The 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.
“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.