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How Should We Handle the Opioid Epidemic in America?

The opiate epidemic has essentially wiped out an entire generation of health advances…” ~ Eli Saslow, What Kind of a Childhood Is That? The opioid epidemic in America is not just continuing—it is ESCALATING. According to a recent article in the New York Times, it is estimated that between 59,000 and 65,000 Americans died last year because of drug overdoses. Not only is this the most overdose deaths in a single year, that number also represents the largest one-year increase in history. In 2015, there were 52,404 fatal overdoses in the United States. If the estimates for 2016 are correct, this means the number of deaths jumped at least 11% and as much as 24%. It also means that overdoses have become the leading cause of death for people under the age of 50. And what is the driving force behind this enormous public health crisis? Opioid addiction.

Opioid Epidemic Statistics

“While my research cannot speak to what percent we are underestimating, we know we are missing cases. It does seem like it is almost an iceberg of an epidemic.” ~ Dr. Victoria Hall, a Minnesota-based field officer for the Centers for Disease Control and Prevention The American Society of Addiction Medicine reports that in 2015, the most recent year on record:

  • 2.6 MILLION Americans age 12 and up met the criteria for a medical diagnosis of an Opioid Use Disorder.
  • This breaks down as 2 MILLION people addicted to prescription opioids, and another 591,000 addicted to heroin.
  • In 2007, the number of heroin addicts in America was approximately 340,000.
  • That represents a jump of over 70%.
  • 77% of opioid abusers misuse prescription pain medication.
  • Over 63% of all lethal drug overdoses involved prescription opioids or heroin.
  • That equates to more than 33,000 deaths involving some type of opioid.
  • In 2010, there were approximately 20,000 opioid-related deaths.
  • That represents a 65% increase.
  • A 2016 study calculates that prescription opioid abuse, dependence, and overdoses placed a $78.5 billion economic burden on the United States.

One worst-case estimate predicts that if the current overdose rates continue, drug overdoses will kill over 650,000 Americans in the next 10 years. That’s roughly the population of Boston. The problem is so pervasive in every segment of American society that CNN has coined the phrase “opioid orphans” to describe the children being raised by their grandparents because their parents are lost to addiction. Parental substance abuse is cited as a reason why a child is removed from parental custody in 80% of protective services cases. Obviously, in the face of so much human tragedy, SOMETHING has to be done, because what we are doing now just isn’t working. But before a possible solution can be discussed, we first have to identify the reasons for the problem – the WHO, WHY, WHAT, WHERE, and HOW of the situation. The WHEN is easy – the answers must be found NOW, before hundreds of thousands of more lives are lost, and millions more lives are affected.

WHO Are Opioid Addicts?

Although the disease of addiction can strike people of any age, race, income/education level, or background, there are, nonetheless, tendencies among opioid addicts. For example: People who abuse oxycodone are more likely to:

  • Be young
  • Be male
  • Engage in thrill-seeking or risky behaviors
  • Inject or snort their drugs
  • Be willing and able to spend twice as much as hydrocodone addicts

People who abuse hydrocodone are more likely to:

  • Be elderly
  • Be female
  • Avoid risk
  • Obtain their drugs from physicians, friends, or family members

Even the “face” of heroin addiction has changed from generations past. Today, the average person using heroin is nothing like the urban stereotype:

  • 80% of new heroin users start out by misusing prescription painkillers.
  • 90% of heroin users are white.
  • The average age is 23.
  • The risk of heroin use starts even younger. For example, in 2014:
    • 28,000 adolescents and teens 12-17 years old reported past-year heroin use.
    • 16,000 said they were current heroin users.
    • At some point during the year, 18,000 met the criteria for a Heroin Use Disorder.
  • Among women, overdose deaths involving heroin tripled between 2010 and 2013.
  • Comparing 2002 through 2004 and 2011 through 2014 – heroin abuse rose 60% in homes with annual household income of $50,000 or more.
  • Again, comparing those two time periods, heroin use increased more than 62% among people who had private insurance.

WHY Are People Abusing Opioids?

