How Did We Get into an Epidemic of Prescription Opioid Abuse?

 

Vicodin. The name might ring a bell, it’s the most prescribed medication in the US and Knoll Pharmaceuticals best selling product. Vicodin was a no name until the 80’s when it first became available. Opioids were not always like this and initially did not pose the threat of an epidemic like we see today. In 2019 the US is experiencing an Opioid Epidemic as said by the White House. Opioids first came to light in the US in the late 70’s when medical ethics and patient advocates voiced a need to manage pain in the new and modernized world. Pain was undertreated for patients with terminal illness and cancer, the latest most promising drugs for pain were, opioids. Cancer and terminal illness accounts for a fraction of the reasons doctors prescribe opioids today contrarily, the global leader, back pain, takes up the majority of the prescriptions filled in the US. A paradox like this is not new to the US and agencies like the Center for Disease Control (CDC) who has been recording and reporting on the opioid crisis. The epidemic starts because 50 million people are reported to suffer from back pain and the leading medications for chronic back pain, are various Opioids. As reported by the CDC people who are addicted to prescription opioid painkillers are 40 times more likely to become addicted to heroin. This dependency shared in drugs of the opioid family are what can scale a minimal dose of a weak form to being given morphine. Morphine doesn’t quite cut it for some users and that’s where the dependence becomes and addiction in stronger and illegal forms such as Heroin and Fentanyl. Cases of users scaling into stronger doses and more extreme doses is not rare and are often what lead to using the illegal opioids. An article from USA Today highlighted the road of dependency experienced by General David Fridovich who was given Motrin and Morphine initially after a leg injury at the gym. Followed by more fast acting opioids like OxyContin and Roxicet to relieve pain post treatment. As pain became chronic for Fridovich, his dependence on Opioids grew as time continued. The starter dose of OxyContin became obsolete and had pushed him to ingest five dozen Oxycontin pills in a 24 hour period. After this Fridovich pushed himself to taking less pills until again his pain was too much and he was prescribed considerably stronger form of Opioids – Morphine. Until doctors finally operated on him which lead him become and advocate against the current practices of Opioid prescriptions.(USA Today) Opioid popularity still dominates the medical drug market and statistical scare tactics don’t change the increased use amongst the population. Opioid treatment in turn becomes a dependency and a treatment that for many patients is not improving their pain but is compromising their lives and futures. The facile efficacy and widespread prescription of Opioids has caused an epidemic that continues to lead patients to be dependant on the treatment for years or life.

Opioids bring in way more money than the poppy seeds on a bagel at breakfast. The opioid market has a strong economic grip in the medical community and is promoted by the pharmacies that create them. Despite the facile treatment the revenue is clear with the opioid market being priced at $8.4 billion dollars which was calculated by tracking the use of the medications. Part of the money distribution in medicine today is partially what promotes Opioids and OxyContin. Doctors do not take time to counsel and guid patients about addiction until they are properly paid for doing so. With current systems it is faster and pays better to diagnose pain and prescribe an opioid than to diagnose and treat addiction. Outnumbered emergency physicians who would like to refer patients with addiction for appropriate treatment have few resources to do so. Opioids were like a wonder drug for doctors who treated pain as it would decrease pain of all kinds which meant less time to find exact problem in the patient. It’s difficult to move through so many patients and help each of them personally, but, Opioids helped make the patient leave and welcome the next one. This dominance in the market came from the product promotion that the pharmaceutical companies incorporated.

One instance comes from the start of OxyContin and Purdue Pharma. Like most products, prescription drugs use advertising and campaigns to spread the word. Pharmaceutical companies claimed that the drug safety and efficacy were, of course, safe. Opioid dominance came from heavy control by Opioid manufacturers in various medical media and medical societies. Videos released by Purdue had promotional advertising for OxyContin and highlighted the later false claim that the drug is non addictive and safe. Opioid painkillers carry a significant risk of addiction and overdose, especially for long-term users who build up a tolerance of the high and use more and more of the drug without building as much resistance for the respiratory effects that lead to overdose. In addition medical societies such as the American Academy of Pain Medicine (AAPM) had given Opioid manufacturers “Premier Status” which gave them the ability to host sponsored meetings. Companies as Purdue Pharma, Abbott Laboratories, and Endo Pharmaceuticals, the makers of OxyContin, Vicodin, and Percodan also appear as the Corporate Council Members of the American Pain Society. (Deyo, 55) Between 1996 and 2002, Purdue Pharma funded more than 20,000 educational programs through direct sponsorship or financial grants and launched a multifaceted campaign to encourage long-term use of Opioids for chronic non-cancer pain. (United States General Accounting Office, 2003) This was resolved in 2008, despite the settlement and calling out the company for false claims the opioid problem has not improved. Ohio Attorney General Mike DeWine stated that opioid companies spend millions of dollars on promotional activities and materials that falsely deny or trivialize the risks of opioids while overstating the benefits of using them for chronic pain.” arguing its “borrowing a page from Big Tobacco’s playbook.” (German Lopez) DeWine uses the big tobacco analogy to push a similar method of getting the nation hooked. Similarly to big tobacco opioid manufacturers released false claims that the medicines are not as harmful as they are in reality. Like the advertising in big tobacco it was effective enough to cause an epidemic in the US. With the lawsuits behind them opioid manufacturers still have billion dollar revenues that don’t seem to decline as more medication is being prescribed annually.

