I Know Hardly Anything About Opioid Addiction

You might read the title of this blog, coming 7 months after my last, as somewhat of a repeat topic. Well, it is. And I’m not ashamed. In fact, I think I’ll go ahead and just promise that in another 7 months, you can count on hearing it some more. But I’ll take a different angle this time.

A few disclaimers: I’m going to use the colloquial term “addiction” over the medical term “abuse”, since it’s an easier read. And, the following quasi-historical tale has been edited for your sanity and to better support my thesis.

About 6,000 years ago in Eastern Europe, a person experienced pain. We’ll call him “the minstrel.” He didn’t like it, and sang a song of heartache. A gatherer discovered, right there on God’s green Earth, the opium poppy, and gave it to the minstrel. At first, all seemed great: not only did the plant relieve the minstrel’s pain and reduce his singing, he also became very happy. But then the pain came back, and the euphoria faded, and the minstrel returned to his painful song. This cycle continued, with the minstrel becoming insufferable, “needing” more and more opium, which eventually made him unable to breathe right, and he eventually died. And there was much rejoicing. (yes, a long way to go for a movie quote joke, but we got there)

Of course, over the ensuing millenia, people repeatedly found that opium (and the chemical morphine, contained in it) could really mess someone up, and that a person who used it a lot would kind of become a drag on the colony or tribe or whatever group they were living in. So, gradually it’s use was restricted to some healers and certain ceremonies, because otherwise the society (or at least the part using it too much) would fail.

But then in the 19th century, Europe decided to share opium – and its addiction problem – with the rest of the world, including Asia (ostensibly to cover trade debt, but I digress). This created problems in those places which had not known or been accustomed to opium’s power. Around the same time, the drug – and it’s purified form, morphine – became instrumental in allowing the advent of surgery.

Fast forward to the 1980’s. Pharmaceutical manufacturers could now create, synthetically, chemicals like oxycodone – nearly identical to morphine, but with less side effects. And their effects lasted longer – up to several hours. Which was great. But it still left one major problem unsolved: what of when the medication wore off, and the patient’s pain returned? Sometimes he slowly got better, and after a few doses, didn’t need the medication any more. But sometimes he didn’t get better, and like the proverbial minstrel, the pain kept coming back, and he kept needing more drugs. Eventually, his injury might heal, but he might still have discomfort once the drug wears off. Withdrawal. Sometimes the patient intensely craved the drug, and would seek it out, even months or years after his last dose. Addiction. It turns out there were lots of people – millions – who had this experience. Nevertheless, without evidence, papers as early as the mid-1980’s began to espouse these new synthetic opioids as safe treatments for chronic pain (in medical lingo, we call these “expert opinion,” the least reliable form of evidence).

Enter Purdue Pharmaceuticals, who had developed a new, longer-lasting version of the oxycodone medication – OxyContin. In fact, it wasn’t the first of it’s type, but Purdue was the first to try to develop and market the drug for long-term use.

OxyContin’s FDA approval process was murky at best – no studies went past 12 weeks, the effectiveness of the medication was mediocre (about 40%), and rates of addiction were high (about 8%). So by the early 1990’s, armed with a longer-lasting drug and the tacit approval of medical journals, Purdue started aggressively marketing OxyContin. Then, in 1998, the Federation of State Medical Boards – and afterwards the VA, the Joint Commission, the American Pain Society, and other medical bodies – designated “Pain” as the “5th Vital Sign” (pain scoring has since been shown, in numerous studies, to be almost useless as an actual vital sign, in that it is not reproducible, and is a poor predictor of future worsening or recovery). So doctors started prescribing a lot of OxyContin.

By the late 1990’s, patients and doctors started noticing very high numbers of people struggling with addiction to opioids. But since no one (least of all Purdue) had a vested financial interest in demonstrating the long-term dangers of these medications, studies were never performed. Because of the sheer magnitude of the problem, opioid overdose deaths began showing up on epidemiological radars by around 2002. Population health-level data from the Institute of Medicine showed that we were in fact seeing numbers similar to those shown in the original studies (i.e., 8% addiction), and, moreover, up to 50% of prescriptions were being misused, abused, or diverted (sold or given out on the street).

By 2008, several lawsuits had been brought against Purdue (basically alleging false advertising regarding the safety and effectiveness of OxyContin in the treatment of chronic pain). Under the auspices of the FDA, drug manufacturers were required to develop Risk Evaluation and Mitigation Strategy (REMS) programs for opioids, to help educate doctors about the appropriate prescription of opioid pain killers in chronic pain. Unfortunately, as I mentioned, we lacked any meaningful data regarding the safe use of long-term opioids, or the effectiveness of REMS training.

