Inside the Opioid Crisis

by J. Nelson

In an example of flawed decisions in the medical/pharma industrial complex, over-prescribing has catapulted overdose deaths to the top, compared to peak years for auto fatalities, HIV or gun deaths.

“We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths,” writes the Center for Disease Control (CDC).

The National Institute on Drug Abuse says opioid overdoses account for 60% of those deaths.
Researchers from the University of Virginia say these statistics are underreported by 24% for opioids and 22% for heroin overdose deaths, and with particularly large errors in certain states, one being Louisiana.

Overdoses are trending up, not down, by almost 20% for last year. STAT News predicts that
opioids could kill nearly 500,000 people in the next decade.

At the peak of the prescribing frenzy, 2013, doctors wrote nearly 250,000,000  opioid prescriptions––enough for every adult in the United States of have his or her own bottle of pills, reports the CDC.

Despite the flood of legal opioids into the society, the CDC reported no change in pain that would meaningfully drive the prescribing: “…there had not been an overall change in the amount of pain that Americans reported.”

Last year, 20 years after the opioid marketing blitz and prescribing ramp-up began, the
CDC found that there was no long-term benefit for opioids compared to no opiods. However, they did find ample evidence for harm, a fact that the FDA had failed to discover when they approved drugs like OxyContin in the 90s.

Not surprisingly, at least for psychologists, the CDC did find that psychological and physical treatments for pain were beneficial (“CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016,”). This despite the fact that these non-medical approaches are rarely integrated into treatment programs.

Echoing the overprescribing of antidepressants, citizens hoping for genuine healthcare appear to have once again become the unwitting lab rats of a commercial, profit–driven industry, where they and many providers are lulled into quick fixes that ignore long-term consequences and the psychology of the whole person.

Depth of the Problem

Opioids are derived from the same type of compound as heroin, and morphine-like effects for pain relief. The effects also include feelings of relaxation and euphoria. One recreational user described it as “Bliss.” Another as, “Physical––warmth, relaxation. Mental––Joy, boost in self-confidence, loss of anxiety…”.

Schedule I and II drugs have been determined to have a high risk for physical and psychological addiction. Schedule I are illegal and Schedule II are considered to have medical value and so legal by prescription. Heroin is a Schedule I opioid. Drugs like oxycodone, hydrocodone, and methadone are Schedule II opioids.

With continued use, tolerance and dependence result. Increased dosages are needed for the same results. Researchers say that dependency can occur after as few as seven days. Overdose risks go up.

In the 1990s drug manufacturers launched new opioid formulations, assumed to be safe. They expanded markets to non-cancer pain and moderate or temporary pain. Building on a new theme that all pain should be eliminated the opioid market quadrupled from 1999 to 2010, according to the General Accounting Office (GAO).

Physicians for Responsible Opioid Prescribing (PROP) found that the supposed safety of the new formulations in the 1990s was based, not on research, but primarily on a letter to the editor in a medical journal. The sound-bite idea began to circulate in the medical communities and was uncritically accepted as fact, notes PROP researchers.

The risk of addiction is serious. Among new heroin users, approximately 75% report having abused prescription opioids before turning to heroin, notes the CDC. The National Institute on Drug Abuse places the figure at 80%. PROP researchers reported that people get hooked by a prescription and then turn to street heroin.

Heroin use has been increasing among men and women, in all income levels. Those historically low in rates of heroin use––women, the privately insured, and those with higher incomes are seeing the greatest increases, says CDC. While addictions were up overall, those mainly affected were whites, especially those with less education.

In 2015 two Princeton researchers, Anne Case and Angus Deaton, presented findings to the  National Academy of Sciences that drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis, had increased so dramatically that all-cause mortality was up for US
middle-class whites, while declining for Blacks, Hispanics and for those in other countries.

“Over the 15-year period, midlife all-cause mortality fell by more than 200 per 100,000 for black non-Hispanics, and by more than 60 per 100,000 for Hispanics. By contrast, white non-Hispanic mortality rose by 34 per 100,000.”

“This is a disturbing trend,” said Dr. William Schmitz, Jr., Past-President of the American
Suicidology Association The addiction chips away at the person’s hope and adds to the
burdensomeness they experience,” he said. “There is overlap between the accidental overdose and the intentional. The person may think, ‘I’m taking this and if I die, I die and if not, I’ll be here tomorrow.’ What this really speaks to is the increasing need for collaboration in mental and physical health,” he said.

