It may not become common knowledge anytime soon, but if Shakespeare was right that the truth will out, Americans are headed for a remarkable realization.
The worst public health crisis in our time was brought about by the practice of medicine.
There’s little precedent for the pivotal role of American health professionals in the creation of the Great Painkiller Plague of the early 2000s — a genie of opioid and opioid-equivalent use, addiction and early death that until now has been effectively mischaracterized as “opioid abuse,” and which multiple federal entities have now begun scrambling to put back in the bottle.
In the past, great waves of sickness were spread through close contact, poor hygiene and tainted wells. Beginning in the 1990s, however, it fell upon unwitting doctors and a captured medical system to set in motion this drug group’s signature trajectory in far too many users: tolerance, addiction, sobriety, relapse, overdose. That our medical system managed to trigger this by telling us something as unconvincing as it did says as much about our times as it does about the power of the opium poppy.
The system told us we could take heroin, more or less, for back pain.
The long-delayed correction of that lie may finally have arrived, to judge from the flurry of regulatory and legislative efforts now underway to reel in the propaganda of the opioid era. Congress is set to deliver comprehensive addiction and recovery legislation. The president has authorized a $1.1 billion initiative to combat addiction with new medications. And last month saw the release of new guidelines from the Centers for Disease Control and Prevention (CDC) that define long-term use of opioids as medically unsound.
Because the federal government cannot direct the activities of doctors, it will fall to the state medical boards and legislatures to give these guidelines teeth — to treat the professional practices that got us here as unethical and subject to sanction. It’s hard to imagine those laws sweeping the land. But if Minnesota lawmakers should care to join Massachusetts and Florida in reigning in doctors, they now have official support from the federal agency for public health.
As of last month, the CDC has described opioid use as an epidemic, and one caused by prescribing, as opposed to the diversion of drugs produced for legitimate new use. It has been suggested that physicians offer the pills in no more than three-day doses, warning that, when it comes to opioids for non-cancer chronic pain, “for the vast majority of patients, the known, serious, and too-often fatal risks far outweigh the unproven and transient benefits.”
Even the U.S. Food and Drug Administration is walking back its long-standing embrace of the harm-denying mind-set that gave us these pills. After approving the sale of every last tablet and opioid-use indication that created this problem, the agency has decreed that labels for all opioid pain pills must now carry warnings about their potential for addiction, overdose and death.
That’s the FDA for you. Runs over your kid in the parking lot, then shows up at the funeral with a plate of brownies.
But sources who know believe the new CDC guidelines mark a substantial shift in thinking. “It has championed the message that the medical community caused this epidemic,” says Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing and chief medical officer of Phoenix House, a national network of treatment providers.
Kolodny believes doctors will listen to the CDC, which is not beating around the bush. “For the very first time, the federal government is sending a clear message to the medical community that treating common conditions with long-term opioids is inappropriate, and that by doing this we are harming our pain patients and fueling an epidemic of addiction. We have not heard that before now.”
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We may not have heard that doctors are behind the problem before now, but we have heard the outrageous numbers that measure the opioid epidemic. They defy reason. Prescribing rates depict an early 2000s proliferation of pain pill prescriptions that was hopelessly disconnected from what should have been a stable percentage of patients whom the drugs could actually help.
Few would suggest that the pre-Oxycontin early 1990s represented some sort of dark ages in medical care — of lives destroyed by narcotic-free sciatica, headache, neck pain, sprained ankles, fibromyalgia and post-dental-work anguish. Yet following widespread promotion beginning in the mid-1990s, the use of slow-release opioids for chronic conditions was greeted like the invention of penicillin in wartime. By 2010, painkillers had become the third-most prescribed class of drugs in the country. By 2012, there were 289 million opioid prescriptions dispensed in the U.S. — roughly a bottle of opioids for every adult in the nation.
Prior to that time, these conditions had been treated with Advil and Tylenol; long-term use of opioids was known to create tolerance and dependence, the hallmarks of addiction and increasing need. To this day there are no randomized control trials showing that opioids are safe and effective for long-term use. To the contrary, animal and observation studies suggest the drugs actually make pain worse over time, a paradoxical effect known as hyperalgesia.
“Back pain, neck pain, headache pain, fibromyalgia, there’s actually no indication that opioids help those conditions,” according to Jeannie Sperry, a pain-management clinician in the Comprehensive Pain Rehabilitation Center at Mayo Clinic. “… [A]fter about 30 days they start making pain worse.”
Should we think of the pills as treatments, or narcotics? Given their ineffectiveness for chronic use, opioids for chronic pain are effectively Schedule 1 drugs (addictive drugs with no medical benefit ) masquerading as Schedule 2 drugs (addictive drugs with limited medical benefit). At a minimum, the Drug Enforcement Administration would have had every right to deny each request seeking higher production limits for these narcotics. But the nation’s drug police did not raid the warehouses filling up with Percocet, Vicoden and OxyContin, because, when it comes to prescription drugs and their production, physicians are the parties to whom even law enforcement defers.
