Use of opioid-based pain management pharmaceuticals is being evaluated with a critical eye because of their highly addictive qualities – sometimes observed to be a gateway to heroin and fentanyl abuse - and risks of overdose often leading to fatalities.
Asheville Museum of Science invited Katie Leiner from MAHEC (Mountain Area Health Education Center) to give her presentation at The Collider about the Opioid Crisis in America.
Leiner began by addressing that bottle of unused cough syrup parents might have lingering in their medicine cabinet. “Codeine is an opioid narcotic used in cough syrup, not recommended for those who are pregnant or under 18 years old. A lot of people would get this and leave what was left over in their medicine cabinets. Their kids would put this in their water bottles and drink it throughout the day,” she said.
Next, Leiner moved on to a more sinister threat. “Oxycodone is the most tradable pill on the market. It goes for about a dollar per milligram, but now a 30 mg tablet sells for $45 to $50 on the street. Fentanyl is about 50 to 100 times more powerful than heroin. In Western North Carolina we’re unfortunately lucky enough to have powdered heroin from China and black tar heroin from Mexico.
Deaths from opioids in the last ten years numbered 254,000, according to Leiner. “That’s more than four times the number of American deaths from the Vietnam War.” In 1980 Dr. Hershel Jick and his assistant Jane Porter of the Boston Collaborative Drug Surveillance Program at Boston University Medical Center conducted a research study of almost 12,000 patients who received at least one opioid narcotic in the hospital, and thereafter had published a letter to the editor of the New England Journal of Medicine titled “Addiction Rare in Patients Treated With Narcotics.”
They found only four cases of reasonably well documented addiction in these patients. Their conclusion was that despite widespread use of narcotics in hospitals, addiction was rare in patients who had no history of addiction. Leiner said the conclusion that fewer than one percent of opioid users become addicted to these drugs has been cited for many years by pain specialists, nurses, pharmaceutical representatives, and education providers.
“Several years later, 72 percent of the journals used this as evidence that opioids do not cause addiction, and 80 percent of journals failed to note that this was an inpatient study that misrepresented these findings,” Leiner said. A comprehensive statement on pain was published, and sponsored by Purdue Pharma (the manufacturer of Oxycontin). Leiner told the audience the statement said, “some clinicians have an inaccurate and exaggerated concern about addiction, tolerance and risk of death, stating that this attitude stands even though there is no evidence that opioid for pain control increases the risk of addiction.”
Hospitals started sending patients home with surveys asking how successfully their doctors managed their pain. “If doctors didn’t adequately treat their patient’s pain they weren’t paid. Therefore, they were incentivized to overly treat their patient’s pain, and were also told that opioids didn’t cause addiction, so they overprescribed opioids.”
As of 2017, there were 51 opioid pills per resident (including children) prescribed in North Carolina. “In Buncombe County it was 50 to 74. The U.S. shares four percent of the world’s population, but it takes in 80 percent of the world’s opioid consumption. The prevalence of current substance abuse disorder is estimated to be as high as 43 percent,” Leiner said. Eighty-three percent of the world uses no opioids at all.
Data has also come out that there is little efficacy of opioids for chronic pain. A systemic review on opioid treatment for chronic back pain, and four studies, indicated that opioid treatment did not show reduced chronic pain when compared to a placebo and non-opioid pain management.
In 2016, data show opioids were responsible for the most overdoses. Other synthetic narcotics, which include fentanyl and heroin, are also on the rise. As doctors are prescribing fewer opioids, people are buying very potent and inexpensive heroin on the street. Heroin is now frequently laced with fentanyl, which, once again, is 50 to 100 times more powerful than heroin. Fentanyl is more profitable than heroin because it can be made in a laboratory vs. heroin, which requires growing a crop of poppies.
In order to understand our response to the opioid crisis, Leiner said it’s important to note that people who are using drugs and have a substance abuse disorder are operating in a stigmatized context of judgment when they seek treatment. When crack emerged in the 1980s, it made cocaine available in small, inexpensive quantities. Coupled with crack being more addictive than other types of cocaine and a rise in crime, so many people assumed that crack users were synonymous with criminals.
There have been efforts to mitigate the occurrence of opioid overdoses. Fewer people are getting prescriptions for high doses of opioids. “Since January 2016, it’s reduced by 33.1 percent. Opioid prescriptions in general declined by 10.2 percent in 2017.” In Western North Carolina the most common form of treatments are abstinence-based programs. Sadly, 90 percent of the people who enter abstinence-based therapy return to their drug of choice within a year.
Medication assisted treatments with drugs such as methadone reduce cravings and withdrawal. Naltrexone injections are a less widely used treatment recommended for highly motivated individuals. It is an opioid antagonist that completely blocks the body’s opioid receptors, but is less effective than methadone at managing cravings. “An interesting statistic is that every dollar invested in addiction treatment returns a yield of four to seven dollars in reducing drug related crimes, criminal justice, and theft,” Leiner said.