By Dr. Sudip Bose, MD, FACEP, FAAEM
“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency. It’s a national emergency. We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis,” President Donald Trump said yesterday.
It’s likely that President Trump was influenced by an interim report that was presented to him last week by the Commission on Combating Drug Addition and the Opioid Crisis, which compared the nation’s overdose death toll to the toll that resulted from the terrorist attacks on 9-11: “With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks,” the commission’s interim report noted. And the commission urged the president to declare a national emergency under either the Public Health Service Act or the Stafford Act.
President Trump and the commission are right in placing such an emphasis on this national crisis – and it is a national crisis. It’s the biggest epidemic to have hit our country since the HIV epidemic of years ago, so much so that in the emergency room as an emergency physician, I’m seeing patients come in dead from opioid overdoses. People are getting addicted and are coming into our emergency rooms and they’re dying from this. A couple of those instances I remember very vividly – one where a young girl went downstairs at her house to find her older brother and his girlfriend blue and not breathing; in another case a man looked out of the window of his house and saw a teenager lying still on his lawn. I know the stories, because the brother, the girlfriend and the teen on the lawn all came through my emergency room and all were dead from overdosing on opioids. You don’t forget those kinds of things.
According to the Centers for Disease Control (CDC), “In 2009, 1.2 million emergency department (ED) visits (an increase of 98.4 percent since 2004) were related to misuse or abuse of pharmaceuticals, compared with 1.0 million ED visits related to use of illicit drugs such as heroin and cocaine. Prominent among these prescription drug--related deaths and ED visits are opioid pain relievers (OPR), also known as narcotic or opioid analgesics, a class of drugs that includes oxycodone, methadone, and hydrocodone, among others.”
Another alarming statistic, also according to the CDC, is that “Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014 … ”
What caused that kind of explosive growth over those 15 years? The FDA and TV advertising. In 1997, the FDA rules governing pharmaceutical advertising changed. The FDA allowed TV ads to name both the drug and what was for, while only naming the most significant potential side effects. After that, the number of TV ads exploded. An NPR story from 2009 detailed the ongoing phenomena in an article titled, “Selling Sickness: How Drug Ads Changed Health Care.” According to the article, “The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television. And those ads clearly produce results: ‘Something like a third of consumers who've seen a drug ad have talked to their doctor about it,’ says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject. ‘About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.’ ”
Not honoring a request to write a prescription for an opioid can be dangerous. My life has been threatened for not prescribing opioids. Other doctors can tell similar stories. As a matter of fact, withholding opioids cost a doctor his life recently. Less than a week ago in Indiana, Dr. Todd Graham was murdered by the husband of a woman for whom he refused to write a prescription for opioids.
This is deadly serious stuff. As a nation, we’ve got to take control back over opioids.
Opioids are an opium-like substance that’s derived from the poppy plant – poppy seeds – just like the illegal narcotic, opium. As a substance, opium itself belongs to the narcotics class of drugs, commonly known for their highly potent and addictive effects and is often used for pain relief. Opioids are a class of drugs that also include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.
Addiction to these opioids has become a “medicine cabinet” disease – it’s our medicine cabinets where we get these narcotics after they’ve been prescribed. And what happens is that when you take these medicines, they go to your brain and they affect the pain and rewards centers there – your receptors. And you feel good – really good. And the pain goes away. But then it’s hard to come off it, because you feel good and you want more. And then you want even more. And then you withdraw if you don’t have it. And then people switch over to heroin because they can’t get their opioid prescriptions refilled. So now, when you look at the heroin addicts in the United States, it’s not who you typically think of when you think of a drug addict. Anymore, it’s not the drugged-out, emaciated stereotypical abuser – it’s well-off suburban soccer moms or high school and college athletes.
Anymore, it’s not the drugged-out, emaciated stereotypical abuser – it’s well-off suburban soccer moms or high school and college athletes.
Or we may use only three or four of the pills to overcome pain from an injury; we feel better but then later, we take those pills and we’re giving them to our friends or we’re selling them because they have street value. Oxycontin® has street value just like a Gucci or Prada bag because it is branded and widely recognized and highly sought after.
To say it’s become a serious problem is an understatement. If you do the math according to the statistics published in the presidential commission report, well over 50,000 people a year die from opioid overdose. If you look at all the heroin addicts, three out of four of them became heroin addicts because of a prescription medication they received earlier. Opioids, straight from your medicine cabinet, are often now a gateway drug to other illicit and illegal drugs, not marijuana. It’s a widespread, very real problem, and let’s face it – you’re just a fracture away from being potentially addicted yourself. As doctors, pain level has become our fifth vital sign measurement in addition to the once-standard four: body temperature, blood pressure, pulse (heart rate), and breathing rate (respiratory rate), often notated as BT, BP, HR, and RR. In 2001, the Joint Commission – a not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the US and is recognized nationally as a symbol of quality and commitment to meeting certain medical performance standards -- rolled out its Pain Management Standards, which helped expand the idea of using pain as a "fifth vital sign." It required healthcare providers to ask every patient about their pain. Since the US has since experienced a surge in opioid prescriptions – and, subsequently, an increase in overdoses and deaths tied to these painkillers – now the Joint Commission is being asked to rethink that.