The Problem in Louisiana

Louisiana is in the middle of the crisis, with some of the highest opioid prescribing rates and an escalating death rate from overdose.

In a Louisiana House Health and Welfare Committee hearing this past April, Representative  Helena Moreno told members that there are “… more opioids prescribed in Louisiana than are people in this state.”

In 2007, Louisiana prescribers gave out 110.1 opioid prescriptions per 100 persons, based on numbers from the CDC. Only five others were higher: West Virginia (135.1), Kentucky (130.8), Tennessee (128.8), Alabama (120.3), and Oklahoma at (114.4).

Little change has occurred in recent years. In 2012 the map of southern rural states was the
same, with Louisiana a 112.4 rate, with a slight drop to 108.9 in 2015. The rate again dropped
slightly last year, down to 100.4.

The Louisiana Commission on Preventing Opioid Abuse, looking at internal figures from the state’s Prescription Monitoring Program (PMP), says that the number is even higher. “Over the last six years, since the PMP began monitoring narcotic prescribing behavior, Louisiana has
averaged 122 prescriptions per 100 persons. This rate is 39% percent higher than the national
average (87.44).”

Addictions have rocketed up along with prescriptions. Ed Carlson, CEO Odyssey House
Louisiana, testified at a Senate hearing that, “All of the drug and alcohol treatment programs
throughout the state were overwhelmed with the amount of the people who were seeking
and needing treatment. We currently have waiting lists for all of our programs,” he said.

Louisiana has also experienced a significant increase in overdose deaths, with a 12.4%
increase for 2014 to 2015, according to the CDC.

Another characteristic of the opioid crisis is the inconsistency in prescribers, not accounted
for by the illness level of those being treated.

Prescribing varies widely across the nation from county to county. In 2015, six times more
opioids per resident were dispensed in the highestprescribing counties than in the
lowest-prescribing counties, notes the CDC. Characteristics such as rural versus urban,
income level, and other demographics, explain only about a third of the differences
found in prescribing rates across the country.

In Louisiana, highest parishes include Evangeline (192.1), St. Landry (145.5) Rapides (144),
Richland (139.3), Washington (136), and Tangipahoa (129.5).

Examples from ProPublica, using Medicare Part D information, shows that Hydrocodone Acetaminophen was the first ranked drug prescribed in Louisiana with 812,468 claims.

Highest prescribers were physicians in Pain Medicine and Physical Rehabilitation. The top
prescriber wrote 14,223 prescriptions for opioids. Of his 866 patients, 91% filled at least
one prescription for an opioid. The review by ProPublica rated his patients as less sick than
average.

Another prescriber in Alexandria reported 1,333 patients receiving prescriptions from Medicare Part D and 98% of these filled at least one prescription for an opioid.

True Believers: A Bad Idea Gains Momentum

According to a 2003 report by the GAO, several national pain organizations issued new
guidelines in the mid-1990s, based on their belief that pain was undertreated in non-cancer
pain patients.

In 1995, the American Pain Society, led by Dr. Russell Portenoy, a New York pain doctor, recommended that pain should be treated in a special category. In an investigative
report by the Wall Street Journal (“A Pain-Drug Champion Has Second Thoughts”), said
Portenoy urged the tracking of pain as a “Fifth Vital Sign.”

The idea of a 5th vital sign was adopted by the Joint Commission on Accreditation of Healthcare Organizations, the Veterans Administration, and the Federation of State Medical Boards who provided reassurance to doctors who wanted to more freely prescribe opioids. The Federation drew up recommendations with the help of individuals linked to drug manufacturers, including Purdue Pharma (OxyContin), according to WSJ. The federation received nearly $2 million from opioid makers.

Around the same time, OxyContin was approved by the FDA, but lists no research on the drug.

An explanation by the FDA states: “At the time of approval, FDA believed the controlled-release formulation of OxyContin would result in less abuse potential, since the drug would be absorbed slowly and there would not be an immediate “rush” or high that would promote abuse. In part, FDA based its judgment on the prior marketing history of a similar product, MS
Contin, a controlled-release formulation of morphine approved by FDA and used in the medical community since 1987 without significant reports of abuse and misuse.”

