This is the second in a series on opioids, arguably the largest public health crisis of the early 21st century. The goal is to give context through education and facts to supplement the daily news about overwhelmed neighborhoods, police and emergency rooms battling overdoses. Part 1 can be found here.
During the last few days of writing this piece searching “opioid epidemic” in Google News returns from 140,000 to 166,000 items with hundreds in just the last month. Searching “heroin epidemic” returns over 370,000. To understand this epidemic we first need to understand what opioids are. Most of us are probably familiar with the term “narcotic” and in the past may have viewed narcotics as being “street drugs” like heroin or pain relievers administered in the hospital via IV like morphine. More concretely:
nar·cot·ic (nar-kot'ik), 1. Originally, any drug derived from opium or opium-like compounds with potent analgesic effects associated with both significant alteration of mood and behavior and with potential for dependence and tolerance.
2. More recently, any drug, synthetic or naturally occurring, with effects similar to those of opium and opium derivatives, including meperidine, fentanyl, and their derivatives.
3. Capable of inducing a state of stuporous analgesia.
[G. narkōtikos, benumbing]
opioid [ō′pē·oid] Etymology: Gk, opionm, poppy juice, eidos, form
Strictly speaking, pertaining to natural and synthetic chemicals that have opium-like effects similar to morphine, though they are not derived from opium. Examples include endorphins or enkephalins produced by body tissues or synthetic methadone. Morphine and related drugs are often included in this category because the term narcotic has lost its original meaning.
So for our purposes we can use narcotic and opioid interchangeably with the understanding that technically opioids are not derived from opium as morphine is. The other thing that we need to understand is the idea of “morphine equivalent doses” or MEDs:
An MED is a numerical standard against which most opioids can be compared, yielding
an apples-to-apples comparison of each medication’s potency. Although it’s easy to
presume that 10 mg of medication A are equal to 10 mg of medication B, differences
in how opioid medications work in the body prohibits this sort of comparison, thus the
need for calculating the MED of each. It is not about a medications efficacy or how well
it works, but about its relative potency.
Morphine is used as the basis for this comparison because it is considered the “gold
standard” for the treatment of pain. Because there are many other derivatives of
morphine used today, such as oxycodone, knowing the MED helps determine if the
patient’s opioid doses are excessive and is useful if converting from one opioid to
The standard MED is computed using 120 mg morphine although some have begun using a more conservative 100 mg or even 90 mg.
In part 1 we noted that WCRI found the average MED for non-surgical injured workers in NY and LA to be 3,400 mg or enough to take a 5-mg Vicodin® every 4 hours every day for nearly 4 months!
This need for "apples-to-apples" comparison is very important, not least for guiding prescribing doctors when changing from one opioid to another. Here is a calculator geared towards clinicians Opioid Equivalents and Conversions: Overview and another towards researchers Opioid Dose Calculator.
Aside from pain relief the other well-known property of narcotics is the “high potential for abuse”—that is, almost guaranteed addiction with prolonged use. Other key pharmacological aspects:
o Fortunately there is no conclusive evidence showing damage to the kidneys and liver from chronic use.
o Shallow breathing limits removal of carbon dioxide from the blood stream, in severe cases affecting blood pH and subsequently organ systems.
In short, these are serious substances that should be used in only limited fashion.
We are not going to look at the factors that drive individual people to abuse narcotics. But we can look at some of the things that have driven the rise of this outbreak.
1. Over prescribing and incorrect prescribing.
Part 1 touched on this specifically in the workers’ comp industry, but most doctors see few, if any WC patients. There is no reason to believe doctors treat patients differently based on who is paying the bill.
The Canadian Medical Association Journal published a small paper on fentanyl prescribing in April of 2016. Fentanyl was inappropriately prescribed 74% of the time overall, with the good news being incorrect prescribing dropped from 84% to 50% over the course of the study.
Fentanyl given to someone who has never taken opiates is always incorrect.
A Canadian pain management expert blames opiate prescribing practices for fentanyl overdoses. And another Canadian doctor also clearly states that prescription opiates and inappropriate prescribing are the root cause of the problem.