This enabled a fourfold rise in opioid prescribing between 1999 and 2015, a trend accompanied by a four-fold rise in opioid overdose. In his recent New England Journal of Medicine position statement accompanying the new guidelines, CDC director Thomas Frieden described the relationship of prescribing and sickness as a “tightly correlated epidemic of addiction, overdose and death from prescription opioids.”
Death rates have begun rising in the era of opioids, but for whites only, a suggestion that the epidemic has indeed been passed along through contact with the medical system. Two groups historically denied access to health care — blacks and Hispanics — have not seen death rates rise. It’s likely that in this way stigma has spared minority communities from claiming their share of the 165,000 Americans killed by painkillers.
Because 80 percent of heroin users started out on pain pills, and the two drugs act the same way within the body, their combined death rate is a more accurate measure of harm. At 28,000 deaths annually, the toll now rivals that from car accidents and firearms.
Opioids have created secondary sickness in the form of opioid-induced hypogonadism (it’s believed to be part of the demand for drugs targeting “Low T” — testosterone), hearing loss and, of course, opioid-induced constipation (the subject of a notorious, dystopian Super Bowl advertisement). The demand for new drugs to wean patients off opiates will be high as well. One, Suboxone, sells for more than $500 a month and, according to opinions shared online, requires an even lengthier period of withdrawal than do opioids.
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Doctors were misled in this misadventure and should be angry at their leadership, which allowed the capture of continuing medical education by the likes of Purdue Pharma, makers of OxyContin. As has been widely documented, the company spent $200 million for 20,000 opioid training lectures given to doctors, often at tony resorts, and the investment paid off. The drug has earned Purdue $35 billion so far.
The messages in these lectures depicted the potential for addiction from opioids as minimal. State medical boards were persuaded to inform doctors they could be punished for not prescribing opioids for chronic pain. The pain lobby even persuaded hospitals and the VA system to adopt pain as a “fifth vital sign.”
That explains why a receptionist approached me recently as I waited for an appointment for an age-related condition. The receptionist asked whether I was in pain and, if so, to rate it on a scale of 1 to 10. I may have notified them on the phone that I was somewhat uncomfortable, but at the time of my “fifth vital sign” check I was reading a “National Geographic,” an indication that the sign in my case was surely not vital.
The CDC has stated that prescriptions for acute pain should not be written for longer than three days. It says that long-term use of opioids should begin only after all other methods have failed, and even then after a thorough briefing on the risks and whether they are outweighed by the small benefits. It basically is saying there is no good reason for opioids over the long haul unless your life is an uncomplicated horror show of misery that you would like to enhance with drug addiction.
It’s a sound public safety message that is currently being violated by every single doctor in America. A survey just released by the National Safety Council shows that 71 percent of doctors prescribe opioids for back pain and that 99 percent prescribe the pills for longer than three days. Nearly 1 in 4 doctors in the survey said they had given them out in 30-day bottles, a duration shown to make changes in the brain.
So we may have been lied to about the safety of opioids, but the lying goes back a long way with this one. Designers at Bayer picked the name Heroin for their cough syrup opiate because they wanted users to believe they were taking something heroic. They were trying to make a safer form of morphine, but accidentally made a stronger form instead. They lied about that, too, and eventually heroin was banned. For some reason, all talk of banning opiates outside of hospitals has no traction today. “That train has left the station,” as one partisan blasted on Twitter.
Decades before heroin, the pharmacist who isolated the active ingredient of opium called his discovery morphine. He told the truth. Morpheus was the god of dreams.
Which is where opiates have taken us, into the land of dreams, sometimes nightmares from which you never wake. That happened to a young man of 25 found dead of a heroin overdose in a bathroom at the Apache Mall in Rochester, Minn., last summer.
If you could see the Apache Mall, with its Macy’s and its Gap, you would know that this event deposited the opioid epidemic at the doorstep of small-town America. The deceased’s name was John Weivoda, and he had just completed treatment. He wanted more time to stabilize his sobriety, according to his father, but the insurance stopped after four weeks.
Like many kids, he had dabbled in drugs as a teenager, but according to his twin brother, whom I met last fall at a rally outside the Federal Office Building in Minneapolis, John did not discover opiates until he hurt his back while laying carpet.
He was given the drugs by a doctor, “and it kind of snowballed on him,” Weivoda’s brother said.
It makes me feel lucky that when I hurt my back at 26 in the early 1990s, all they offered were muscle relaxants.
Bathrooms in malls and fast-food courts are becoming new places of death in our time, according to a recent New York Times story, with addicts hoping to get the drugs in their system as soon as they acquire them. This is the sort of trend that changes the landscape. It places the sense of urgency we are supposed to feel about noncancer chronic pain in its proper context.
It’s true what chronic pain patients say — their pain is real. But the greater good for society in this story is no mystery.
We just might need to return to the impossibly cruel and premodern pain-control methods of the Clinton years.
Paul John Scott is a health-sciences writer living in Rochester. Twitter: @pauljohnscott