So, here we are. It’s 2016. About 10 million people take opioids for chronic pain. About 1 million of them are addicted. About 24,000 die each year from overdose. Numerous states and specialty societies have published guidelines or rules for opioid prescribing. The CDC recently published guidelines for the prescription of opioids in chronic pain. There are precisely two evidence-based interventions that reduce opioid overdose deaths – (1) Prescription Drug Monitoring Programs (PDMP’s), where doctors can check a statewide database to see how many prescriptions of controlled substances a patient has gotten and where (currently available in 49 states, but not Pennsylvania), and (2) naloxone, which immediately reverses the toxic respiratory-depressing effects of opioid overdose (and, in Pennsylvania, is available behind-the-counter, without a prescription). In short (stop me if you heard this before), we have still have little actual data to guide prescribing opioids for chronic pain or avoiding opioid addiction.


Chronic Pain, Addiction, and Primary Care Medicine

As a family physician, I am licensed to treat addiction and chronic pain, and have not, to my knowledge, ever practiced beyond my license. I am not a specialist in addiction, nor a specialist in chronic pain.

I have, through medical school and residency, and my ongoing “real world” training of family medicine practice, known hundreds of patients who suffer from addiction. Addiction is a physical and behavioral adaptation of a human body to an external substance. I’ve studied, observed, and had the privilege to treat the risks and symptoms of addiction. I’ve cared for people through withdrawal, recovery, and remission. I’ve seen enough patients, in rough numbers, that I have realized the predominantly published 10-20% “success rate” of remission our current medical system can achieve in treatment of addiction. I continue to care for and struggle along with the 85% who haven’t quite gotten there.

I’ve also known hundreds of patients who suffer from chronic pain. Chronic pain is caused by any number of conditions (arthritis, cancer, headaches among them), but its central tenet is that chronic pain does not go away. I’ve studied, observed, and had the privilege to treat the risks and symptoms of chronic pain. I’ve cared for people using medication, counselling, and therapy. I’ve seen enough patients, in rough numbers, that I agree with published studies that our medical treatments for chronic pain are, at best, mediocre. I continue to care for and struggle along with the many patients who continue to search for wellness with pain.

I have patients walk through my door daily with addiction and chronic pain. Try to distinguish for yourself using Dr. Google: you’ll find the withdrawal syndromes from opioid pain killers (a common treatment for chronic pain) are strikingly similar to the symptoms of chronic pain. From the first moment I meet them, many chronic pain patients are sitting on a fulcrum, an uneasy balancing point between two inextricably linked problems.

Our community should care about addiction because of abuse, illegal drugs, heroin, overdose, crime, organized crime, and so on. But more than that, we should all care because of the lives touched, indirectly and directly, by addiction. It is a complex problem – there is not one solution, and none of the solutions are easy.

I see my role in addiction management as an opportunity to connect a patient’s symptoms with his spirit and his perception and his choices. Studies have shown that wellness – not smoking, exercising regularly, eating well, and having a healthy weight – is more effective in treating chronic pain than most medicines. But wellness takes determination, and work. So we move slowly, visit by visit, adding a few minutes of therapy here and tincture of time there. What are your goals? Get through your next day of work? See your kid perform in the school play? Enjoy time with friends? Travel? How can we balance wellness, and the risks and benefits of treatment, so that your lever (mostly) tips on the “success” side of that fulcrum? As a primary care physician, I’m often more of a teacher or a counselor than a pill-prescriber.

But you can help, too. For yourself, make a commitment to wellness. For your family, your neighbors, your friends: lend an ear, and perhaps provide a little motivation. Understand that mental health and substance addiction are drivers of physical symptoms like pain – not that it’s “all in your head,” but that a path to healing embraces activity of both body and mind. Have empathy for the weak, and remind yourselves (and your legislators) how important it is to continue to address addiction, for it’s benefit to the community, and to individuals. (for example…shameless plug: you could encourage the PA legislature to fund and implement the Department of Health’s controlled substance prescriptions database.)

And if you have questions, or just need a person to talk to, see your family doctor. We’re listening.

On blogging

The idea of starting a blog makes me uncomfortable.

It’s public.

It requires work. (I am, at least IMHO, prone to laziness, procrastination, and inertia)

It is permanent. (though wordpress insists I can change anything any time)

It feels egotistical – as if my opinion matters so much it needs this type of venue.

BUT – I have concluded that I need a little more than 140 characters to retell whatever unoriginal, banal, or ignorable tripe I feel you need to hear.

AND – I don’t like that I feel behind the curve of bloggistas everywhere.

PLUS – Capital letters.

SO – Welcome. And, you’re welcome.