In the 1980’s and 1990’s the U.S. was dealing with a drug hysteria, primarily due to media portrayals of people addicted to the smokeable form of cocaine, known as “crack.” First Lady, Nancy Regan, began a highly-publicized anti-drug campaign with the slogan, “Just Say No,” and the increase in political frenzy led to the passage of draconian penalties that dramatically increased prison populations.
Flash forward to Today
Despite more money being allocated in the early 2000’s to combat illicit drug activity, the war on drugs was running out of steam. Public opinion slowly shifted in favor of more sensible reforms that expanded health-based approaches while reducing the harsh criminal prison sentences for drug offenses – we still have a long way to go.
However, as this was going on, a new war on drugs gained traction – this time with prescription narcotics.
In 2016, more than 64,000 Americans died from drug overdoses, and most of these deaths involved a prescription painkiller or an illicit opioid, such as heroin. The White House Council of Economic Advisers pegs the true cost of this crisis at an estimated staggering $504 billion – most of this being attributed to health care and criminal justice spending and lost productivity.
How Did We Get Here?
One word – pain!
In 1986, an American doctor, Dr. Russell Portenoy, challenged the conventional wisdom that opioids can be used for patients beyond those who were suffering from cancer and palliative care.
Based on a small study of just 38 patients, Dr. Portenoy came up with the conclusion that opioids could safely be used in all patients dealing with chronic pain for years on end. He even asserted that the drugs were easy to quit and overdoses were rare.
In fact, Dr. Portenoy, along with several other doctors, cited a single-paragraph letter to the editor of the New England Journal of Medicine stating that less than one percent of opioid users would become addicted to the drugs.
This letter is often quoted as the “1% letter,” and the author of the letter retired Dr. Herschel Jick, recently pointed out that this statistic was misrepresented. The one percent was intended only to represent patients who were prescribed opioids in a hospital setting while being carefully monitored. He never anticipated the devastating impact that this one-paragraph letter would have in the coming years.
Even Dr. Porteny, once mockingly referred to as the “King of Pain,” appeared to have retracted his statement. He acknowledges that this misrepresentation played a big part in the addiction crisis America is dealing with today.
The Opioid Crisis Skyrockets!
Drugs are cheaper than employing a multi-disciplinary approach to treating pain. And from an insurance company standpoint, “cost savings” is music to their ears.
However, there’s a grim connection between opioid painkiller addiction and heroin addiction. In the 1990’s doctors turned to drugs like OxyContin, Vicodin, and Percocet to remedy what was seen as the widespread treatment of chronic pain. The number of opioid prescriptions filled in 1992 was 79 million. By 2012, this number rose to a staggering 217 million!
As these numbers skyrocketed, the U.S. federal government forced drug makers to make prescription painkillers harder to abuse. And at the same time, heroin from Afghanistan and Mexico became a cheaper and more readily available alternative. This led to four out of five new heroin users in the U.S. claiming they had previously misused prescription pain relievers.
Similar as to what unfolded in the tobacco industry, certain pharmaceutical companies misled the public, and the FDA, about the risks of opioid dependence to sell more drugs. Three top executives at Purdue Pharma even pleaded guilty to criminal charges defrauding the public and government regulators.
In 2016, the Centers for Disease Control and Prevention issued new guidelines for treating chronic pain, which warned doctors to avoid prescribing high doses of opioid doses when possible. Doctors have been heeding the message as higher doses of opioid prescriptions have dropped significantly in recent years.
But while doctors have been cutting back on their opioid prescriptions, long-term patients who were on high doses have experienced the adverse effects.
Take, for instance, Doug Hale, a paralegal and computer technician who woke up one morning with excruciating pain six months after surgery to repair a damaged urinary tract. In 2006, eight years after trying various treatments which failed to remedy the pain, Hale was prescribed high doses of opioids.
Fast-forward 10 years and still on the meds, Hale became so addicted to the pills that he frequently ran out of his prescription early. He progressed through a laundry list of opioids, which included Dilaudid, Hydrocodone, Oxycodone, Fentanyl, and eventually high doses of Methadone – a painkiller better known for treating heroin addiction.
By April 2016, Hale was taking a massive dose of 16 methadone pills a day, which was many times more than the daily intake level the CDC recommends. After several warnings from his doctor about the dangers of an early death, and not wanting to risk losing his medical license, the hammer was dropped – Hale was cut off entirely to his supply of opioids and was offered to go yet again to a detox clinic.
Unfortunately, this did not work for Hale as he went back to suffering excruciating pain. And to make matters worse, he now began suffering intense withdrawal symptoms, which included constant tremors and shaking.
Hale returned to his doctor pleading to get back on his opioid medication, but his doctor refused. The following day, Hale left a suicide note stating he could no longer take the chronic pain and killed himself by putting the barrel of a small-gauge gun in his mouth and pulling the trigger.
The Problem With Treating Pain Using Opioids
Counties in the U.S. with the highest prescription rates tend to have larger white populations, higher rates of unemployment and greater numbers enrolled in Medicaid.
With the recent expansion of Medicaid coverage in 32 states, enhanced federal funding covers adults up to 138% of the federal poverty level. This expanded coverage has enabled many states to provide addiction treatment and other health services to low-income adults with opioid addiction who were ineligible for coverage previously.
However, despite this progress, the GOP’s Better Care Reconciliation Act (BCRA) has proposed to restructure the Medicaid program through a per capital cap, which would phase out the enhanced federal funding, and remove the requirement to cover addiction treatment.
While the BCRA appropriates $4.97 billion each year over nine years for state grants to cover substance use disorder, mental health treatment, and recovery support services, the reduced overall federal funding could lead to reductions in Medicaid eligibility and coverage of services. This ultimately will affect state efforts to address the opioid epidemic.
And to compound the issue with a lack of coverage, Medicaid does not cover FDA approved safer alternative forms of treatment for chronic pain, such as acupuncture therapy. Patients must come fully out of pocket for these forms of treatment, which are proven to work without the risk of side effects or withdrawal symptoms that come from medications.
Opioids are highly dangerous and addictive drugs. Safer alternative forms of treatment should be considered first before putting a patient on these drugs to treat chronic pain.
In the long-run, improving chronic pain by identifying and treating the root cause of the problem(s) is the safest and more effective route to take as opposed to masking the issue(s) with dangerous prescription medications. Even alternative forms of treatment, such as acupuncture therapy are proven to work.
Fewer patients on opioids will reduce the number of overdose deaths, and this can be a giant step forward in helping America overcome our modern war on prescription drug narcotics.
Meet Dr. Neil Spiegel
For over 20 years in osteopathic medicine, Dr. Spiegel has applied traditional and alternative methods to diagnose and treat his patients. He has a special interest in caring for patients with acute and chronic musculoskeletal and neurologic pain syndromes. Dr. Spiegel has received numerous professional and volunteerism honors including Top Doctor Survey Awards and the State of Maryland Volunteer Service Award. He also serves on the Board of Directors of a free clinic serving the uninsured in Montgomery County, Maryland.