I’ve been teaching a course on substance abuse for about 30 years now. In this course, I cover a new drug class each week and always review the history of the drug. All of the drugs of abuse, cocaine, alcohol, marijuana, opiates are not new on the human scene. They date back to the Sumerians and the Greeks. The question for me is what accounts for epidemics? All of a sudden, cocaine is epidemic in the 1980s. (What, no one remembers that Cole Porter wrote “I get no kick from cocaine” around World War I and Edison loved the stuff?) Outside of Baltimore, there really wasn’t much heroin around in the 1990s in the east. In a study of 230 homeless men in Atlanta I conducted in 2000, I encountered only one person whose drug of choice was heroin and he was from the north. However, now we have a nation-wide opiate epidemic. So why the sudden discoveries? I have come to believe that epidemics are supplier driven rather than a function of consumer demand. For the current opiate epidemic, the suppliers were the pharmaceutical houses, in particular Purdue Pharma.
Sam Quinones has written a fascinating account of how Purdue Pharma effectively created the current opiate epidemic. Quinones begins with the Sackler brothers who started Creedmoor Psychiatric Institute in the 1950. Arther Sackler began as a researcher but became a marketer. He founded Williams, Douglas, McAdams, which after Sackler was no longer with the company became the marketer for Purdue Pharma and its product OxyContin. Sackler developed the practice of having drug reps visit individual physicians and having doctors market to other doctors.
According to Quinones, several publications appeared in the literature which Purdue Pharma capitalized on to promote OxyContin. First, a letter to the editor of New England Journal of Medicine in 1980 by Jink & Porter reported on very low rate of addictions observed in 11,882 hospitalized patients who had been treated with opiates. The report was not a study, but rather a paragraph long letter. It did not provide information on the patient characteristics, the conditions for which they were being treated, nor the duration and dose of the opioid treatment. However, physicians at Continuing Medical Education events accepted the findings without questioning. Later, a 1986 study by Portenoy & Foley of 38 out-patients with non-cancer related pain, about a quarter of whom were back pain patients, found that only 2 patients exhibited drug seeking behavior. These “studies” became the lynch pins in the case that pain patients would not be addicted if treated with opiates. Later, the FDA approved Purdue Pharma’s claim that OxyContin, because of its extended release formulation, was less addictive than other opiates. These studies and the FDA approved characterization were broadly cited in Purdue Pharma’s marketing efforts for OxyContin.
Coincident with development of marketing of medicine, the specialty of “Pain Management” developed. The past assumption that opiates should be employed cautiously was supplanted by the idea that patients had a right to have their pain treated aggressively. In 1996, James Campbell, president of the American Pain Society, in a speech characterized pain as the fifth vital sign. In 1998, the VA made it mandatory for pain to be assessed along with other vital signs. The Joint Commission for the Accreditation of Healthcare Organizations, the agency which accredits hospitals, added assessment of pain to their criteria for accreditation (Quinones, 2014).
With reassurance from the leaders of the profession that aggressively treating pain constituted good treatment, prescriptions for OxyContin took off. In 2010, opiates were the most frequently prescribed drugs. Many unscrupulous doctors began taking a liberal view on assessing pain. Pill mills emerged in the east. When the pills became too expensive, addicts switched to street heroin. As Quinones documents a new system of marketing had emerged for delivering heroin. Dealers, many of whom were Mexicans, did not carry guns, would not go to the inner-city, and prided themselves on customer service. They made home deliveries and were always polite.
Only later, the downsides of the new approach became apparent. Opiate overdoses were epidemic. Opiate deaths climbed among Workmans Compensation clients being treated for carpel tunnel and back-pain. 75% of new heroin addicts had become addicted through pharmaceutical opiates rather than street heroin. Requests for maximum dosage recommendations from the medical community were heard but were protested by Purdue Pharm.
