Over 400,000 Americans have died from opioid overdoses in the last two decades and millions more have become addicted. The numbers continue to escalate. This is because the federal government’s response to the epidemic has been the equivalent of closing the barn door after the horse has escaped, then injuring or killing many of the horses who haven’t escaped.
How the opioid epidemic started
There is considerable consensus in the medical community about when the epidemic started. Opioid addiction has long been a problem afflicting young people in poor, mostly urban communities. It was only after Purdue Pharma began aggressively marketing its extended release opioid, Oxycontin, to physicians, claiming it was safe to prescribe widely to pain patients, that the problem of opioid addiction began spreading to rural and suburban communities and began affecting people of all ages and income levels.
Purdue Pharma and other pharmaceutical companies claimed that the addiction rate would be a fraction of 1%. The most comprehensive study to date, a literature review that was published in the journal Pain in 2015, estimated the addiction rate of patients in pain prescribed opioids was 8-12%.
The U.S. is targeting the wrong population in the wrong way for opioid reduction
A rate of 8-12% for a serious complication from a pharmaceutical drug is extremely high, even when compared to pharmaceuticals in general, which often have serious adverse effects. That still leaves 88-92% of patients prescribed opioids who will not become addicted. Virtually all of those non-addicted patients, however, will become dependent on opioids. That means that their bodies will make an adaptation to ingesting the drug that will result in withdrawal effects if the drug is discontinued. They will also develop tolerance, which means that, because of their body’s adaptation to the drug, more opioids will be needed over time to achieve the same level of relief. Higher doses lead to a higher risk of adverse consequences from taking the drug.
Cindy Perlin
Prescribing an opioid to a new patient, even for acute pain, is like playing Russian roulette. While there are certain characteristics, such as being young, having a history of addiction or a history of emotional trauma, that can raise the risk of addiction, anyone can become addicted. It is impossible to predict who it will be. In fact, surprisingly, a 2015 study published in the journal Pediatrics found that, “Use of prescribed opioids before the 12th grade is independently associated with future opioid misuse among patients with little drug experience and who disapprove of illegal drug use.“ Middle-aged housewives and senior citizens with no prior history of addiction have also become addicted.
There is a group that we do know will not become addicted. That is the group of chronic pain patients who have been taking the drug long term, as prescribed, sometimes for decades, who show no evidence of addiction. This is a group of patients who believe that the benefits of their use of opioids, i.e. pain reduction, outweigh any negative side effects. That is also the group that has been most negatively and unfairly affected by US drug policy.
U.S. opioid policy has targeted physicians treating patients in severe pain for criminal prosecution
Initially, when the scope of the opioid problem was becoming clear, the federal Drug Enforcement Agency (DEA) began targeting “pill mills” for raids and prosecution. These are clinics that are run by doctors who prescribe large amounts of addictive drugs to people who are not their patients and who have no legitimate medical need for the drugs.
When those efforts failed to stem the tide of addiction, the DEA began targeting doctors who were prescribing large doses of opioids to their patients who had severe chronic pain. Even though these doctors were following standard medical procedures of the time, these doctors’ offices were raided at gunpoint and the doctors prosecuted as drug dealers. Their assets were immediately seized, depriving them of the resources they needed to defend themselves.
According to Linda Cheek, MD, who founded Doctors of Courage, over 1300 doctors have been charged, and close to 500 have served or are serving prison terms. Dr. Cheek was herself a victim of these practices. Those doctors who do not end up in prison often lose their licenses and suffer financial ruin. Dr. Cheek also reports that the targeted doctors tend to be minorities and/or practicing independently rather than working for hospitals. They do not have deep pockets to defend themselves.
When other doctors heard of these DEA raids, they were terrified. Many began refusing to prescribe opioids, often cutting their patients off abruptly, throwing these patients into withdrawal. Then, along came new guidelines from the Centers for Disease Control (CDC). These guidelines “recommended” that doctors refrain from prescribing high doses of opioids. Guidelines are considered “standard of care”, which doctors knew left them even more vulnerable. Even more doctors began cutting long term patients off from their medication.
Significant harm has been done to chronic pain patients by U.S. opioid policy
A study published in the Journal of Substance Abuse Treatment in August 2019 looked at Medicaid patients in Vermont from 2013 to 2017 who filled opioid prescriptions at dosages of at least 120 morphine milligram equivalents for 90 or more consecutive days and who subsequently discontinued opioid prescriptions. Half of the patients were discontinued in one day, with no tapering. 86% were discontinued within 21 days, which Is considered rapid tapering. 49% of those patients subsequently had an opioid-related hospitalization or emergency department visit. Although 60% of the patients were diagnosed as having a substance use disorder prior to discontinuation, less than 1% were transitioned onto an opioid use disorder medication.