A group known as the Physicians for Responsible Opioid Prescribing sent a letter to the Joint Commission, according to a report in Medpage Today, noting that the previous four widely recognized vital signs can be measured objectively. “Pain,” the letter stated, “is a symptom, not a vital sign." According to the report in Medpage Today, the group has asked for “removal of the pain-related questions from HCAHPS, the patient satisfaction survey used to determine hospital reimbursement rates. The letter focuses on three specific questions: whether patients needed medications for pain, if their pain was well controlled during their stay, and if hospital staff did "everything they could" to help with pain. Linking reimbursements to patient satisfaction with pain treatment results in opioid over-prescribing, the groups said.
It once was commonplace to prescribe a bottle of Vicodin for a sprained ankle. When I was a training resident, I thought my colleagues and I were doing the right thing. Patients were happy when they got tablets of Vicodin for their ankle sprain. We were happy and felt compassionate. The regulatory bodies were happy because we were addressing pain – that fifth vital sign. Pharmaceutical companies were happy and kept advertising to us. It was a win-win for all unless or until that patient came back asking for a prescription refill. After 30 days on a sprained ankle, you know it’s not the pain they’re looking to alleviate, you know they’ve become addicted to the opioid you initially prescribed to help manage the pain. We don’t give opioids any more to manage ankle sprain pain, but now a fracture can elicit an opioid prescription.
You’re going to have pain if you injure yourself, but it’s better to have a little pain as you’re weaning yourself off or coming off these opioids, and it’s better than having the emotional pain, too, of becoming an addict. Generally, it takes about three days to get off of prescription opioids. You’ll feel like crap, you’ll probably get sick to your stomach, and you’ll probably have flu-like symptoms on top of that. But if you can tough it out for three days and maintain your mental stamina to stave off the craving for whatever opioid you were on, you’ll be through it and come out the other side.
You’ve got to trust your doctor when it comes to pain management sometimes. You might not need a painkiller. Your doctors are not lacking compassion if they’re not giving you pain medications.
Let’s look at it this way: Have you ever had a runner’s high when you’re running? Many people do. When you’re running, your body releases a natural substance known as endorphins, which stick to the receptors in your brain that are the pain centers and the rewards centers of your brain. And as a result, you feel good. Opioids hit the same receptors that endorphins hit -- the same pain centers and reward centers in your brain, and you feel good. And human behavior being what it is, you want more. You want to continue to feel good. This is what’s contributing to opioid abuse in the US.
But why are we having this opioid epidemic? It’s a lot more than just feeling good and wanting more. That’s a big part of it. But it’s everything from government decisions – border control and what’s coming into our country; it’s lobbying; it’s pharmaceutical marketing; it’s physician satisfaction scores. Physicians want to make you happy and decrease your pain. Still, people are getting addicted to these opioids, and I’m concerned about these having become the gateway drugs to other illicit drugs; it’s not marijuana anymore, as many people might typically think.
According to a recent U.S. Surgeon General’s report (2016) titled, Facing Addiction in America, “Over-prescription of powerful opioid pain relievers beginning in the 1990s led to a rapid escalation of use and misuse of these substances by a broad demographic of men and women across the country. This led to a resurgence of heroin use, as some users transitioned to using this cheaper street cousin of expensive prescription opioids. As a result, the number of people dying from opioid overdoses soared—increasing nearly four-fold between 1999 and 2014.”
That same report noted that, “Despite the fact that we have treatments we know are effective, only one in five people who currently need treatment for opioid use disorders is actually receiving it.”
Treatment for opioid addiction can include both behavioral and medical protocols. Behavioral therapy could increase a patient’s motivation to change, increase their belief in themselves and help them avoid disruptive behavior patterns and abnormal thinking is beneficial, assuming a patient’s acceptance of such a treatment.
Medications are available to assist people addicted to opioids shed that addiction by preventing the prescribed drug’s pleasurable effects on the brain, or by creating an unpleasant reaction when the medication is used, or by controlling symptoms of withdrawal and craving. At the receptor level there are other ways to stop pain such as nerve blocks and other categories of medicines that are not as harmful. At the receptor level there are reversal agents that can kick the opioid medicine off the receptor and save the patient's life (such as naloxone). The Surgeon General’s report also called out other “medications for treating opioid addiction—methadone, buprenorphine, and naltrexone—have been identified by United States public health authorities as an essential part of tackling America’s current prescription opioid and heroin crisis.”
I think the lesson is you have to trust your doctor, who’s going to prescribe the right treatment and give you the right medicine for the right situation at the right time.
And remember, pain is part of life; when you’re healing, pain is part of it. It’s OK to feel some pain. For example, when we talk about world events, in order to bring peace to a region, unfortunately sometimes there is going to be the pain of war. Our body is like that. In order to experience peace in a region of our body, we need to endure the pain of recovery. Sometimes that’s rehab. Sometimes that’s weight lifting. It’s painful, but your muscle grows back stronger. It’s OK to have pain sometimes, and you have to wean off those opioids and use them only when necessary.