How did we get here?

pillflagThe numbers are staggering: in the United States, the number of overdose deaths from prescription opioids has more than tripled in the past decade, resulting in nearly 15,000 fatalities in 2008 alone and now accounting for more than 40 deaths every single day – not to mention the fact that estimated annual health care costs from this epidemic are as high as $72.5 billion.

How did we get here?

In the latest issue of Emergency Medicine News, Dr. Leon Gussow, a physician and editor of The Poison Review blog, examines how opioid analgesics – once feared as dangerous medications with high risk for addiction and overdose – became the drug class most frequently prescribed in the U.S., with four million patients a year receiving scripts for these powerful medications.

There were several factors at play, Dr. Gussow notes, but among the more disturbing facts is that much of the scientific evidence behind the claimed safety of using long-term opioids in patients with chronic nonmalignant pain was faulty. Quoting a recent Wall Street Journal article, Gussow says that Dr. Russell Portenoy – a New York physician who championed wider prescription of pain medications like OxyContin in the 1990s – relied on a flawed study that reviewed just 38 cases to conclude that opioids had little addictive risk – as little as one percent, a claim that seems to have been based on “a one-paragraph letter to the New England Journal of Medicine that anecdotally described the authors’ experience with short-term use of narcotics in hospitalized patients.” (According to the WSJ, Portenoy now says he shouldn’t have used that information because it wasn’t relevant for patients with chronic, noncancer pain.)

Portenoy hit the lecture circuit to advocate for the increased use of opioids while minimizing their potential adverse effects, and then, Gussow states:

“The American Pain Foundation (Russell Portenoy, director) joined the push for more aggressive treatment of chronic pain. At about the same time, the American Pain Society (Russell Portenoy, president) began advocating that pain level be considered the fifth vital sign. Both organizations collaborated on a position statement (Russell Portenoy, co-author) stating that using long-term opioids to treat nonmalignant pain carried only minimal risk of overdose or addiction.”

Meanwhile, Gussow says, the Federation of State Medical Boards recommended that state boards punish doctors and hospitals for under-treating pain; “coincidentally or not, the federation has reported receiving almost $2 million in funding from opioid manufacturers since 1997.”

Gussow adds that after the Joint Commission ordered hospitals to focus on pain treatment in 2001, it issued a guidebook along with its 1-10 pain score and smiley-frowny face scale which stated that “there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” The guidebook, he says, was paid for by OxyContin manufacturer Purdue Pharma, which pleaded guilty in 2007 to mismarketing the drug as less addictive and less subject to abuse than other pain medicines and paid $635 million in fines.

Gussow concludes:

“It is now generally accepted, even by former evangelists such as Dr. Portenoy, that the risk of addiction in patients prescribed opiates for chronic pain is substantial; some say as high as 40 percent. And, of course, many other significant problems are associated with the long-term use of opioids, including tolerance, gastrointestinal dysfunction, increased sensitivity to pain, immunosuppression, and decreased levels of cortisol, testosterone, and estrogen. By the way, no studies have demonstrated that long-term opioid therapy is effective, let alone safe, treatment for chronic nonmalignant pain. Almost all studies of the topic are limited to 16 weeks or less.”

History is littered with examples of backtracking; it isn’t rare for products – especially drugs – to be rolled out as generally safe, only to later be found to carry certain risks. It’s clear that this has been the case with opioids. Why, then, is there so much resistance to current efforts to address the out-of-control painkiller addiction epidemic?

My father died of leukemia at age 47. His battle was long and arduous. Would I have denied him relief from his pain as the cancer ravaged his body whole? Absolutely not.

My brother died of a heroin overdose after becoming addicted to painkillers. He also fought a long and arduous battle. Do I believe painkillers were solely responsible for his death? No, not directly, but something is wrong in a world where his access to those painkillers was absolutely unfettered.

Yes, he made choices. But our society has also made the choice to look away from the mess we’ve created. We need to face the facts: the science we’ve relied on to justify the use of opioids to treat chronic noncancer pain is flawed. The pharmaceutical industry has provided millions of dollars in funding to consumer and advocacy organizations that promote the increased use of painkillers – a practice, by the way, that is currently under investigation by the U.S. Senate. And today, one person every nineteen minutes dies of a prescription drug overdose.

I can already hear the naysayers banging on my door, accusing me of denying them their much-needed medications. Why, they ask, should they suffer just because addicts like my brother can’t control themselves?

Their argument misses the point. Like it or not, the safety of narcotic painkillers has been called into question. Deaths resulting from opioid overdoses rose 400 percent between 1999 and 2008.

If we can’t at least agree that there is something wrong with this picture, then we live on different planets.

About Erin Marie Daly

I’m a freelance journalist based in San Francisco. My book on prescription drug and heroin addiction was published in August 2014 by Counterpoint Press.
This entry was posted in Editorial, Informational, Pain Advocates, Pharmaceutical Industry, Trends and tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink.

