The current opioid epidemic and its related heroin crisis have devastated families in virtually every American community. Opioids include legally prescribed painkillers like oxycodone, hydrocodone, codeine, morphine, and fentanyl, which are often recognized by brand names such as Demerol, Dilaudid, OxyContin, Percocet, and others, as well as the street form of the drug—heroin. Prescription opioids, which are comprised of purer forms of heroin, are fueling this epidemic. Once patients become dependent on opioids, many will turn to heroin, which is cheap and in abundant supply, to stave off withdrawal when doctors reduce or stop their prescriptions or they can no longer afford these pricey drugs. According to Centers for Disease Control and Prevention, at least 75 percent of new heroin users first used a prescription opioid.1
Over 2 million Americans are now addicted to or abusing prescription opioids and over half a million or more citizens are struggling with heroin addiction. Since 2000, this problem has claimed the lives of at least 250,000 Americans.2 As noted by MIA bloggers Elizabeth Capps and Kurt Michael, such deaths quadrupled between 2000 and 2015. The cumulative death rate is equivalent to having wiped out a packed crowd at the Indianapolis Speedway. Another 1,000 people are treated in emergency departments for problems stemming from misuse of opioids every day. Over the course of a year, this amounts to the entire population of cities the size of Tampa, Cleveland, or Minneapolis requiring urgent care.
In 2007, three former Purdue Pharma executives pleaded guilty to criminal charges for misleading regulators, doctors, and patients about the drug’s addictiveness. Consequently, the company paid $600 million in fines to resolve civil and criminal charges for “misbranding” OxyContin—the once best-selling opioid. This fine was a drop in the bucket relative to the billions Purdue Pharma and other drug companies continue to rake in because of the drug epidemic they helped create. It’s time Americans demand that the drug companies that fueled and benefited from the opioid epidemic fund efforts to end it.
A National Emergency
The current opioid craze took root in 1984, when Purdue Pharma began promoting oxycodone (OxyContin)—a slow-release form of morphine—as a non-addictive pain medication. Oxycotin and other opioids are anything but non-addictive. Many addicts and drug dealers know them as “white man’s heroin” or “killer.”
The American opioid epidemic snowballed into such a catastrophic public health crisis that the Trump White House recently declared it a national emergency. Solving this crisis will require an all-society response; however, more than anyone else, companies that manufacture and sell opioids ought to fund efforts to solve this problem, but they are unlikely to volunteer to do so.
Propaganda Masquerading as Marketing
Drug companies have spent millions marketing opioids as non-addictive. Their efforts worked: one of the most infrequently used classes of drugs is now one of the most frequently used classes of drugs. Once reserved primarily for use among hospitalized cancer patients and for end-of-life care, opioids are now prescribed to over half of all U.S. hospital patients.
Central to this remarkable marketing coup was selling the notion—the big opioid lie—that less than one percent of patients would become addicted to opioids.
Merriam-Webster defines propaganda as “the spreading of ideas, information, or rumor for the purpose of helping or injuring an institution, a cause, or a person; ideas, facts, or allegations spread deliberately to further one’s cause or to damage an opposing cause.”
According to Joseph Goebbels—a prominent member of the Nazi propaganda machine that convinced German soldiers and citizens that it was their duty to exterminate Jews—“If you tell a lie that is big enough and keep repeating it, people will eventually come to believe it.” Goebbels’ infamous quote also warned that successful propaganda depends on suppressing concern about the truth: the group wishing to promote a big lie must also “use all of its powers to repress dissent, for the truth is the mortal enemy of the lie.”
Looking back on the evolution of the current opioid epidemic, the marketing of opioids looks like profitable propaganda. The big opioid lie was repeated so often that doctors eventually believed it was true despite previously thinking otherwise. As if on cue, doctors prescribed these drugs with increasing frequency, believing it was the right thing to do.
In accordance with Goebbels’ strategy, those wishing to convince people that opioids were not addictive also used their power to hide the truth. They crafted and promoted the concept called “pseudoaddiction,” claiming that it refers to the treatment-related syndrome of abnormal behavior that develops as a direct consequence of inadequate pain management. As such, addictive patient behavior was a signal for a need for more—not less—of the drug. In truth, “pseudoaddiction” is simply a made-up concept; it amounts to another lie, another piece of propaganda.