In a Los Angeles Times investigation, based on sealed court documents, the physician who led the agency’s review of the drug, declined to speak with the press. The Times noted that shortly after OxyContin’s approval, the physician left the FDA and in two years was working for Purdue Pharma.

As enthusiasm grew the then Agency for Health Care Policy and Research, part of the national Department of Health, offered reassurance to prescribers about their “exaggerated concerns.”

The GAO noted that providers and hospitals were further required to ensure that patients received pain treatment. The Joint Commission implemented its pain standards for hospital
accreditation in 2001, a guide sponsored by Purdue Pharma.

Reassurances of safety appeared to be based on limited scientific research, a letter to the editor to JAMA, according to PROP and others, and perhaps a small study of 38 individuals.

How could such a gap in scientific decisions occur?

“Most doctors and virtually all patients are unschooled in how meaningfully to compare the
risks of foregoing versus undergoing treatment, and the patient’s frantic desire to ‘do
something now’ often trumps the doctor’s ancient commitment to ‘first, do no harm,’” wrote law professor John Monahan in a special report on statistical illiteracy in medicine, published by the Association for Psychological Science.

Dr. Jason Harman, a decision science expert at LSU, notes, “Doctors have very complex jobs. I know from some of my work on learning in complex systems that accurate and timely feedback is essential for optimal performance in a complex task.”

Some outcomes however have delayed or obscured feedback. In terms of opioids, the
immediate feedback a doctor receives is generally positive––pain is reduced––while
feedback about negative consequences is delayed if it is received at all. This basic
structure of feedback in the environment makes it very understandable to me how
doctors, who have the best intentions, could fall into such an ultimately harmful practice
…”

Marketing Blitz on Doctors’ Psyches

In 1997 Purdue Pharma created a marketing effort that overshadowed anything previously and catapulted sales of OxyContin.

“Purdue directed its sales representatives to focus on the physicians in their sales territories who were high opioid prescribers,” said the GAO. “This group included cancer and pain specialists, primary care physicians, and physicians who were high prescribers of Purdue’s older product, MS Contin. One of Purdue’s goals was to identify primary care physicians who would expand the company’s OxyContin prescribing base. Sales representatives were also directed to call on oncology nurses, consultant pharmacists, hospices, hospitals, and nursing homes.”

By 2003 primary care physicians had grown to constitute nearly half of all OxyContin prescribers, based on data from IMS Health, an information service providing pharmaceutical market research. The GAO report stated that the DEA expressed concern that this resulted in OxyContin’s being promoted to physicians who were not adequately trained in pain
management.

Purdue doubled the total OxyContin sales force by 2000 to nearly 700 and reached up to
94,000 physicians. Bonuses topped at $240,000, on a salary of $55,000.

Purdue expanded its physician speaker bureau, conducted speaker-training conferences,
sponsored pain-related educational programs, and issued OxyContin starter coupons for
patients’ initial prescriptions.

They also sponsored pain-related Web sites, advertising OxyContin in medical journals, and
distributed OxyContin marketing items to health care professionals–fishing hats, stuffed plush toys, coffee mugs with heat-activated messages, music compact discs, luggage tags, and pens containing a pullout conversion chart.

Purdue conducted over 40 national pain management and speaker training conferences,
usually in resort locations, to recruit and train health care practitioners for its national speaker bureau. Over five years, more than 5,000 physicians, pharmacists, and nurses, whose travel, lodging, and meal costs were paid by the company, were engaged. By 2002, Purdue’s speaker bureau list included nearly 2,500 physicians and over 20,000 pain-related educational programs.

“For the first time in marketing any of its products, Purdue used a patient starter coupon program for OxyContin to provide patients with a free limited-time prescription,” and by 2001 34,000 coupons had been redeemed nationally.

Purdue’s market share increased fourfold for cancer pain and tenfold for non-cancer pain by 2002.

Outdated Medical Model of Pain

“It is now widely accepted that pain is a biopsychosocial phenomenon,” clinical health
psychologist and Past-President of the Southern Pain society, Dr. Geralyn Datz, told the Times.

“For many years the biomedical model of treatment has prevailed as a way to treat pain patients,” Datz said. “This model is based on some very early research about acute pain and basically states that there is a one-to-one correspondence between the extent of injury and the amount of pain experienced. Therefore, large injuries lead to large pains and small injuries lead to small pains,” she said.