As discussed in my last post, the US government’s response to the current heroin epidemic is to promote more methadone clinics and more buprenorphine providers. Unfortunately, this paradigm shares many characteristics with the campaign that led to the epidemic in the first place. The pain people wanted to promote the idea that people in pain could not be addicted. SAMSHA tells us that methadone and buprenorphine are not opiate substitutes but rather are “Medication Assisted Treatment” and buprenorphine is characterized as a partial agonist at mu receptor although this is true only on some but not all measures. There were no maximum dose guidelines for pain clinics and there are no maximum dosage guidelines for methadone or buprenorphine. Private docs set up pill mills and the incentives were to “treat”. The same fee for service model obtains for methadone and buprenorphine. Beyond needing an MD as medical director, anyone can operate a methadone maintenance clinic and again the more you treat, the more you earn. There are no criteria for determining what level of pain is required for opiate treatment; there are no criteria for deciding who is really an addict and is therefore appropriate for methadone or buprenorphine treatment. While J. David Haddox suggested that a pain patient who appeared to be drug seeking was really under medicated, now, Nora Volkow (see Knopf, 2014) tells us that the current street market in buprenorphine is because addicts are in withdrawal and not receiving adequate levels of treatment. It should be noted that Quinones suggests that the bad economy and lack of living wage paying jobs contributed to the opiate epidemic in Ohio. Nothing has changed here. So will we just be repeating the past?
In the next couple of years it will be interesting to determine which criteria will emerge for evaluating whether the expansion of methadone maintenance programs is a good for the society. Given the barrier to becoming a methadone client have been lowered (you no longer need to be addicted for a year), will more young people become patients? Will the society be in any way impaired if high rates of the population are methadone maintenance clients? (I do believe the data that methadone clients can sustain productive employment.) Will overdoses from opiates increase or decrease overall? Perhaps these questions will be answered in the near future.
Lest I be misinterpreted, I am not categorically against methadone or buprenorphine. In my next post, I’ll consider the pharmacological upsides and downsides of opiates. (In my opinion, they are certainly better than antidepressants.) My concern is how much of the society on drugs can any country sustain?
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Cicero T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry, 71(7), 821-826.
Franklin, G. M., Mai, J., Wickizer, T., Turner, J. A., Fulton-Kehoe, D., & Grant, L. (2005). Opioid dosing trends and mortality in Washington State workers’ compensation, 1996-2002. American Journal of Industrial Medicine, 48 (2), 91-99.
Knopf, A. (June 23, 2014). Congress and administration look at ways to expand buprenorphine treatment. Alcoholism and Drug Abuse Weekly.
Leece, P., Cavacuiti, C., Macdonald, e. M., Gomes, T., Kahan, M., Srivastava, A., Steele, L., Luo, H., Mamdani, M. M., & Juurlink, D. N. (2015). Predictors of opioid-related death during methadone therapy. Journal of Substance Abuse Treatment, in press.
McCance-Katz, E. F., Sullivan, L., Nallani, S. (2010). Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. American Journal of the Addictions, 19(1), 4-16.
Meier, B. (May 10, 2007). In guilty plea, OxyContin maker to pay $600 million. New York Times, http://www.nytimes.com/2007/05/10/business/11drug-web.html?_r=0
Portenoy, R. K., & Foley, K. M. (1986). Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain, 25(2), 171-186.
Quinones, S. (2014). Dreamland: The True Tale of America’s Opiate Epidemic. New York: Bloomsbury Press.
Volkow, N. D., Frieden, T. R., Hyde, P. S., Cha, S. S. (2014). Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine, 370, 2063-2066.
Weissman, D. E., & Haddox, J. D. (1989). Opioid pseudoaddiction—an iatrogenic syndrome. Pain, 36 (3), 363-366.
Zedler, B., Xie, L., Wang, L., Joyce, A., Vick, C., Brigham, J., Kariburyo, F., Baser, O., Murrelle, L. (2015). Development of a risk index for serious prescription opioid-induced respiratory depression or overdose in Veterans’ Health Administration patients. Pain Medicine, in press.
Zedler, B., Xie, L., Wang, L. Joyce, A., Vick, C., Kariburyo, F., Rajan, P., Baser, O., & Murrelle, L. (2014). Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Medicine, 15, 1911-1929.