There is no one, single identifiable cause of addiction. The disease is influenced by – and influences – several separate factors. The biggest contributing factor is genetics. A recent study by the Medical College of Virginia indicates that recreational drug misuse moves to abuse, dependence, and addiction “due largely to genetic factors”. According to multiple twin studies, it seems that approximately 50% of a person’s vulnerability to addiction is because of genetics. Other risk factors that can increase the risk of opioid addiction include:

  • Environment
    • Childhood exposure to parental drinking or drug use
    • Excessive Stress
    • Social isolation
    • Peer pressure
  • Mental Illness – According to a report put out by Washington State University Spokane and the Washington Institute for Mental Illness Research and Training, 51% of people with a lifetime history of a mental disorder have a concurrent addictive disorder.
    • Anxiety – over 3 ½ times greater likelihood
    • Depression – an approximately tripled risk, especially among women
    • PTSD – at least an almost tripled risk. In fact, a male child who has 4 or more  Adverse Childhood Experiences is 46 times more likely to be an intravenous drug user in adulthood.
    • Personality Disorder – up to 60% of patients
    • Disordered Eating – a risk of substance abuse that is 5 times greater than that of the general population
    • ADHD – between 15% and 30% of substance abusers have ADHD
    • Bipolar Disorder – 56% of patients have a lifetime prevalence of addiction
    • Schizophrenia – up to 65% have a current SUD
  • Personal History and Habits
    • History of alcohol and/or drug abuse/addiction
    • Episodic binge-drinking
    • Long-term prescriptions for other opioids or benzodiazepines such as Xanax, Klonopin, or Valium

Why is identifying risk factors so important? Responsible screening methods by doctors and pharmacists can pinpoint those people who are most-likely to misuse their opioid prescriptions. Then, they can intervene proactively, before the substance use progressively worsens and causes permanent damage to their physical and mental well-being.

WHAT Opioid Is Prescribed Matters

Recent studies indicate that some people prefer one type of opioid painkiller over another. In December 2013, PAIN published the following findings:

  • 3 out of 4 people dependent on opioids prefer either hydrocodone or oxycodone as their drug of choice.
  • Of those, oxycodone – OxyContin, Percocet, Percodan – is significantly more popular than hydrocodone – Vicodin, Lortab, Norco – by a rate of 45% to 29%. People preferring oxycodone say that it is due to the “quality” of the high.
  • 9 out of 10 opioid abusers self-report that “mood alteration” is the reason for their preference.
  • However, 60% report that “pain management” also plays a role.

Significantly, prescription hydrocodone drugs often contain acetaminophen. This could act as a deterrent for some users, and may partly explain the preference of oxycodone over hydrocodone. This thought is supported by the fact that when an abuse-resistant oxycodone formulation was first introduced, diversion rates measurably decreased.

WHERE Is the Opioid Problem the Worst?

It is also important to identify which areas of the country are being hit hardest by the opioid epidemic and which areas are turning the tide. This way, we can expand what works and allocate resources and efforts where they will do the most good. According to the CDC, there were 19 US States that saw a statistically significant increase in drug overdose deaths from 2014 to 2015:

  • Massachusetts +35.3%
  • New Hampshire +30.9%
  • Maine +26.2%
  • Connecticut +25.6%
  • Florida +22.7%
  • Ohio +21.5%
  • Kentucky +21.1%
  • Rhode Island +20.5%
  • New York +20.4%
  • Maryland +20.1%
  • Pennsylvania +20.1%
  • West Virginia +16.9%
  • New Jersey +16.4%
  • North Carolina +14.5%
  • Tennessee +13.8%
  • Michigan +13.3%
  • Louisiana +12.4%
  • Washington State +10.5% Of special relevance, Washington was the only state in the West or Northwest with such a statistically significant increase. Between 2012-2016, King, Snohomish, and Pierce counties saw the most opioid-related overdose deaths.
  • Illinois +7.6%

HOW Misinformation Started the Opioid Epidemic

The misinformation started with a Letter to the Editor of The New England Journal of Medicine in 1980. Dr. Herschel Jick and some colleagues had conducted an analysis of opioid patients, and their conclusions differed from the early consensus about painkillers. Of special relevance, their findings were not submitted for peer review. So, Jick wrote in to the NEJM as a way of commenting on an earlier article, saying, “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” Big pharmaceutical companies took that excerpt and ran with it. Over the next several years, the “Jick Letter” was quoted HUNDREDS of times by sales representatives who claim that opioids were not addictive. Experts consider the letter to be one of the biggest factors in the opioid epidemic. But Big Pharma left out an important detail from Dr. Jick’s study – it only included those patients who received very small doses of opioids in a controlled hospital settingnot those given opioids to take on an unsupervised outpatient basis. Because of this purposeful omission about their drug’s potential for addiction, Purdue Pharmaceutical – the manufacturer of OxyContin – was fined $634 million for misleading both the medical community and the public. Considering the fact that Purdue has made $31 BILLION from OxyContin, maybe that fine didn’t go far enough. Dr. Jick regrets his role, saying, “The letter wasn’t of value to health and medicine in and of itself… if I could take it back — if I knew then what I know now, I would NEVER have published it. It wasn’t worth it.”