Promoting The Fifth and False Vital Sign—Pain
In his award-winning book, Dreamland: The True Tale of America’s Opiate Epidemic, Sam Quinones details how even the Joint Commission, which is the largest hospital regulatory body, got on board with the brilliant drug industry propaganda.3 In 2001, the Joint Commission declared that pain represents the fifth vital sign, something that should be monitored as closely and often as body temperature, pulse rate, respiratory rate, and blood pressure.
With the mandate for close monitoring of pain came the demand for aggressive amelioration of it. In fact, Medicare reimbursement rates became tied to results of government-sponsored patient satisfaction surveys that ask patients about how well they felt the hospital managed their pain. That’s also why pain charts are now plastered on hospital (and clinic) walls. These charts depict pain on a scale of 1-10 with corresponding smiley and sad faces and are designed to remind providers to ask about and control patient pain.
In due course, healthcare providers came to believe every patient’s pain levels should be kept to a minimum, and that opioids are the most effective means of doing so. Moreover, doing anything less could result in a hospital being cited by the Joint Commission or the doctors being reprimanded by hospital administrators, shunned by peers, or sued by patients.
It might seem bizarre that physicians jumped on board with the notion of pseudoaddiction, but they did. Eventually, however, the compounding wreckage of liberal opioid use overwhelmed the propaganda. Today, many doctors realize they were duped and are once again thinking of pain simply as a symptom rather than a vital sign that can or should be measured frequently. They also know opioids are powerful substances to which many patients will become addicted with high dosages or sustained use, appreciating also that some patients will become addicted even after short-term exposure to low dosages.
Last year, the American Medical Association (AMA) officially acknowledged the danger of thinking of pain as a vital sign that should be aggressively treated. The guild’s president stated that physicians played a role in the opioid epidemic and they were ready to take responsibility for it. The AMA’s main solution is to stop repetitively asking patients about their pain as a matter of routine.
Protesting Costly Change
The AMA’s decision to discourage doctors from routinely inquiring about pain drew outrage from pain specialists, including a past president of the American Academy of Pain Medicine. He claimed that the new AMA policy would set pain management back three decades. Such a response is not surprising.
Asking pain management specialists to get on board with reversing this trend would be like asking the fox to guard the hen house. Wittingly and unwittingly, pain specialists earned sizeable incomes from prescribing opioids and then treating patients who became dependent on them.
Translating Policy Into Practice
It generally takes 15 to 17 years for medical research findings and policies to become routine practice. Robert Pearl, MD provides a great case example in his new book: Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong.4 In the early 1980s, Dr. Barry Marshall, an Australian physician, discovered that stomach ulcers were almost always caused by a specific bacterium and treatable with antibiotics. Medical peers protested, continuing to believe that spicy food and stress were the usual culprits. Frustrated by such resistance, Marshall infected himself with the bacterium and allowed an ulcer to develop before treating himself (successfully) with antibiotics and published the results of his personal and well-documented experiment in the Medical Journal of Australia. Yet medical management of peptic ulcers didn’t begin to change for 20 years, when Marshall received a 2005 Nobel Prize for this work.
Even in the face of abundant evidence that liberal use of opioids is not effective and is harmful to the health of patients and the broader society, as well as criminal charges and company fines for promoting such practices, changes in medical care remain slow. Case in point: earlier this year, I had the opportunity to witness how difficult it is to un-ring the opioid bell. While visiting my friend Nancy Thom in California, her son, Wes, landed in the hospital for a painful infection that stemmed from a needle tip breaking off in his ankle while shooting heroin a few weeks earlier.* Despite being a self-disclosed heroin addict in the early stage of recovery, he was given opioids that he could have done without.
Recognizing Competent and Caring Professionals
By the time Wes visited an emergency department, his ankle had been gradually getting redder and more swollen—symptoms Wes tried to ignore while his best friend from college was in town. When his friend left and Wes finally went to the doctor, he was immediately sent to the hospital.
Wes bravely disclosed to all the doctors and nurses caring for him that he had been an intravenous drug user and recently entered an intensive outpatient treatment for his heroin addiction. Everyone treated him with respect, showing no sign of substandard care because of his addiction. Nonetheless, at every turn, his mother—an allied health professional who had read a great deal about heroin abuse and recovery—hovered nearby to reinforce the message, if necessary, that her son was not to receive any opioids.
