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.