Overprescribing of Opioids

Throughout mankind, humans have experimented with drugs for a vast assortment of purposes. While some people use drugs for recreational use, most of the population will consume them for pain management. During the early 19th century, when Friedrich Sertümer isolated an active alkaloid in opium, known as morphine and pharmaceutical companies started to flood the market with morphine, the U.S developed its first opioid epidemic.

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Fast-forward to the present time, with the advances in chemistry and pharmacology (science of drugs and their interactions), our nation still hasn’t learned from past mistakes, resulting in another opioid epidemic. These prescription opioids that were meant to help patients manage pain is causing addiction leading to overdose deaths. The opioid epidemic that is so prevalent across our nation is due to the overprescribing of opioids by the medical community and predatory marketing campaigns from the pharmaceutical companies. With the use of alternative pain management methods, administered by healthcare practitioners and new guidelines placed our nation can overcome this opioid epidemic.

Opioids are used in healthcare to treat patients with acute and chronic pain, these drugs are also known by many as “powerful painkillers.” Originally derived from the poppy plant as opium, many of the today’s opioids are synthesized or semi-synthesized in the laboratory. Opioid drugs such as oxycodone (OxyContin), hydrocodone (Vicodin) and meperidine (Demerol) are the most commonly prescribed opioids in the U.S. To address the drug abuse that these opioids can produce. The Food and Drug Administration (FDA), working under the Controlled Substance Act (CSA), developed a subsection of prescription drugs in a category known as “scheduled drugs.” Scheduled drugs are drugs that have the potential for addiction and/or dependence. The FDA has demarcated a grading system ranging from I – V, with Schedule I drugs begin the most addictive and Schedule V drugs the least addictive. All drugs in Schedules II through V are presumed to have medical benefits and can be prescribed by a doctor with a valid DEA license. Schedule I drugs are drugs such as heroin and lysergic acid diethylamide (LSD) and according to the federal classification, they have no medical benefit and cannot be prescribed by a doctor under any circumstances. Prescription drugs such as oxycodone (OxyContin) and hydrocodone (Vicodin), which are prescribed by physicians for the treatment of chronic pain have a high possibility of abuse and are clustered in Schedule II.

Even though prescription opioids can have a positive outcome for the pain management, they can also affect the body in many ways and even cause addiction with long term use. These effects can range from confusion, nausea, drowsiness, and euphoria. In the article, The Problem with Painkillers, Miller states:

The risk of developing a painkiller addiction depends on more than just prolonged use of these drugs. In its clinical guidelines for prescribing opioid, the American Pain Society notes that the most significant risk factor for developing a painkiller addiction is a personal or family history of an alcohol or other substance use disorder. One review of 24 studies found that patients with chronic pain who also had a current or past substance use disorder were about 17 times as likely to develop a painkiller addiction as other chronic pain patients. (Miller, 2019 par. 4)

Can addiction be the first line of attack responsible for our nation’s current opioid epidemic? In an article, The Opium Odyssey: The Power of the Plant (1860), it states, “Opium addiction was never eliminated and has remained part of American culture from the 1700’s to the twenty-first century.” (The Opium Odyssey: The Power of the Plant (1860), 2018) In order to get addicted to something you need repeated exposure to an addictive stimulus. Since most people live a very fast and stressed life, developing different forms of addiction is unavoidable for some. When someone has a gambling addiction it doesn’t affect the nation, it only affects that individual and his/her family. On the contrary when someone is addicted to opioids it affects more than one person, it affects the whole nation. Such affects are loss of productivity, which causes lower revenue for the company. Another affect is that tax payers usually end up paying for government assisted treatments for the low-income patients on Medicaid. In the end everyone is either directly or indirectly affected by opioid addiction. It is the physician’s job to know everything about the patient, so they can help them overcome any chronic ailments without causing more problems for that person. For the patients that have a prior history of substance abuse, physicians should be wary about prescribing these strong drugs because it will cause more harm than good to that patient.

