When I retired from my job as associate dean at Brown University Alpert Medical School, I decided to work part-time in community health centers taking care of underserved populations. My first job was in a small city in rural eastern Connecticut. I almost quit after my first week. Up to a third of the patients I saw were seeking prescriptions for narcotic pain relievers like Percocet and Vicodin. Most of the patients didn't have a medical problem that justified opioid pain killers.
I soon learned that a black market in opioid pain killers was a major part of the economy in this depressed city. A nurse told me not to take it personally. "It's their business," she said, "but it doesn't have to be yours." The drug dealers were checking me out as a new doctor in the clinic to see if I was an easy mark. I soon earned a reputation as a hardliner when it came to prescribing narcotics and the number of drug-seeking patients tapered off.
One of my patients was a former prescription reseller and had recently been released from prison. He was very open with me about his former occupation. Pills with oxycodone—the opioid in Percocet—were selling for $5 a milligram on the street. A typical Percocet pill contains 5 milligrams of oxycodone and sells for $25. A recent drug bust in Manhattan reported that a single prescription for 180 30-milligram oxycodone pills could net as much as $7,200 on the street, according to a D.O.J Press Release
The demand for opioid pain killers is huge. In 2010, 254 million prescriptions for opioids were filled in the United States generating $8 billion in sales, making this class of drugs the biggest seller in the U.S. One out of every five doctors’ visits ends in a prescription for opioids—twice the rate in 2000. Many of the pills get diverted to illicit use. Deaths from overdose of prescription opioids have skyrocketed four-fold since the late 90s. In 2010, opioid overdoses numbered nearly 17,000, exceeding the number of overdose deaths from heroin and cocaine combined, according to the CDC.
How did this happen? When I was a medical student in the 1960s, we were taught to be very cautious in the use of narcotics. They were appropriate for short-term use for the kind of pain patients experience after surgery or after breaking a bone, but not for long-term use except for patients dying from cancer who were experiencing severe pain.
At some point between the 1960s and the present, the "conventional wisdom" about pain control and opioid use began to change. I remember hearing in the early 1980s that doctors were undertreating pain, especially in cancer patients. The major limitation of using opioids for extended use in chronic pain is that the body gets accustomed (the medical term is tolerant) to the narcotic and larger and larger doses are needed to achieve the same level of pain relief. Escalating the dose and using the drug continuously inevitably leads to physical and psychological dependence on the narcotic.
Using opioids, especially higher doses, comes with very significant risks, including potential addiction, and death. These risks are outweighed by the relief of suffering in patients dying from cancer. Such is not the case for patients with chronic pain from other causes such as arthritis, backache, or headache.
But drug companies saw that expanding the scope of chronic medical problems beyond cancer would represent an economic bonanza. Without using the names of specific drugs, which avoided scrutiny by the Food and Drug Administration, manufacturers of opioid drugs began to "re-educate" doctors about the benefits and allegedly low risks of using narcotics to treat chronic non-cancer pain.
I remember hearing that patients with pain rarely became addicted. I remember being admonished that good doctors don't undertreat pain and that patients' demands for more narcotics meant that their pain was not being adequately treated and the narcotic dosage should be increased. I remember being told that good pain control with narcotics would restore patients with pain to a normal or close-to-normal life.
All of what I heard as part of this campaign of "re-education" was false. In fact, up to 40 percent of patients taking long-term narcotics become addicted. Studies showed that narcotics didn't restore patients to normal functioning. In fact, nonnarcotic pain relievers were actually more effective in restoring normal functioning. And there are no scientific studies measuring the effectiveness of opioids for pain relief beyond 16 weeks.
Purdue Pharma—the drug company that makes OxyContin—pleaded guilty in 2007 to systematically misleading doctors into believing that OxyContin was less likely to be abused than traditional narcotics. The company paid a $600 million fine and promised to end making false claims, according to the New York Times.
Yet the false messages about the safety of opioids, and the undertreatment of pain are firmly embedded in the minds of many doctors, and will be difficult to expunge. Worse still, millions of patients have now become addicted to chronic opioid treatments. Most will find it physically and psychologically difficult to get off their narcotics. Some may even be condemned to a lifetime of opioid dependence. And as new state laws are starting to prevent the over-prescribing of opioids, more reports are coming in about addicted patients switching to heroin, which can be easier and cheaper to get.
Addiction treatment does work, but there isn't yet enough to help everyone. The Affordable Care Act and advocacy by Community Catalyst, state and national groups and some policymakers are succeeding in expanding coverage, but there is much more to be done.
Meanwhile, the dope-pedaling drug companies continue to rake in their profits and drive up addiction rates. Lawsuits being brought by the city of Chicago and the state of California against five different manufacturers of opioids might possibly start to make them pay for their campaign of deceit.
Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consultant