After hours of waiting in the emergency department, Wes and Nancy Thom learned that a trauma surgeon who had recently graduated from an Ivy League Medical School was going to perform the operation. To Nancy Thom’s enormous relief, the surgeon assured them that, although addictive substances would be used during the surgery, there were a number of effective non-opioid pain management regimens that could be used to treat any post-operative pain—a point the surgeon reiterated to Nancy immediately after the surgery. The surgeon also volunteered that he had just recently become sensitized to the need to consider non-opioid alternatives to pain management. He emphasized that if the first non-opioid treatment regimen was ineffective, there were others he could prescribe.
Advocating for Patients
Wes managed to get through his first five days in the hospital stay without taking any opioids. During the first few post-operative days, a nurse practitioner who was part of the surgeon’s team checked on him. She always listened attentively as Wes described his pain and then reassured him that what he was experiencing was normal, would soon subside, and was not a sign that anything was wrong.
Nancy Thom was proud of her son for having turned his life around. Fearing, though, that Wes’ resolve might wane under the present circumstances or something else could go wrong during the hospitalization, Nancy Thom stayed close to Wes until the wee hours of the morning, when she would return to her nearby home to clean up and catch a few hours of shut-eye. The nurse practitioner that oversaw Wes’ postoperative care seemed to understand and support Nancy Thom’s protectiveness.
Overcoming Resistance to Change
Because the surgical team’s nurse practitioner was off on weekends, a hospital doctor (called a hospitalist) checked on Wes on Saturday and Sunday (postoperative days four and five). After listening to Wes’ response to her inquires about his pain, the first hospitalist to check on him immediately said she would order stronger opioid pain medication. When Nancy Thom questioned the hospitalist about whether she had read Wes’ chart (which she hadn’t) and interjected that he was a recovering heroin addict, the hospitalist slunk away never to be seen again.
Something similar happened the following day, but Nancy wasn’t around. The hospitalist on call on Sunday took it upon herself to convince Wes’ surgeon that he needed stronger pain medication and had the order to withhold opioids changed, making Percocet (oxycodone) available to Wes upon request. Rather than waiting for Wes to request the drug, the nurses repeatedly asked whether he needed it.
Tolerating Temporary Pain
Although Wes hadn’t needed the drug to get through what was arguably the worst of his ordeal, once it was offered, he “caved.” Wes reasoned that the Percocet would provide more relief than the intravenous Toradol—a non-narcotic anti-inflammatory drug—and that he’d be safe from abusing the drug in the hospital. In fact, he felt confident that he was far enough along in his recovery that taking the drug as prescribed would not “send me on a tear” or otherwise precipitate a return to heroin.
The Percocet did provide greater pain relief than the Toradol. Perhaps because the Percocet didn’t eliminate all the pain or because Nancy kept harping at Wes—reminding him how he’d managed to get along without the drug and how great it would be to keep the sort of drug that nearly killed him out of his system—or because of a combination of both, or because of something else, Wes quickly decided to stop taking the Percocet. A day and a half later, Wes was discharged.
Wes’ first day at home was rough, probably due to the sudden increase in physical activity associated with getting home and settled in and the uptick in physical therapy demands. But the pain lessened every day and he was off all pain medication and back to work nine days after surgery. Normally, this would not have been the case. Most patients undergoing a 2.5-hour surgery like Wes’ would have been medicated with opioids throughout the hospital stay and sent home with a prescription for more of the drug.
Interestingly, it wasn’t that long ago when postoperative pain was not reflexively treated with opioids nor were patients sent home with opioid prescriptions. These “untreated” patients did not suffer long-term consequences. Pain is a funny thing; it’s hard to recall it once it is gone. And, unless there is a complication from the surgery, postoperative pain generally disappears.
Once Wes was given a few Percocets and then declined them, Nurse Aneeka offered to sneak some more to him so his mother wouldn’t notice, believing Nancy Thom was interfering with her grown son’s medical care. Although Wes informed Nurse Aneeka that it wasn’t necessary to hide what was going on from his mother, she showed up with Percocet in a medicine cup and announced it was Benadryl and then whispered to Wes that it was really Percocet. Wes actually appreciated his mother’s close monitoring and advocacy, even though he wasn’t convinced that avoiding opioids during his hospitalization was critically important.
