In the 1970s, doctors in inner city hospital saw many patients suffering complications of heroin use, but outside those communities there was no talk in the media about an epidemic of opiate abuse. Now, four decades later, the state of Kentucky is suing Purdue Pharma for the devastating effects of its opiate drug OxyContin on its citizens, the Governor of Vermont devoted his 2015 State of the union address to the problems of prescription opiate and heroin abuse in his state, and a California doctor was recently convicted of second degree murder in the narcotic overdose deaths of three patients. And these just a few of the news stories related to our current “opiate epidemic.” Is this a new problem, and if so, how did we get here?
What are opiates?
Opiates are psychoactive substances that have been used for over 5000 years. They are derived from the poppy plant and ingested, smoked or injected to produce relaxation, pleasant euphoria and mild hallucinations. Medically speaking, they also alleviate pain, coughing and diarrhea. Opium, the general name for poppy plant extracts, is a complex mix of substances which include the alkaloid chemicals morphine and codeine. Morphine was isolated and named in Germany in 1805. Though very effective as a pain remedy, morphine was, by the end of the Civil War, termed a “hydra headed monster” that was “wrecking lives and home.” In a search for a non-addictive opiate, an English pharmacist created heroin in in 1874. Synthetic offshoots like Vicodin, Percodan and Percocet followed in the 20th century, and OxyContin debuted in the mid-1990s.
Dependence and addiction
Opiates alter the brain’s structure and chemistry. Normally, the brain produces “endogenous opioids” in response to activities that are pleasant and rewarding. In response to opiate drugs, the brain promptly lowers its own opioid production. If the drug supply is interrupted, the lack of internal production of opioids causes withdrawal symptoms – agitation, nervousness, high blood pressure, pain, nausea, vomiting and seizures. Opiate use has produced dependence on an external source. Its severity depends on dose and length of time opiate drugs have been used. When the next dose preoccupies thinking and drug seeking interferes with routine life, causing medical and social ills, dependence has become addiction.
Withdrawal symptoms are relieved by taking more opiate drugs, but over time the dose required to keep withdrawal symptoms at bay increases. This is called tolerance. At the same time, however, the opiate dose that causes respiratory depression does not change and one of the side effects of progressively larger doses of opiates is respiratory depression – failure to breathe. Respiratory depression is the usual mechanism for death in someone who has overdosed on an opiate drug.
The road to heroin addiction
Since 1999, opiate overdose deaths have quadrupled in this country. Prescriptions for opiates have skyrocketed, as has heroin use. The US accounts for eighty percent of the opiates consumed in the world and an estimated 2.1 million Americans have opioid related substance abuse problems. Medically speaking, though, this is not an epidemic and it is not a new problem. The reasons for the hyperbolic use of epidemic language in the media are sociologic. We have entered a new era in which the pattern of use of heroin has changed dramatically, moving out of the lower socioeconomic strata into smaller cities, towns and wealthy suburbs and into the lives of children. In this story, the medical profession and pharmaceutical industry have played roles as large as those of innovative drug dealers from a small town in Mexico.
In the modern history of the poppy plant derivatives, heroin was a street drug and heroin users were typically found in decaying inner cities. The other opiates remained under the control of physicians, who were constrained in their prescription writing by the fact that these drugs fell under federal controlled substance laws. Use was restricted even in terminally ill cancer patients because of fear of addiction, a view that changed only after the advent of the hospice movement in the 1970s.
By the 1980s, buoyed by the good feelings of providing relief for cancer pain, doctors who dealt with other forms of chronic pain – typically orthopedic in nature, but also nerve pain and headaches – began to change their views about the use of narcotics. A short letter in the prestigious New England Journal of Medicine in 1976 stated that a review of hospitalized patients who had received opiates showed no evidence of significant risk of later addiction to the drugs. Though it was nothing of the kind, this letter was later described as a “landmark study” and used to support the view that, when used to treat pain, opiates did not cause addiction.
By the 1990s powerful opiates were flowing into the community in large quantities for routine treatment ankle sprains and dental work. In hospitals, pain became the “fifth vital sign,” measured subjectively by the patient on a 1-10 scale, and used in hospital satisfaction surveys used for quality control. Opiates flowed much more freely because patient satisfaction surveys counted for insurance reimbursement and discharge medications often included narcotic prescriptions.
While medical prescribing practices were changing, Purdue Pharma developed OxyContin. Heavily marketed as a product that could not cause addiction because the patented timed release would prevent the initial high and euphoria associated with the conventionally produced pills, the drug came in large doses. But people seeking a high soon learned to crush the continuous release pills. OxyContin quickly became a popular street drug, sold by the people who were getting prescriptions for the myriad pains that bring people to doctors’ offices. Pill mills popped up where drug seekers could find unethical doctors willing to write prescriptions with no requirements other than money.
Heroin is cheaper than OxyContin
Heroin requires no doctor’s prescription, is far cheaper than stolen OxyContin sold on the streets, and satisfies the dependence, tolerance and addictions of people who have slipped into those traps with prescription drugs. Heroin overdoses are claiming teenagers in wealthy suburbs of Midwestern cities and in New England – because heroin has arrived there with young men who deliver small amounts directly to customers who contact them by phone. These dealers are salaried non-users, they provide reliable quality heroin, and they disappear back into Mexico after short term stays.
Solutions will have to come from objective study of the results of loosening the standards of prescribing addictive and mind-altering drugs for self-limited problems that can be adequately treated with lesser drugs. And while the care of the terminally ill and some patients with severe nerve pain may require opiates, there have been no controlled studies on risk vs benefit for the treatment of other chronic pain problems, ones which may benefit more from a comprehensive approach combining lifestyle changes, exercise and counselling such as had been provided in pain clinics in the past. Last but not least, doctors and patients could all benefit from a widespread educational campaign about signs of increasing tolerance to and dependence on brain altering drugs.