 

Opioid modest advantages and why it’s so prescribed in doctors angle (not including previous arguments)The common way doctors treat pain is through the universal pain remedy of opioid medicines. Opioids are effective in scarce administration periods or in short term prescriptions like those after a surgical procedure. Repeated use of opioids is what causes dependence and the initial stages of the drug becoming ineffective. As noted by James White from the Department of Clinical and Experimental Pharmacology at the University of Adelaide, “Increases in drug concentration arising from administration serve only to reduce the degree of pain and mood disturbance. These aversive pain and mood states may contribute to the motivation for continued drug use and the dysfunction associated with drug dependence.”(White, 1) Giving the clinical findings that opioids are ineffective in prolonged use such as it is today. Since opioids are commonly prescribed for chronic pains the efficacy is diminished as stated above since the user is not only dependant because the pain doesn’t secede but on top of that the withdrawal symptoms are opposite to the drugs initial effects. These include most importantly pain and as Fridovich described as “emotionally and physically draining”. If it’s not the patients that are trying to quit Opioids, those that are users experience a variety of side effects as well. Studies showed that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting and constipation compared with placebo. Comparisons of opioids with non opioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality.(Opioids for Chronic Noncancer Pain, Busse) Long-term use also can lead to sexual problems due to the decline in testosterone levels when Opioids are started. The levels do return to normal when medicine is stopped but for chronic patients it persists. In older patients prolonged use increases the likelihood of falls, fractures, and osteoporosis. (Saunders, et al. ) The side effects and cycle of prolonging treatment. The scale and current science behind pain treatment is very crude. Hospital procedures that assess the patient’s condition and pain, may sound like a helpful tool. By this method doctors use pain documentation to continue prescribing opioids. The origins of the ten point scale that doctors or nurses ask patients in hospitals is well intentioned. A quick and effective scale of how sever the patient is feeling the pain but, the simplicity means quickly moving onto the next patient. Doctors liberally come to the habit of prescribing opioids to give the patient relief and continue out of the hospital. As patients pile up in the growing population means doctors have less and less time to effectively prescribe the right medicines and when to stop. Pharmaceutical companies were able to market a solution to this slow system of prescribing pain medicine. Opioids have come to treat all kinds of body pain broadening the treatments from terminal illness and cancer to common chronic pains experienced by patients.

Millions of Americans suffer from back pain annually and similarly millions of prescriptions are written for opioids to treat them. We quickly shun opioids today because of their addictive nature that wasn’t apparent initially and has brought us to an epidemic. Opioids were a solution in a sense, for many years, in which doctors had found a universal medication that cures all pain. Opioids made pain management easy for doctors because it moved the growing number of patients as hospital and medical practice spaces are limited and the number of patients seeming unlimited. The time and energy needed by the patient and physician is what Opioids cut out of the practice. Theres is a variety of non Opioid treatments that work similarly in other drug treatments with lower addiction and similar if not identical in effectiveness. As Americans grow weary of opioid treatment for chronic pain the opportunity to give a chiropractic a go opens up. Despite the pseudoscience belief in the medical world, a chiropractic and the spinal adjustment does provide relief. However, the relief comes from having the patient work alongside the treatment and for some this is not possible. Above all chiropractic require human skill and a workforce unlike pharmaceutical companies who spread production over a supply chain system. Unlike drugs spinal manipulation is non addictive.