7 Responses to How did we get here?

  1. HM Epstein says:

    Excellent column and important points. “The science we’ve relied on to justify the use of opioids to treat chronic noncancer pain is flawed.” So is the medical community’s commitment to staying abreast of the latest knowledge in their specialty. For example, are you aware that it takes an average of 17 years for all physicians in a specialty to implement new life-saving information, like avoiding contraindicated prescription combinations or recognizing that a class of drug is over-prescribed? Thank you for getting the word out. Maybe physicians will start listening.

  2. Pity The Fool says:

    Using statistical percentages can be factually misleading. When the media becomes involved in stories of this type, media often searches for the most sensationally skewed statistics and rhetoric. Often failing to craft coverage in a fundamentally objective and rational manner, many in the media often have anecdotal experiences, that preclude their absolute objectivity. When it comes to publishing stories about deaths due to RX drugs, the basic statistical abstracts used, fail to differentiate self-inflicted deaths caused by those people who are addicts, or are recreating with illegally obtained meds, consumed in an unsafe and/or abusive manner, from those who have legitimate conditions, proper RXs, are closely medically supervised by MDs and are consuming the RXs in a safe and responsible manner. When statistical abstracts are closely scrutinized, virtually ALL of the deaths fall into the former category, rather than the latter. It’s incredibly rare for an otherwise “healthy” patient to die from RX meds, if they are responsible and have quality medical supervision. When the issue becomes politicized (Senate hearings, FDA panels, etc) it’s critical to carefully analyze the “agenda” of those who testify and of those who hold the hearings., Any discussions about crafting any RESPONSIBLE public policy, should begin with these considerations.

    • says:

      I agree with everything you said. I note the date of these posts as 2013. I have been a pain patient in the same clinic since 1992; I have fibromyalgia, 3 neck surgeries after a camper explosion leaving me with 3rd degree burns, several surgeries. I have chronic pain! I am almost 70 yrs. I was with the same Dr. in Seattle until my Dr. retired, then on his recommendation (3 choices) I went with another Dr in the same clinic. Both were Rheumatologists. The second Dr. did not read my previous Drs notes so he had no idea what kind of a patient I was. This Dr was not very willing to prescribe oxy for me and thought I was a drug chaser. I’ve been taking oxy since it came out about 1995. Before that I tried everything including going to the U of W study on Fibro (1 1/2 years). The new Dr. did continue to prescribe for me BUT, 3 months ago he decided to go to Overlake Clinic in Seattle, his reason was plain enough to understand. He did not want to deal with pain patience or prescribe pain meds so he left all of his pain patience. I asked if I could see him at Overlake and he said “they don’t take pain patience”. I want to let you know that in the meantime we moved to Northern Idaho (2001), I was surprised to find out that no Dr wanted to take a pain patient. I kept on seeing the Dr in Seattle quarterly….800 miles round trip. The past weekend I had an appointment with a new Dr. She is at the same clinic and has been a Dr for 13 years. (The government has had a hand in teaching new Drs that drugs are bad and we should see a shrink, exercise and eat healthy, really! She also claimed that the Dr I had been seeing since the early 90’s was prescribing pain meds often…we tried everything before he did prescribe oxy. Anyway, this new Dr’s appointment was short, she said she would not prescribe pain meds or take me as a patient. I had this appointment to see her for 3 months. This clinic has kicked all pain patience out! They are a huge clinic and are affiliated with the U of W, & Swedish I believe. I can only think that all clinics are getting rid of us? The government is making it terribly hard on Drs. They want us to go to pain clinics. That sound perfect except that those clinics are there to get you off pain meds and make you feel like an addict. Again, I am seventy in Jan. have taken oxy since 1995, same dose, it is the only thing that helps me. I’ve tried other meds before oxy. they had very bad side effects, were worse on your organs than most of these meds (Cymbalta & others) I know we are all different and some can’t take oxy…many can and we could continue a fairly regular life. I own my own business (developed products used on airplanes, boats and homes) I tell you this so you understand I am not a person unable to function. What can we do? The government, Drs, people who believe in what people are writing who do not understand statistics or that few studies that deal with pain patience have been done. All the new medications now can be sold without the long process of making sure they are safe for people so now we are guinea pigs to! This situation is outrageous but we are not the most important issue today. I don’t know what to do. Now I am older, just had a full knee replacement, have Chronic neck pain do to the 3 surgeries, osteoarthritis among other pain problems. These things are here to stay for me. A good diet, lots of exercises and a shrink will not be helpful. I am fortunate that I have never been depressed many of us are not. We are not addicted we are dependent on drugs, yes it will/would be very hard to stop taking these pills but they don’t give us a high or alter our personalities.