Withdrawal symptoms after abrupt discontinuation of opioids can be very severe and include agitation, anxiety, muscle aches, insomnia, sweating, abdominal cramping, diarrhea, nausea and vomiting. While opioid withdrawal is not considered life threatening, the symptoms can be so unbearable that addicts will often do anything to get their next fix. Many pain patients who have been abruptly withdrawn from their medication are buying much more dangerous opioids, including heroin and fentanyl, on the streets. Treatment centers are reporting that 80% of new heroin users started with prescription opioids. Many other pain patients are reportedly committing suicide, driven to it by their unrelieved pain. It is rare that these patients have been offered other treatments for pain. Those who don’t hit the streets looking for drugs or kill themselves are left to suffer vastly diminished lives.
A study published Aug. 29 in the Journal of General Internal Medicine found that patients on chronic opioid therapy whose opioids were involuntarily discontinued were three times as likely to die of an overdose than patients who were kept on opioids.
At the other end of the spectrum, in acute pain care, the official word from the medical community and most of government is that opioids are the best treatment we have for pain. Opioids are almost universally prescribed after an accident, surgery or many minor medical procedures, including tooth extraction.
A study published in 2019 in JAMA Network found that dentists in the United States prescribed opioids 37 times as often as dentists in England. The frequent use of opioids in dental care are despite the fact that studies have demonstrated that a combination of ibuprofen and Tylenol is as effective or more effective than opioids for dental pain. The National Safety Council has produced an infographic similarly showing that a combination of Tylenol (acetaminophen) and ibuprofen are effective for a larger number of patients than opioids.
Failure to prevent unnecessary initiation of opioids ensures a steady stream of new addicts that will continue to fuel the opioid epidemic.
There are safe opioid alternatives the U.S. government is blocking
There are other alternatives for treating acute and chronic pain, but the U.S. government is either doing everything it can to block them or doing nothing to make them more accessible and affordable
The federal government continues to block access to marijuana, listing it as a schedule 1 drug, which means it is a drug with high potential for abuse and no known medical benefits. This is despite the fact that a significant number of medical benefits of marijuana have been found. Possessing or using it continues to be a federal crime. Marijuana has pain relieving properties superior, in many patients’ estimation, to opioids. It is not physically addictive, so there is no withdrawal. And it is far safer than opioids. Marijuana has been in medical use all over the world for over 10,000 years and in that time not one overdose from marijuana has ever been reported. Furthermore, it can prevent development of tolerance and ease opioid withdrawal.
The federal government has also attempted to block access to kratom, another safe, potent pain reliever. Kratom is an herb that grows in Southeast Asia. Kratom is being used by many pain patients as an alternative to opioids. It is a relative of the coffee family and no more addictive than coffee. Besides helping with pain, it can also help ease withdrawal symptoms from opioids. The DEA has tried to have kratom classified as a Schedule 1 drug and the FDA is trying to ban It on the basis that a few dozen people have died of it over the last few years. All of the people who died while using kratom had other drugs in their system that could have caused the fatality or had consumed kratom from one contaminated batch.
When efforts to ban kratom failed due to activism on the part of kratom users, representatives of the FDA reportedly paid a visit to Indonesia, where 95% of kratom used in the U.S. is grown. The purpose of the visit was to try to get the Indonesian government to ban its export. As a result, the Indonesian government has announced a ban to take place in 2024, giving farmers time to convert to other crops.
The U.S. could be doing much more to make safer treatments affordable and accessible
There are other herbs and supplements that have been proven to help with pain, such as turmeric and Omega-3 fatty acids. Federal law makes it a crime for producers or sellers to make medical claims for these substances without first going through the FDA drug approval process. This process, which costs hundreds of millions of dollars, is beyond the reach of those who produce and sell these substances.
There are many other treatments that are safe and effective in relieving pain. For instance, one study found that acupuncture was more effective than injected morphine for pain. Low level laser treatment is another potent intervention for acute or chronic pain. Other alternative treatments that are safe and effective for pain include biofeedback, chiropractic, nutritional interventions, physical therapy, and much more. Health insurers refuse to cover these treatments adequately or at all, and the federal government has done nothing to require coverage.
A sane U.S. opioid policy
A sane federal opioid policy would ensure that all options for pain management were accessible and affordable for patients in pain and would encourage the use of the safest options first. It would give doctors more options for treating pain and provide education about those options. And it would protect those whose pain is most severe and chronic from any action that would increase their suffering.
Cindy Perlin, LCSW is the founder of the Alternative Pain Treatment Directory and the author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free.