Opioid painkillers like OxyContin were once touted as wonder drugs, promising long-lasting relief to people suffering from intractable pain. Today, prescription drugs containing oxycodone or hydrocodone, along with methadone, heroin and illicit Fentanyl, are largely blamed for a rise in overdoses now killing more Americans than traffic fatalities. Overall, U.S. life expectancy is dropping thanks to the opioid epidemic.
On Jan. 9, the Senate Committee on Health, Education, Labor and Pensions heard testimony from journalist Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic,” on the opioid crisis. Last week, in a U.S. News interview, Quinones discussed the cultural context that brought the problem to this point. In addition, Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, offered his perspective on opioid addiction and treatment today.
[See: 4 Opioid Drugs Parents Should Have on Their Radar.]
The opioid epidemic didn’t occur in a vacuum. Causes are complex and many. Experts describe a perfect storm of misinterpreted evidence, massive pharmaceutical marketing, well-intentioned pain advocacy, weak regulation, a rush to prescribe in liberal quantities and missed opportunities by insurance companies to support safer, more-holistic treatments.
Here’s a far-from-comprehensive timeline of the opioid epidemic:
Late 1970s: Short-acting, combination opioid drugs come on the scene. Before OxyContin, painkillers such as Vicodin, which combines hydrocodone and acetaminophen (the active ingredient of Tylenol), and Percocet, an oxycodone-acetaminophen combination, were introduced in the U.S., with their use expanding later in the 1980s. Relatively short-lasting, they’re typically taken every four to six hours.
January 1980: Medical journals provide “nonaddictive” message. A Boston physician built a database of the effect of various drugs on hospitalized patients. It revealed that only a tiny proportion of addiction cases developed among those treated with opioids. A one-paragraph letter summarizing the findings appeared in the New England Journal of Medicine. Widely misinterpreted, the NEJM letter was taken in the medical community as evidence that opioid painkillers were nonaddictive and safe to prescribe to patients — in or out of the hospital.
A dearth of strong, independent research for safety and effectiveness of long-term opioid use persisted. A systematic review, published February 2015 in the Annals of Internal Medicine, found studies on opioid treatment to date lacked comparison groups and were short-lived, with participants followed for 12 weeks or less.
Late 1980s/early 1990s: Concern grows over untreated and undertreated pain. Whether pain after surgery or due to conditions like cancer, “pain management specialists were outraged at how poorly we treated pain in this country, which was true,” Quinones says. “There were a lot of people in agony toward the end of life, for example.” Doctors were frustrated, he adds: “They felt we had the tools to treat pain and we weren’t doing it. We were afraid of using these tools. And these tools were narcotic painkillers.”
December 1995: Food and Drug Administration approves OxyContin. Sustained release was the big attraction for this new, long-acting pill containing oxycodone, manufactured and aggressively marketed by Purdue Pharma. A single dose treated pain for a 12-hour period. “So for folks with chronic pain, they no longer had to watch the clock,” Quinones says.
1995: Pain suggested as “fifth vital sign.” In a push to better evaluate and manage pain, the idea of treating pain as a vital sign, to be routinely addressed like blood pressure or respirations, was introduced and adopted in pain-assessment “toolkits.” Pain scores assessed in hospital patients were used as quality-monitoring measures by influential hospital agencies.
[See: On a Scale From 1 to 10: The Most Painful Medical Conditions.]
Late 1990s: Pharma marketing blitz continues. From wooing family doctors with gourmet lunches to providing slides and graphics on the “nonaddictive” benefit of OxyContin, Purdue Pharma waged its all-out campaign to get physicians and patients on the bandwagon, as Quinones describes in “Dreamland.”
1998: FDA approves Fentanyl-containing Actiq for cancer breakthrough pain. Fentanyl, a synthetic opioid that’s 50 times stronger than heroin, is available in prescription forms such as skin patches (Duragesic) and lollipops (Actiq). Access to Fentanyl is heavily restricted; however, overdoses can occur both when used as prescribed and illicitly.
Early 2000s: Overprescribing grows rampant. Sales of prescription opioids in the U.S. increased nearly fourfold from 1999 to 2014, according to the Centers for Disease Control and Prevention. “After a steady increase in the overall national opioid prescribing rate from 2006, the total number of prescriptions dispensed peaked in 2012 at more than 255 million and a prescribing rate of 81.3 prescriptions per 100 persons,” the CDC summarized.
Early 2000s: Overdose deaths climb. Overdose deaths involving opioids, both from prescription drugs and heroin, have quadrupled since 1999, according to the CDC. More than one-half million Americans died from drug overdoses from 2000 to 2015, with 91 American lives lost daily to an opioid overdose. In addition, more than 1,000 people are treated in emergency departments every day for misusing prescription opioids.
Early 2000s: U.S. flooded with opioids. The sheer quantity of opioids — from a variety of sources — exploded throughout the country. For example, in an investigation of drug shipment data, the Charleston Gazette-Mail in West Virginia reported on a glut of 780 million opioid painkillers arriving via large drug wholesalers from 2007 to 2012 into the state, one of the hardest hit with opioid deaths.
Into the 2010 decade: Tide of public awareness turns. Overdose cases became routine in hospital emergency rooms and morgues, affecting families throughout the country. In November 2012, the Los Angeles Times published the first in its “Dying for Relief” series of investigations on overdoses caused by prescription drugs. Along with the media, Medicare and state and federal agencies increased their scrutiny of physicians’ opioid-prescribing practices.
[See: 10 Concerns Parents Have About Their Kids’ Health.]
August 2010: Abuse-deterrent opioids are introduced. Abuse-deterrent opioid preparations are designed to prevent crushing of the drug (which enables snorting, injection or other misuse). A reformulation of the opioid painkiller OxyContin was linked to a 36 percent decrease in the use of that medicine, Alexander noted in a June 2015 article he co-wrote in the Pharmaceutical Journal. However, he pointed out, that result was coupled with a 42 percent increase in the use of heroin over the same time frame. The value of abuse-deterrent opioids is unclear and lacking a strong evidence base, critics contend.
Early 2016: Prescribing guidelines tighten. On March 15, 2016, the CDC released new recommendations for more careful prescribing of opioid painkillers.
Late 2016: The Surgeon General issues the “Facing Addiction in America” report. The Affordable Care Act included addiction coverage to improve access to treatment. Even so, only one in 10 people addicted to opioids or other substances currently receives such treatment, as highlighted in the Surgeon General’s report.
October 2017: Opioid epidemic declared a public health emergency. President Donald Trump officially pronounced the opioid crisis as a national health emergency, making it a top government priority.
Today: Ongoing horror and glimmers of hope. “The bottom line is, nearly 20 years into the epidemic, incredibly more people are expected to die than ever before,” Alexander says. Glimmers of hope can be seen, he adds, including rapidly increasing awareness of the dangers of opioids for noncancer pain, modified insurance coverage and more investment in expanding the addiction-treatment infrastructure. “People are beginning to recognize the incredible stigma that’s associated with addiction,” he says. “Finally, they’re starting to recognize that addiction is a disease, not a behavior.”
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Opioid Epidemic: What Brought Us Here? originally appeared on usnews.com