HOW Demand Feeds the Opioid Epidemic

Most doctors were completely fooled, right along with the rest of us. They were urged to aggressively treat their patients’ pain with “safe” opioids. In a 2016 letter to EVERY doctor in America, then-Surgeon General Dr. Vivek Murthy wrote, “Many of us were even taught – incorrectly – that opioids are not addictive when prescribed for legitimate pain.” As a result, physicians, unconcernedly dispensed opioid painkillers to their patients in pain. Between 1999 and 2010, prescription pain reliever sales QUADRUPLED. By 2012, there were 259 MILLION opioid prescriptions being written in the US. To put that number in perspective, that is enough to give every American adult their own personal bottle of pain pills. Not surprisingly, as opioid sales grew, so did the rates of abuse and overdose. During the same time frame, the overdose rate also quadrupled and the treatment admission rate SEXTUPLED. Dr. Lynn Webster, the former President of the American Academy of Pain Medication, said, “It leads them down a path that can be very harmful, and that’s what physicians have to watch for.” How big a problem did this become? A 2012 Los Angeles Times investigative article reported that in four Southern California counties, almost half of the accidental prescription drug deaths resulted from a legitimate prescription. Defying stereotypes, the CDC says that just 15% of the medications misused by “chronic abusers” are obtained from illegal sources. An analysis of coroners’ records over a five-year period in San Diego, Ventura, Orange, and Los Angeles that 47% of fatal overdoses involved medications for which the victims had a prescription that was later determined to be the cause of death. Significantly, a disproportionately-tiny fraction of all the prescribers in those four counties – just .1% – wrote the prescriptions involved in 17% of the deaths. More distressingly, every doctor in the .1% had three or more patients who fatally overdosed. So now that we understand more about the problem, how can that information be used to combat the opioid epidemic in America?

Solution #1 – Stop Opioid Overprescribing

Eventually, the truth finally came out about the dangers of opioid medications and the government and the medical community responded. For example, in 2016, the FDA, CDC, and the Surgeon General all supported new guidelines for the prescription of painkillers. Now, doctors are urged to only use opioids as a “last resort”, when all other methods of treating pain have failed – diet, exercise, massage, acupuncture, chiropractic therapy, over-the-counter non-opioid medications, meditation, hypnosis, etc. And, when opioids absolutely MUST be prescribed, the recommendation is that they should be given for the lowest dose possible and for the shortest duration possible, with frequent follow-up. Here’s the thing – opioids should only be prescribed for acute – short-term – pain. Not only does this reduce the risk of diversion, addiction, and overdose, but it is also better for the management of pain. According to a 2016 study by researchers at the University of Colorado, the long-term use of opioids actually WORSENS chronic pain. There are continuing efforts to rein in unscrupulous “pill mill” physicians.

Solution #2 – Screen for Risk Factors

Prescription Monitoring Systems are now in place in most communities that allow health professionals such as doctors, dentists, pharmacists, nurse practitioners, physician assistants, and other licensed clinicians to access a patient’s information before any new prescriptions are dispensed. When used in conjunction with recommended drug use screening protocols, monitoring systems form a protective system for detecting prescription medication abuse. This is beneficial in several ways:

  • It discourages “doctor shopping”.
  • It prevents a patient from having multiple prescriptions.
  • It safeguards against harmful drug interactions, particularly with other opioids or benzodiazepines.

Solution #3 – Improve Access to Treatment

Proper patient screening will lead to earlier identification and opportunities for intervention, thereby promoting more referrals to opioid addiction treatment services. Unfortunately, the US Surgeon General reports that only about 10% of people with substance abuse disorders get the help they need. Opioid addiction is particularly helped by Medication Assisted Treatment, which has been shown to curb drug cravings, ease symptoms of withdrawal and improve retention rates in rehab programs. This means that to be successful, any measures taken will have to include easier and expanded access to certain medications, as well as the development of new medications that can fight opioid addiction at the molecular level. Earlier this year, the National Institutes of Health – the largest funder of medical research in the world – announced it was meeting with numerous pharmaceutical companies to work on finding new solutions – anti-addiction medications, overdose reversal drugs, and more effective, non-addictive painkillers. The hope is that by developing new tools to fight pain, dangers opioids will become obsolete.