Here is a 2014 NY Times article on prescriptions opioids as the primary gateway to heroin use. Once you are addicted heroin is appealing as the cheaper, easier to procure alternative.
And March, 2016 from the Chicago Tribune:
Ninety-nine percent of primary care doctors routinely prescribe potentially addictive opioid painkillers for longer than the three-day period recommended by the Centers for Disease Control and Prevention, according to survey results released Thursday by the National Safety Council.
The Itasca-based nonprofit also found that doctors routinely prescribe the drugs for unsuitable conditions, such as lower back and dental pain, and that they often overlook nonaddictive medications some research has shown to be more effective.
2. Marketing by the manufacturers.
I mentioned working on this series to a medical doctor I know and she suggested I look into the required CME (continuing medical education) units on pain management mandated by the California Medical Association. “In these classes they tell us we are not prescribing enough,” she said. By the way, she is a psychiatrist, not a primary care doctor. While I couldn’t find much confirmatory evidence (you have to be a doctor to access the materials) I did see that the courses offered by The American Academy of Pain Management use doctors who are compensated by pharmaceutical companies, such as Pfizer, Purdue, AstraZeneca and Lilly.
In February 2009 Dr. Art Van Zee, MD published The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy in the American Journal of Public Health. Dr. Van Zee gives a detailed account of the initial promotion and marketing by Purdue, the makers of OxyContin®.
Dr. Van Zee points out that misrepresenting the risk for addiction was costly for Purdue, who pled guilty in 2007 to misleading doctors and the FDA about addiction and abuse potential and were ordered to pay over $600 million in fines.
But today, there are those who think it was not enough. The late David De Paulo, a prominent workers’ comp thinker and blogger states flatly that Comp Should Sue Purdue and points to a multipart LA Times investigative piece. I found this through a post over on Managed Care Matters, Opioids – You Have No Idea.
A few days later on the same blog, Joe Paduda highlights the fact that the pharmaceutical industry is currently very actively lobbying against constraint in a piece called What it’s like fighting against the opioid industry.
3. Lack of “medication education” for patients.
This is something I haven’t yet gathered much evidence about. But I have been continually surprised by the lack of understanding of the importance of proper medication adherence among my friends and family. Education is a key component to reducing addiction and abuse—for patients and non-patients alike. [Over on Linked In I came across this post Know your NSAID that teases with “About half of the responders to a small online survey said they didn't know what an NSAID was, nor did they know why they are used.” Non Steroidal Anti-Inflammatory Drugs are often used as a non-narcotic alternative to opioids for pain relief]
One big misunderstanding people have about pain medication is that it can fix pain; it cannot, as the Cleveland Clinic points out in number 6 of its 6 myths about pain killers. Both narcotic and non-narcotic pain relievers only mask pain. The other big myth that persists is that good people can’t get addicted. In this day and age we are very prone to thinking we are the exceptions to the rule, whatever the rule is. Nearly always it just isn’t true.
In the third part of this series we look at a sampling of the seemingly unending bad news to further understand the scope of the problem. Part 4 will shift to a more positive view, looking for actions that will lead to resolution of the opioid crisis.
Narcotic drug. (n.d.) Farlex Partner Medical Dictionary. (2012). Retrieved from http://medical-dictionary.thefreedictionary.com/Narcotic+drug
opioid. (n.d.) Mosby's Medical Dictionary, 8th edition. (2009). Retrieved from http://medical-dictionary.thefreedictionary.com/opioid
Opioid Equivalents and Conversions: Overview
Opioid Dose Calculator
Opioid Medications: Use and Abuse, 2011 webinar by Coventry Workers’ Comp Services
Safety of fentanyl initiation according to past opioid exposure among patients newly prescribed fentanyl patches
http://theweek.com/articles/541564/how-american-opiate-epidemic-started-by-pharmaceutical-company (Another piece on Purdue from March 2015, not directly referenced above)
Jesse Sharp is an expert in the analysis of health care data. Passionate about data and the ethics of analysis he writes on topics related to medicine, public health and statistics. More...