The fact that long term use of these opioids leads to addiction is no surprise. To fully understand how this epidemic all started it is important to look at the DEA and how their tactics changed the prescribing patterns of these opioids by healthcare practitioners. In the book, Pain Control and Drug Policy: A time for Change, Guy Faguet states:

The DEA uses familiar law enforcement methods from the War on Drugs, such as aggressive undercover investigation, asset forfeiture, and informers. Its tactics, especially vigorous and broadly publicized when prosecuting physicians suspected of drug malfeasance, have had a chilling effect on legitimate narcotics prescriptions. (Faguet, 2010, p.83)

When the DEA decided to put barriers on the pain treatment, patients with chronic pain started to suffer. It was reported that in 1997 nearly 97 million patients suffered from unrelenting pain. There were additional barriers including inadequate pain treatment in medical schools and a shortage of pain management specialists. With all the fierce enforcement done by the DEA, U.S. physicians feared being prosecuted by the state or federal government for drug distribution, manslaughter, or even murder for the deaths of patients that misused or overdosed on prescription opioids. With this fear, physicians started to under prescribe or use a lower dose for their patients. This had a trickledown effect which caused the patient to experience recurring pain, pain that was treated with the previous dosage strength.

It is reported that 80% of people suffering from chronic pain worldwide do not get the proper treatment they deserved. Having this problem leads to an assortment of additional problems for the nation and the person. The patient that has chronic pain that persists for weeks or even months and doesn’t get the proper treatment, can lead the person to depression, violence, alcoholism, and eventually suicide. There is an economic cost to society by this problem, which cost the United States an estimated $100 billion per year from medical expenses to lost wages. It is the DEA’s job to look over the prescribing of opioids but using fierce tactics just causes ethical physician’s to be wary of the way they help their patients treat pain causing more harm than good.

Even though the DEA played a small part in epidemic, their tactics didn’t exuberate the problem further. In the article, the opioid epidemic in 6 charts, Kolodny states, “Over the last two decades, as prescriptions for opioids began to soar, rates of addiction and overdose deaths increased in parallel.” (Kolodny, 2018) To put this all-in numbers, data shows that from 1999 to 2017, around 400,000 people died from an overdose linked to the use of opioids. Furthermore, data shows that the increased prescribing of opioids in the 1990’s, contributed to two additional waves, which lead to people taking harder synthetic drugs. The second wave started in 2010, which saw an increase in overdose deaths involving heroin. The third and final wave began in 2013 and saw an increase in overdose deaths involving illicitly manufactured fentanyl. There is no race, age group or income bracket that this epidemic hasn’t affected.

One group that got hit hard are the low-income patients on Medicaid or Medicare. When OxyContin got to expensive for them, they had to resort to heroin to get their fix. Another group that is affected by opioid medications are older adults. Older adults are at a higher risk for the misuse or abuse of opioids because they tend to have many prescriptions for a vast array of illnesses and drug-drug or drug-disease interactions can occur. When taking so many prescriptions all at once it is expected that the person will have slowed metabolism, which can affect the breakdown of the drugs. Before the 1980’s, doctors used to prescribe pain relievers sparingly and only for short term cases of severe illness or during surgery.

So, what sparked a change in the prescribing of these opioids? Well for one it was the pharmaceutical industry (Big Pharma), specifically Purdue Pharma makers of the opioid known as “OxyContin.” To put all the blame on Big Pharma is cutting is short. In her book “Drug Dealer, MD,” Anna Lembke, MD writes:

The pharmaceutical industry was able to influence doctor-prescribing only by joining together with academic physicians, professional medical societies, regulatory agencies (the Federal of State Medical Boards and The Joint Commission), and the Food and Drug Administration. Together, these different factions manipulated and misrepresented, deliberately or otherwise, medical science to serve their own agendas. (Lembke, 2016 p.57)

It is alarming that the pharmaceutical industry was able to influence so many different organizations to serve their agenda. The group that should have never been influenced are physicians. These medical doctors took the Hippocratic Oath to uphold ethical standards. One of the stand out principles is, non-maleficence, which means “first, do no harm.” Whatever happened to “do no harm.” When someone comes down with an illness, the first person they go see is their physician, knowing that they have the interest of the patient. But it turns out that for the past two decades the medical community only had the interest of Big Pharma. Before 2000, it was common for doctors to accepts gifts, payments, and other services from the drug companies in exchange for recommending their products. This type of behavior was later banned by hospitals and health care organizations.