Datz explained that this model also assumes that surgery and medications can fix pain. “While
this is sometimes true, this model fails to appreciate what we now know about the central nervous system,” she said.

“We know that chronic pain is a complex and dynamic process, and it involves a person’s
thoughts, beliefs, experiences and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can worsen pain through interactions of the brain with the body.”

“In order to really address chronic pain, we must address the persons reactions to it and teach ways to overcome it, including retraining the brain away from the unpleasant pain signals. This is a psychological process involving education and training and coaching,” Datz said.

“We know that cognitive behavioral treatments create quantifiable changes in the brain, and
that these are distinct to this type of treatment. So these effects are lasting and result in long
term success.”

Dr. Datz says that the “best results are achieved through collaborative care,” but too often, insurance companies make it difficult for patients to have this type of help.

Treating with inappropriate drug therapy, is costly,” said Dr. John Caccavale, author of Medical Psychology Practice and Policy Perspectives. The cost for adverse drug reactions in 2001 was $72 billion to $172 billion while the cost for the drugs was $132 billion. “Actually, it’s now worse,” Caccavale said. “The incidence of hospitalizations from adverse events has risen substantially because of the growing use of medications in all categories.”

Failed Health System

The opioid crisis suggests one more area of poor outcomes for the U.S. healthcare system.
Bloomberg has reported that of 55 countries in a measure of life expectancy and high medical
care spending, the U.S. ranks 50th, dubbing the U.S. the “least-efficient” health- care system in the world. In a comparison of age–adjusted deaths from all causes, the World Health Organization ranks the United States last in similar countries.

Medical care is the largest industry in the U.S., accounting for almost $3 trillion in sales in 2015, according to the National Health Expenditure Data from CMS. At the same time, life expectancy in the U.S. is only 78.9 years, falling behind all other nations except for those such as Jordan, Colombia, and Russia, said Bloomberg.

Likewise, Louisiana ranks 50th of all the states, according to the Louisiana Department of Health and the 2015 Report from America’s Health Rankings.

“Health is a misnomer, because most activity involves illness,” say authors of “The Anatomy of Health Care in the United States” in a 2013, JAMA article. “Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases,” the authors write.

The system is politically closed to innovation. Three hundred “Advisors and Experts,” primarily from the American Medical Association’s House of Delegates, representing 109 medical specialties, lobby an “Editorial Panel,” composed of representatives from medical societies,
insurance companies and the government, decide on what is paid for, by way of codes.

The “Current Procedural Terminology” or CPT codes, and how much is paid for each service, is decided behind closed doors of the Relative Value Scale Update Committee,” or “RUC,” by those who stand to profit the most.

The system includes the FDA. Dr. Irving Kirsch, Associate Director of the Program for Placebo Studies at Harvard Medical School, has laid out the damning evidence that drug companies and the FDA skew research to approve drugs that have little actual value. The FDA receives 40 percent of its funding from the pharmaceutical companies, Kirsch said.

Add to this the political force of the top spenders for lobbying in Washington: Blue Cross/Blue Shield (3rd), American Hospital Association (4th) the American Medical Association (5th), and the Pharmaceutical Industry (6th).

This closed system is not surprising. In 2002 the 10 drug companies in the Fortune 500 made $35.9 billion in profits, more than all the other 490 companies profits combined.

Legislators in Louisiana are trying. In 2017 there were numerous bills and resolutions put forth to stem the tide of prescribing.

Senators Mizell and White asked for medical societies and hospitals to eliminate pain as the 5th vital sign, in Resolution 21. House Bill 192 led by Representative Moreno and 43 others, put some restrictions on prescribing opioids, became law as Act 82.

Act 88 by Representive Leger and others established the Drug Policy Board’s Advisory Council on Heroin and Opioid Prevention and Education, and Act 76 led by Senator Mills encourages prescribers to use the Prescripton Monitoring Program, where currently only about one third use the system.

The enforcement of these measures will depend on the professional boards. The Department of Health has filed a suit against drug companies.

It will be seen if this can help in the opioid prescribing crisis or the “underlying epidemic” suggested by Case and Deaton that may have contributed what author Christopher Caldwell calls, “American Carnage.”

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