Current guidelines by the CDC focus on warning people of the dangers in decay and addiction of opioids. They released an updated guideline in 2016 that stated a different method of opioid use that most people didn’t really come to think of initially.  “If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate, to provide greater benefits to patients in improving pain and function,” (CDC, 2016) As Opioids are not a sham product they do alleviate pain but work most effectively for a short period and in sync with non pharmacological remedies. This can be things like a chiropractor or acupuncture. Current prescriptions don’t require a physical type of solution aside from opioids, which means like earlier stated, people just become dependant. As spinal manipulation and physical therapy can bring results no drug can provide like relearning to walk and move. What pills and other medications can’t solve is a permanent solution. Spinal manipulation is the core treatment that all chiropractors use, though they prefer the term spinal “adjustment.” There are many techniques, varying in the force delivered and the amplitude of movement. It’s unclear how spinal manipulation works to relieve pain. Various theories focus on the small facet joints in the spine, on repositioning disc material, on reducing muscle tension or stiffness, and on other possibilities. Chiropractors also often recommend therapeutic exercise and sometimes make use of massage and acupressure in addition to spinal manipulation. (Deyo,78) This is the solution side of the pain treatment spectrum, where a pill falls short. As part of the treatment requires patient cooperation in the form of exercise, for some this is limiting and sometimes impossible. Ideally, many advocate that the system should rely less on exclusively pharmacological treatments and find that physical therapy and chiropractors are serious sciences. This in part has the scientific community to blame as these two practices are arguably pseudoscience that have gotten enough support to call themselves legitimate. For example, D. D. Palmer, was a magnetic healer practicing in the Midwest in the late 1800s. He claimed that he once cured a janitor’s deafness by manipulating his neck. This was what the earliest of chiropractics looked like, a snake charmer of sorts that without scientific proof and only results to show. Comparatively, Opioids and OxyContin had millions of dollars and sponsored programs that integrated their pills into the medical procedure of today’s pain treatments. To doctors Opioids have almost become ingrained if they had been practicing during Purdue Pharma’s aggressive advertising of OxyContin. Other homeopathic remedies are not as familiar to al doctors and need careful diagnosis and referral to the many varieties and sorts of alternatives. Other non drug treatments include acupuncture, massages, cryotherapy and many more. The solutions to fix and manage pain without opioids are promising but take up effort and work from the patient themselves. Most importantly those practicing these various physical remedies don’t make a monopoly selling their services.

 

Like every human, pain is unique to each person, and it is not the simplest task to locate and fix. Millions of Americans are in constant pain and a fraction of that are doctors available to properly treat the pain to make it all go back to the way it was.  This paradox of the rapid growing amount of patients and a small supply of doctors to help them asks for a solution. AS the 21st century provides us with more medical advances we seemed to have hit a plateau in pain management progress. The nation had gone into a state of Epidemic. The solution was not just a simple trick that can cure all and make the world whole again. Marketing and sponsored conventions for medical professionals influenced a sense of hypo and relief around OxyContin. A seemingly low addicting and dependency drug that actually worked. Until, this was all found to be a lie, a generation of doctors reliant on moving through patients on opioid perscription at a time, and a nation addicted.  Highest, in this chain of events sits, the manufacturers and their supply chains. Pharmaceutical companies had changed a part of medicine and we see it till this day. Where once, people seeked homeopathic remedies or elevating legs during sleep to relieve pain, the medical industry changed this. Introducing potent opioids that had great potential in terms of efficacy but backfired as people became addicted. Treating pain had been seen as a simple task these past years but had brought light to a harder task, rehabilitation. As users face the impending doom of having to detoxify and underdog withdrawal symptoms if they were to stop using Opioids. The revenue from these medications gave pharmaceutical companies advantages that kept a tight grip at dominating the pain maintenance field. While alternatives exist, the tight grip of the market and efficiency at the cost of addiction give Opioids their number one spot in the US. For some people it is a wonder drug but also the start of a life reliant on Opioids.

 

Bibliography

 

1581. Lembke, Why doctors prescribe opioids to known opioid abusers, N Engl J Med 367 (2012): 1580–1581.

 

Busse JW, Wang L, Kamaleldin M, et al. Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis. JAMA. 2018;320(23):2448–2460. doi:10.1001/jama.2018.18472

 

DEYO, RICHARD A. Watch Your Back!: How the Back Pain Industry Is Costing Us More and Giving Us Less—and What You Can Do to Inform and Empower Yourself in Seeking Treatment. 1st ed., Cornell University Press, 2014. JSTOR, www.jstor.org/stable/10.7591/j.ctt1287d4b.

 

Dowel D, Haegerich TM, Chou R, US Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain: United States, 2016. Dec 2015

 

W. Saunders, K. M. Dunn, J. O. Merrill, M. Sullivan, C. Weisner, J. B. Braden, B. M. Psaty, and M. Von Korff , Relationship of opioid use and dosage levels to fractures in older chronic pain patients, J Gen Intern Med 25 (2010): 310–315;

 

Zoroya, Gregg. “General’s Story a Warning about Use of Painkillers.” USA Today, Gannett Satellite Information Network, 27 Jan. 2011, usatoday30.usatoday.com/news/military/2011-01-27-1Adruggeneral27_CV_N.htm.