I paid only tacit attention to the illicit drug epidemic that defined much of the late 1960s, as I was occupied with high school and other pursuits. But when I entered Pharmacy School, it certainly became a hot topic for discussion. Many of my professors proclaimed it to be the worst example of substance abuse they could ever have imagined occurring. It was bad… very bad. Heroin and psychedelic drug use were rampant, while at the same time, synthetic opioids such as Percodan and Percocet were launched by Big Pharma and approved by the FDA. I wonder what my erstwhile professors would say about today’s opioid epidemic? I’ll be very clear: Today’s crisis is unprecedented – and far surpasses opiate use when such substances were not regulated by prescription in the early 1900s, as well as the aforementioned 1960s.
Today, more people succumb to drug overdoses than any other type of accidental death.
Influences
A confluence of circumstances is associated with this, and similar to other major crises that garner general public and professional attention, whom or what is to blame for this crisis takes center stage. Drug dealers and the much better organized cartels run by the likes of “El Chapo” and others are obviously a source of illegal drugs such as heroin. However, reports from the Substance Abuse and Mental Health Services Administration (SAMHSA) show that when it comes to prescription opioids, the dealers and cartels are small-time players – with fewer than 10 percent purchased by non-medical users. Fifty percent of such users obtain the opioids from friends or family, with 25 percent getting them from physicians and/or other prescribers. And it’s a myth that multiple prescribers are involved in acquisition, in that most users get prescriptions from a single doctor.
As much as we hear about drug smuggling via local, regional and national media outlets, the role that the drug companies played – and continue to play for that matter – has spawned lawsuits galore claiming that these companies deliberately duped physicians about the dependence and addiction potential of the products. The ringleader targeted in these local, state and possibly federal lawsuits to come is Purdue Pharma – the manufacturer of the notorious OxyContin. There is no doubt that opioid manufacturers like Purdue and others have marketed these products with tenacity and determination and have thus contributed to the current epidemic. But for better or worse, their job is to aggressively solicit physicians to prescribe the products by hook or by crook.
The crook part included preposterous claims that synthetic opioids like OxyContin were safer and less addicting than their earlier opiate counterparts, morphine and codeine. OxyContin was also touted to be safe and effective not only for acute pain, but chronic pain events as well. Such ridiculousness paralleled the efforts of the snake oil salesman, who routinely appeared at American old-west medicine shows – posing as a traveling doctor while peddling fake information about magic elixirs and cure-alls with trumped-up enthusiasm and marketing hype.
In spite of the fake claims emanating from the mouths of these companies and their field staff of representatives, far worse is that someone who went to medical school for 4 years and spent a minimum of 3 additional years in post-graduate training could be so naïve or uneducated about opioids. And claims by some medical professionals that the prescribing mistakes they made were a result of being misled by the information doled out to them, maybe shouldn’t be practicing medicine or writing medication prescriptions.
What is the forerunner of this lack of accurate knowledge about opioids? This is an important question because when doctors claim that no one could have anticipated that patients prescribed opioids for pain issues might wind up misusing them, they’re either too inexperienced, inadequately educated, on have their heads buried in the sand and thus don’t really care. Why? Because research published more than 25 years ago was raising red flags about abuse issues with opioid analgesics. The answer here is easy and clear: most physicians here in the states are inadequately educated about pain management, and chronic pain in particular, remains poorly understood. Think about it for a moment, physicians in practically all specialty areas encounter patients with pain complaints, so its diagnosis and treatment doesn’t fit squarely within one single specialty. Thus teaching at the medical school level for sure, and post-graduate level in particular, winds up being uneven, begging the question, who really are the pain specialists?
In most teaching medical centers, pain management is concentrated in anesthesiology departments. Does this make sense? Anesthesiologists specializing in pain management mostly perform procedures, with little interest in medication management and only marginal training in the proper use of oral analgesics.
We can revoke the licenses of unethical physicians and rogue pharmacies, and somewhat manage the dissemination of false information thrust upon prescribers by pharmaceutical companies through the likes of fines or sanctions, but we also have to better educate future generations of physicians about pain management and the judicious use of opioids. Otherwise, don’t expect a change for the better. Reducing the overall number of prescriptions generated for opioids is to be applauded, but instruction regarding not only their proper use but also their limitations is absolutely essential to reeling this crisis in – now and going forward.
Social Issues Linked to the Opioid Epidemic
Even with reductions in prescribing, opioid-related deaths in the United States haven’t declined and actually are on the rise. This is because there is more to this epidemic than pain-ridden circumstances like arthritis, fractures and cancerous events, among others. The social issues associated with psychic pain – poverty, homelessness and unemployment are on full display – thus opioids have come to serve as vehicles for dissociation from everyday life circumstances by creating a different emotional reality – providing relief from depression, anxiety, demoralization, low self-esteem, abuse and neglect. These are deaths by anguish coming from suicide and overdoses, driven by miserable life circumstances which fuel despair and utter hopelessness.
Suboxone (buprenorphine) is an opioid agonist or activator and serves as a safe replacement for opioid use, particularly potentially deadly opioids purchased on the street. It also dampens cravings. As such, opioid overdoses, so many of which are fatal once feelings of hopelessness take over, are significantly curbed once someone is started on Suboxone.
Naloxone, in most states, has become available as an over-the-counter (OTC) product. Naloxone is an opioid blocker, or antagonist drug that quickly blocks the actions of any opioid consumed. It is essentially a “revival” drug in that those on the brink of death by respiratory depression are revived, breathing resumes, and essentially a life is saved if this agent is administered in time and at adequate dosage.
Medication aids such as Suboxone and naloxone are, of course, not an answer to the severe opioid epidemic gripping this country. This is a very complex problem requiring a wide range of medical and behavioral intervention strategies coordinated by the private sector along with local, state and federal agencies that will be challenging to fix. Coordination efforts aimed at solving, or even better, managing an epidemic of this magnitude are cumbersome and very slow to take effect, if at all.
Our job as clinicians – regardless of professional discipline – is to help keep those we encounter and work with alive, until they’re fortified and able enough to actively engage in and hopefully benefit from comprehensive treatment, so as to regain their lives, self-respect and dignity. Doctors and other prescribers are currently in the best position to advance progress by writing prescriptions for Suboxone and naltrexone, while we await collectively coordinated efforts to quiet this horrible crisis.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.