      We are being punished because addicts are killing themselves and if they can’t get drugs they use other things that will give them a high. I want to be of help to others and think if we had a congressman/women and others to fight for pain sufferers that maybe we can get some real progress. I am probably too old to hope for help and yes I am sad (not depressed). Please let me know if we can all band together and make a difference. Following is a very good article about how pain Drs. are coping with the influx of pain sufferers, I hope you will read this.
      God Bless us Drs and Patience alike. I am not happy that the Drs are not standing against the government as a whole body of people but they are not.

  3. Jtb81 says:

    I love how all of these “experts” state that long term use of pain medicines shows no benefit. I wouldn’t wish my pain on my worst enemy, but I make an exception for these “experts” and those in their life’s that they love the most. I wish I could pass my pain onto them. I wish they could feel what it is like to be in horrible pain 24/7 then be made to feel like an addict every time they try to get their meds. I wish they could suffer through opiate withdraw when those medicines are denied by the pharmacy when policies are changed without patients being informed. I wish they could deal with the daily depression of living in pain that is so bad they wish they could put a bullet in their head, but don’t because of what it would do to their family. I wish I didn’t get hit by a drunk driver which led to 3 spine surgeries in 7 months with no relief. I wish I didn’t have to choose between a life of pain meds or a next surgery that has a high likely hood of either killing me or making me lose function of my right leg. Opiate addiction is an issue I will not deny that, but since the people who are making these rules have never gone through this they make rules that punish people with real pain like myself. And for that I say I hope that someone they love goes through exactly what I have to and I hope it rips apart their family, causes unbelievable amounts of pain and stress for them. Until that day, do not ever judge me or those like me. You think there are high overdose deaths? Just wait until you take the pain meds away from those who are truley suffering. We would rather die than live in the horrible pain we have each day. If this is done I will have the surgery that could likely kill me. If it doesn’t and doesn’t help my pain I will be one of the first to go.

  4. Jeffrey says:

    I’m so connected with Jtb81. You have no idea what it is like. Chronic pain patients are compairable to soldiers. You will never know what it is like to be on a battlefield until you put on a helmet, grab a gun and start killing the enemy. Conversely, the author here has a brother die of a heroin overdose. Which he connects to his access to prescription opioid medication. As bad as I feel for he and his brother, it does seem as though he made a bad decision to start using herion. As chronic pain myself for 10+ years, I too would not wish my pain on others. It has ripped my life into little pices and I have picked them up and taped as many of those pieces back together as I could- it never seems to be good enough. Married 28 years with two kids would never have been possible without the use of opioid medicines. You know -I thought I would continue, but those of you who are so entrenched with negative opinions – I doubt I could ever say anything that would sway the way you perceive someone who is suffering. However, you should not let your family members, or yourself , take any opioid medication when you feel your body failing. Please make sure you remember this – because you are telling others they don’t need them. When your on your knees wondering if there is a God and why he would put you through this pain. Reject all pain medicine… can’t have it both ways.

  5. Dennis says:

    I’m not in pain, but I care about a friend who has had chronic pain for 10 years. Whereas she had been able to live a fairly normal life through management of a steady low dose of Percoset, Washington State legislation has so messed up the system that now she’s unable to get the prescription on a regular basis, or needs to find a doctor who’s willing to deal with the red tape, which then makes her a doctor-hopper, which then makes her look like an addict. And to those who say there are alternatives, most people I’ve found who live with chronic pain find little or no relief from alternatives such as acupuncture and meditation. If legislators had the pain, there’d be a no-bull push-through bill in support of pain management in a week. I stand with you who are in pain. Completely.

  6. Ellen Evans says:

    I am horrified by the new limitations on prescription painkillers. I understand that they are highly addictive and have led to many deaths. However, so has meth, heroine and ecstasy. There are thousands who rely on prescription pain medications to live a relatively functional life. Are you really going to pull the plug on these individuals?Drug abuse is rampant and it is a terrible truth about the human condition. However, those who honestly need this type of help deserve it- after all we do live in America. How can you take away the right to a reasonable existence? If people abuse this drug, how about looking at legalizing marijuana. This drug has killed countless individuals. It is interesting that one does not even need a prescription to get it. I have a friend who has been in chronic pain for approximately 10 years. She has now been cut off what she needs simply to get through a day without severe pain and the vomiting that accompanies it. She has told me that she plans to end her life. There is nothing that can be done surgically as she has a crippling spine disease. Yes, I do blame the government for not being able or willing to find a compromise for these individuals. The outcome of your new law will cost many their lives. Why don’t you crack down on the drugs that are being brought into this country illegally, rather than jeopardize the lives of those who need these medications to survive? Actually, I do know why and it is because there are political/financial repercussions from doing so. I hope this topic gets the media attention it deserves. I’m not sure it will as it is such a controversial subject. In the meantime many will die needlessly due to their inability to tolerate their pain.

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