Even though this behavior was banned supposedly, there are physicians that still take kickbacks from these pharmaceutical companies. Data shows that Big Pharma spend a total of $3.5 billion from August to December 2013 on 546,000 individual physicians and 1,360 teaching hospitals. Robert Hampton author of American Fix says, “The massive pharmaceutical companies that create control, and distribute the medications we take every day are at the core of America’s drug problem.” (Hampton, 2018 p.114) The bottom line is that these pharmaceutical companies don’t care if people get addicted or die from an overdose they only care about one thing, profit. With the use of aggressive and dishonest marketing on uninformed buyers caused a domino effect which eventually produced our nation’s second opioid epidemic. Our nation’s first opioid epidemic in 1890 was from the overprescribing of morphine by doctors and dubious marketing by pharmaceutical companies. Now that 120 years had passed since then, the same people are responsible for today’s opioid epidemic.

The opioid epidemic has killed a lot of people over the years, with the rest living with addiction. For our nation to recover and end the opioid epidemic, critical steps must be taken for this to transpire. In an article called, The New Opioid Problem: Prescription Drugs Gone Wrong, it states, “The administration has proposed a three-prong approach: Two prongs are based on strategies meant to reduce the supply of drugs or to increase punishments for those involved in the drug trade; the third prong is based on increasing availability of treatment options.” (The New Opioid Problem: Prescription Drugs Gone Wrong (2018), 2018).

This initiative was released on March 19, 2018 and it covers a vast array of solutions. The first solution is to prevent drug demand by educating the medical community, providing awareness, and preventing the over-prescription of these opioids. Providing the proper education to the medical community would be a great start because ideally these are the people prescribing these drugs and if they have the proper knowledge patients can avoid addiction or even overdoses. Also preventing over prescribing of these drugs will also limit the patient drug quantity, reducing the possibility for addiction. Another solution is to expand opportunities for treatments that are proven to work for opioid and other drug addictions. This will be beneficial for low-income patients and older adults on Medicaid. Since most insurance companies don’t want to cover the patient’s treatments costs. The last is to reduce the prescribing of opioids fills by one-third within three years. This sounds all great on paper but, this can cause some problems. People already on these opioids would have to look for alternative pain management methods making it hard for patients to make the switch. Also, the medical community would need to educate patients on alternative pain management methods that are available, which can take longer for the relief of pain. If there is any chance for our nation to overcome this epidemic, the Government needs to intervene. This initiative is a step in the right direction. If this plan gets fully implemented this would bring a big change to how physicians prescribe opioids and how opioid addiction get treated.

With the U.S government taking steps to reduce the opioid epidemic it is important to look at alternative methods for pain management that can be used to substitute opioids. In an article written by Rebecca Frey, she states, “There are over a hundred different forms of alternative treatments and therapies as of early 2000s.” (Frey, 2013) Having access to these CAM (Complementary and Alternative Medicine) therapies can become life saving for certain group of people with a specific chronic illness. For example, if a cancer patient is going through chemotherapy and radiation treatments, CAM therapies can be used to relieve the pain and side effects of those hard treatments. Cancer patients can use mind/body therapies such as meditation, yoga, and relaxation techniques or manipulative and body-based therapies such as massage therapy and chiropractic.

These therapies can be substituted for strong opioids. According to the NCCAM and Health Canada, CAM therapies have become more popular among the people living in North America since the 1970s. People experiencing emotional or physical pain can use these therapies to help them recover. Some of the conditions Americans seek alternative treatments are back pain, neck pain, joint pain, anxiety or depression and chronic pain. Even though these alternative therapies work, most people won’t be able to use these therapies due to the high cost. Most people have basic health insurance that won’t cover these treatments. Instead patients are forced to take these opioids because its cheaper for the insurance companies.

With the opioid epidemic affecting so many people in our nation it is critical that the paradigm shifts. Prescription drugs have always burdened our nation from the morphine epidemic in the early 19th century and addiction crisis during the civil war, to the current opioid epidemic. It is hard to believe that these opioids will ever be removed, seeing how much influence Big Pharma has in our country. With the current advancement in pharmacology, new pain management prescription drugs might treat chronic pain without causing addiction in patients. But why wait for the future when there are alternative pain management options available now, that don’t require people taking opioids. In the end it all comes down to the individual to say no to these opioids.

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