lives without meaning, and use drugs to fill the void.
Addiction, like other human failings, will always be with us. What has recently made it more lethal is more dangerous drugs from foreign sources, NOT our domestic pharmaceutical industry or prescribing providers.
Sadly, it is more politically expedient to scapegoat drug companies and degreed professionals, which are ever-popular objects of hatred and demagoguery. It does not play well to blame voters who buy dangerous drugs on the street or import them from mail-order Chinese pharmacies.
Dr. Kim Henry
October 27, 2019