Solution #4 – Expand the Availability of Naloxone

Naloxone – sold under the brand name Narcan – is an emergency medication that saves lives by rapidly reversing an opioid overdose. Although many first responders such as police officers, EMTs, and firefighters carry the medication, and although pharmacies in over 30 states sell Narcan without a prescription, there is still room for improvement.

  • “Many” or even “most” is not enough. Narcan needs to be standard issue for every first responder, law enforcement officer, hospital, clinic, high school, college, and homeless shelter in the country.
  • Increase public knowledge about “Good Samaritan” laws, so no fears being arrested during an emergency overdose.
  • Regular training sessions for the general public should be held in every city.

Solution #5 – Treat Opioid Addiction Like an Illness

Poor public perception can impact recovery. Even though chronic substance abuse is recognized as a legitimate medical condition, there is still a stigma attached to anyone admitting to alcoholism or drug abuse. People with an addictive disorder are looked upon as weak and somehow unworthy. Even family members of a substance abuser will hide their loved one’s illness out of shame and embarrassment. The stigma is glaringly apparent in a number of ways. People with an SUD or a criminal record related to their illness are more likely to:

  • Be denied housing
  • Lose custody of their children
  • Have problems getting or keeping a job

Each of these problems contribute to continuing instability and stress in their life—both of which can trigger a return to active substance abuse. However, when addiction is treated as a medical problem, instead of strictly a criminal/social, then there is a shift in the opportunities afforded people in recovery.

Solution #6 – Make the Drug Companies Pay for Treatment

As mentioned earlier, the dishonest practices of some drug companies greatly contributed to the opioid public health crisis. And while the fines levied against drug companies hardly make a dent in their profits, that money can make a huge difference if it is funneled into public awareness, prevention, and treatment programs. There is already a precedent. As part of the largest civil litigation case in American history Big Tobacco has paid out BILLIONS of dollars, much of it specifically earmarked for public anti-smoking campaigns and cessation programs. And it’s working – in 1998, over 24% of adults in the United States smoke cigarettes – more than 47 million people. By 2015, cigarette use had dropped to just over 15%. Why not Big Pharma? The 21st Century Cures Act was lauded as one of the most monumental pieces of legislation ever introduced to fight addiction, and it only allocates $1 billion towards the struggle. Purdue Pharma has made over $31 billion from OxyContin alone. It’s not difficult to imagine how much good that kind of money could do. That kind of favorable eventuality may be coming. Several states – and even individual counties and cities – are currently suing a number of top drug companies, alleging their corporate responsibility for the devastation that the opioid epidemic has wrought on their communities. Among the companies named are:

  • Purdue Pharma
  • Johnson & Johnson
  • Watson
  • Insys Therapeutics
  • Endo Pharmaceuticals
  • Janssen Pharmaceuticals

Josh Hawley, the Attorney General for the State of Missouri, says, “These companies knew that the drugs they sell and market are highly addictive, even life-threatening if misused. And yet they have engaged in a deliberate campaign of fraud to convince Missouri doctors and Missouri consumers otherwise.” In what may turn out to be a watershed moment, the Chicago Tribune reported in early August 2017 that Insys Therapeutics had reached a $4.5 million settlement with the State of Illinois. While (comparatively) that may not sound like much, that is just one company and one lawsuit. With any justice, it may lead to more settlements from other companies, more millions of dollars that can be used to prevent and treat opioid addiction and other substance abuse disorders.

Where Do We Go from Here?

Two things are clear – FIRST, we as a nation cannot allow the opioid crisis in America to continue. The cost, both in human and economic terms, is simply unsustainable. SECOND, current efforts don’t go far enough. There needs to be a national paradigm shift where we become willing to make the massive investment in time, research, and resources needed to overcome the greatest public health crisis to hit America in decades. That’s not hyperbole – in 2016 alone, more Americans died because of drug overdoses than the entire 20 years of the Vietnam War. Dr. Keith Humphreys, PhD, a Professor with the Stanford School of Medicine, says, “Crises in a nation of 300 million people don’t go away for $1 billion. This is the biggest public health epidemic of a generation. Maybe it’s going to be worse than AIDS. So we need to go big.”