Apparently, like many American nurses, Aneeka thought it was important for patients to “stay ahead of the pain” and failure to do so would represent substandard and inhumane care.
The 36 million people who are addicted to opioids include healthcare providers, especially hospital nurses. As detailed in The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital by Alexandra Robbins,5 hospital nurses are employing a range of tactics to steal opioids from patients in hospitals, nursing homes, and hospice care centers. For example, they are supposed to “waste” (safely discard) patients’ leftover pain medications, but it is surprisingly easy for nurses to give patients only a portion of what is prescribed and pocket or shoot up the rest. Some have even admitted to peeling pain patches off of patients.
The Nurses includes a riveting side note. Jan Stewart, a nurse who had been certified for 28 years as a nurse anesthetist and rose to become president of the American Association of Nurse Anesthetists and widely respected and beloved by her colleagues, suffered from addiction to opiates and died at the age of 50 from an opiate overdose. Nurse Stewart’s addiction began with the painkillers she was prescribed after back surgery. Just like the main character in The Goldfinch,6 a 2013 Pulitzer Prize-winning novel, people can appear to be functioning relatively normally while abusing or addicted to opioids.
Targeting Outpatient Surgeons and Dentists
A year before I visited Nancy Thom in California, I had undergone a minor orthopedic operation at a freestanding surgical center. During the discharge processes, a nurse handed me an opioid prescription, noting the medication “could cause drowsiness.” Nobody asked me whether I or other family members had a history of substance abuse or discussed other precautions.
Wanting to “stay ahead of the pain,” as I’d so often heard healthcare providers recommend, I took one pill at bedtime for the first two nights but none during the day and never experienced more than mild discomfort. In retrospect, taking the pain pills was unnecessary.
That same year, I saw a periodontist for a dental implant. Each time, I was numbed and felt no pain during the procedure. Afterwards, the periodontist told me everything went well, shook my hand, and turned me over to his assistant. Each time, the assistant handed me a prescription for an opioid. When I asked about the level of pain to expect, I was told that it should be “minimal” and that I could probably return to work immediately. Each time, I took 800 mg of Tylenol before leaving the clinic. I never filled the prescriptions or felt any pain.
Three times in one year I was given an unnecessary opioid prescription. If I hadn’t been knowledgeable about the overuse of prescription drugs and generally predisposed to avoid any unnecessary medication, I might have taken all of the opioids prescribed by my surgeon and my dentists. This is not because I have an unusual pain tolerance. A close friend underwent the same orthopedic surgery a few months after me and he, too, did not need any of his prescribed opioid medication.
Advancing Patient Safety
MIA blogger Lawrence Kelmenson, MD suggests that the epidemic rise in the use of ADHD drugs that began in the 1990s helped fuel the current heroin epidemic. As a psychologist who once studied fallout from overuse of stimulants for ADHD, I learned that a doctor’s prescribing pattern is driven more by what his or her colleagues do and by what his or her patients demand than what professional guidelines suggest.7 While writing my new book, Your Patient Safety Survival Guide, I was reminded that it takes a long time for information contained in new and revised medical guidelines to translate into routine clinical practice… except when pharmaceutical companies step in with brilliant marketing campaigns.8 This point is also made clear in Drug Dealer, MD—a book about psychiatry’s role in the opioid epidemic by Anna Lembke, MD.9
It is obvious that when drug companies put their marketing know-how and dollars to work, they are wildly successful at changing patient expectations and doctor behavior. So the quickest way to restore safe use of opioid prescription is to insist that the drug companies that promoted the overuse of opioids now create a pot of money to develop powerful TV, radio, and print ads, free continuing education offerings, and drug rehabilitation research.
A note of caution: unless industry-funded efforts to end the opioid epidemic are overseen by people without financial or reputational ties to the pharmaceutical companies, they are unlikely to be successful. As Capps and Michael explained in their August 28, 2017 MIA blog, some of the pharmaceutical industry efforts to address this problem actually intensified the epidemic.
*Note: This story is true: however, for the privacy of others, it includes fictitious names and slight modification of inconsequential details.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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