In last month’s The Sober World Magazine, I reviewed the biological, psychological and sociological aspects of the disease of addiction; and differentiated tolerance, dependency and addiction. I also listed ten reasons of who or what to blame for the heroin/opiate epidemic raging through our cities, suburbs and rural America. The reasons include:
1. War in Afghanistan
2. Injudicious Prescribing by MD’s
3. Patient Expectations
4. Internet Sale of Pain Pills
5. OxyContin Reconstitution
7. Supply & Demand – “War on Drugs”
8. Physician Training & Biases
9. Mental Health Treatment
10. Public Officials
Last month’s article reviewed how the War in Afghanistan has fueled the heroin epidemic
in America. Today, we will discuss three more reasons for the opiate scourge.
When I was a medical student some decades ago, we were taught to very carefully prescribe opiates, such as Morphine, Demerol, Percocet and other pain medications typically referred to as “narcotics” (opiates). Well, it came to pass that we as physicians were under-medicating patients for relief of pain. In fact, it has been shown that for severe pain, if the patient waits for the pain to recur to high levels before taking their next dose of medication that in fact it may require larger doses of medication to again relieve the symptoms. With improved understanding of pain syndromes, physicians became more educated regarding opiate prescribing.
However, the pendulum has swung too far in the other direction and there are several factors contributing to this such as: patient expectations to have “all” pain eliminated; “Big Pharm” focused on profits; the increasing number of pain pills available on the internet; and the need for additional medical education so physicians do not inappropriately prescribe pain medications to patients at risk of addiction and/or prescribe in excessive dose amounts, frequency of administration or length of treatment.
In general, long term use of opiates in most cases of non-cancer pain has not been shown to be advisable. However, for intractable pain, exceptions may need to be made. Fortunately, many states now have continuing medical education requirements that obligate physicians to take courses in appropriate opiate prescribing as a prerequisite to renewing their medical licenses.
So, yes we can and should blame the doctors for the increase in opiate/heroin addiction, but as we explore the other reasons, it will be clear that this is not just a physician prescribing issue – there is plenty of blame to go around. Let’s look at what role patients may play.
Returning to reflect on my past as a medical student, I chose not to enter the field of Pediatrics despite loving the kids, relishing in a work environment of toys and games in the waiting room, and finding ways to entertain and distract kids while at the same time investigating their ills. Sure it’s tough when a young patient becomes extremely ill, is diagnosed with a terminal disease, or dies. But that is not why I shied away from this specialty. Simply stated, it was the ear infections!
A large number of early ear infections are caused by viruses. When Mom or Dad arrived with little Johnnie or Suzy pulling at an ear and acting fussy or not eating well, the diagnosis was easy. However, suggesting initial treatment with Tylenol and decongestant remedies was frequently fraught with contempt, despite taking the time to explain how antibiotics do not treat viruses, can have annoying or harmful side effects, and can lead to antibiotic resistance. So despite my reasoning why we should hold off prescribing antibiotics and recommending a re-evaluation in a day or two if not improving, I would not infrequently hear responses such as: “My neighbor’s son had an ear infection and he got antibiotics”, or “I want my son to take an antibiotic”, or “I don’t care that you think it might be a virus – I have a busy life; why can’t you just prescribe an antibiotic and that way I won’t have to come back if my child’s not doing better.” You get my point; parents want quick fixes for their children and we as a society want quick results for ourselves. And when it comes to pain, Americans frequently have a common request, “Can’t you just put me out?” or “I don’t want to feel anything.” I wonder how many Americans would opt to have surgery under acupuncture!
So yes we can and should blame the doctors; but patients also contribute to the dilemma and in more ways than just their simply asking for complete pain relief. It is not practical to review all the ways prescription drugs find their way into so many lives, but I encourage everyone to read the article by the National Institute on Drug Abuse: Popping Pills: Prescription Drug Abuse in America. It clearly explains factors such as:
Where prescription drugs are obtained?
• Bought on the internet
• Drug dealer or stranger
• Bought/took from friend or relative
• Free from friend or relative
Some of the reasons teens use prescription drugs:
• Easy to get from parent’s medicine cabinets
• Available everywhere
• They are not illegal drugs
• Easy to get through other people’s prescriptions
• Can claim to have prescription if caught
• Less shame attached to using
• Fewer side effects than street drugs
• Parents don’t care as much if caught
• Easy to purchase over the internet
The last bullet brings us to the next reason of who or what to blame for the heroin/opiate epidemic: Internet Sales of Pain Pills – an easy way to get prescription drugs without a doctor’s approval. All one needs to do to fully understand the intricacy of the internet business of selling pharmaceutical drugs is to go to www.StreetRx.com “StreetRx.com gathers user-submitted information on street prices of diverted prescription drugs. Visitors can anonymously view, post and rate submissions in a format that offers price transparency to an otherwise opaque black market, while providing a novel data set for public health surveillance.” www.radars.org/home2/programs/streetrx
The detail of the information is quite revealing as to the black market sales of medications that are purchased to “get high” or to offsetwithdrawal symptoms or to self-medicate for a variety of reasons. Here is a sampling of the information one might find on the internet:
$60 Reasonable OxyContin (hard to crush) 60 mg Hartford, CT
$25 Cheap OxyContin (old OC-crushable) 20 mg Wiscasset, ME
$3.75 Reasonable Methadone 10 mg Hartford, CT
$15 Pricey Oxycodone 15 mg Burlington, VT
$3 Overpriced Oxycodone 5 mg Providence, RI
$10 Overpriced Dilaudid 2 mg Worcester, MA
There is plenty of blame to go around but we cannot ignore the ease by which one can illicitly purchase mind altering drugs with just a simple click of the mouse. As a result, our kids and our neighbors can easily get hooked on pharmaceutical pain (opiate) pills and then many will switch to heroin (a first cousin to morphine and other opiates) because the heroin of today is so cheap and so pure. And because of its increased potency, you can snort it – no needles needed!
As a final thought, we must wipe out all our past visions of what a heroin addict looks like. It has become a white suburban disease and women in their 20’s and 30’s are among the most rapidly increasing group of heroin users. In next month’s and subsequent articles, I will explain how “Big Pharma” also plays a role; that many physicians are also biased toward patients who have drug dependency/addiction issues; and how medical schools are woefully deficient in providing sufficient education and addiction training to students.
One of the main reasons I wrote Addiction on Trial was to bring to light the complexities of addiction and to destigmatize the illness; but to do so in an entertaining manner to reach a wide audience of readers. I am extremely pleased that Addiction on Trial has been added to a medical school curriculum to give students an inside look at the complexities and to hopefully mitigate bias before it sets in. I look forward to sharing more with you in future editions of The Sober World Magazine.
Dr. Kassels has been Board Certified in both Addiction Medicine and Emergency Medicine. He serves as the Medical Director of Community Substance Abuse Centers. He is the author of “Addiction on Trial”, written as a murder mystery/legal thriller to reach and educate a wide range of readers. The book has recently been entered into medical school curriculum to help decrease physician bias. The book is available at: Amazon (www.amazon.com/Addiction-Trial-Tragedy-Downeast-Maine/dp/1491825316) and free author book club presentations and educational meetings (in person or using Skype) can be arranged at: www.addictionontrial.com/author-events/