In 2012, Americans received nearly 260 million prescriptions for opiate painkillers. Now, the National Institutes of Health (NIH) has released a white paper that reports “a dire need for research” to make up for the “scant” evidence that opioid painkillers should be used to treat chronic pain.
The NIH white paper condenses the final work of a seven-member panel that was convened in September to study the place of opioids in medicine. That panel, comprising independent experts in psychiatry, epidemiology and other disciplines, wrote in its full report that “the prevalence of chronic pain and the increasing use of opioids have created a ‘silent epidemic’.”
“The overriding question,” the panel wrote, “is whether we, as a nation, are currently approaching chronic pain in the best possible manner that maximizes effectiveness and minimizes harm.”
There is not nearly enough good research to say for sure, the experts said, writing: “Evidence is insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain.”
That dearth of evidence combined with high numbers of substance abuse and overdose deaths in the US have created circumstances doctors need to confront immediately, the authors said.
By 2010, there were more than 160,000 hospitalizations a year for prescription opioid addiction. In 2012, healthcare providers wrote 259 million prescriptionsfor opioids, according to the Centers for Disease Control and Prevention (CDC). That year, more people aged 25 to 64 died from overdoses than car accidents.
The next year, 2013, the agency found that 71% of overdoses from prescription drugs – a total of 16,325 deaths – were caused by opioid painkillers. Last year, the CDC reported that doctors were a primary source of drugs for opioid abusers, and a doctor at the CDC estimated that 46 Americans died every day from overdoses of prescription painkillers.
Oxycodone, codeine, dilaudid and methadone are among the opiates most frequently abused; morphine is also often prescribed for patients who report extreme pain.
The new NIH white paper estimates that between five and eight million Americans take opioid painkillers to manage chronic long-term pain, but nearly all opiate drugs consumed for months and years were approved on the basis of 12-week studies.
Although people have consumed opioids to dull short-term pain for centuries, new research shows there are distinct kinds of physical pain, and that not all treatments work as effectively to manage them. The panel found that patients with chronic pain were too often “lumped into a single category”, even though humans have three distinct pain mechanisms, such as those caused by inflammation versus nerve damage or arthritis and cancer.
But experts told the panel almost unanimously that they feared physicians could not distinguish between people who were at risk or could be at risk to develop problems with misuse.
The health system itself encourages doctors to prescribe drugs, the panel noted, since many plans “nonopioid alternatives as second- or third-line options rather than placing them more appropriately as first-line therapy”.
“Important clinical tasks” have fallen by the wayside, the experts warned, in favor of seemingly easy answers such as prescriptions.
“In the case of pain management, which often requires substantial face-to-face time, quicker alternatives have become the default option.”
Ultimately, the NIH panel recommended that providers tailor treatment to each individual patient, and suggested “a multidisciplinary approach”, including a mix of physical therapy and non-drug options, “similar to that recommended for other chronic complex illnesses, such as depression, dementia, eating disorders or diabetes”.
Opioids can be very effective for some patients, the experts acknowledged, but even for those for whom the drugs work the panel recommended regular check-ups.
There is “a dire need for research on the effectiveness and safety of opioids”, the panel wrote, while also recommending an overhaul of the electronic health record system to better help doctors keep track of a patient’s medical history.
Over the past two decades, the number of prescriptions for opiate-based painkillers has tripled, while dosages have grown stronger
Elaine and Steve Pozycki
The prime source for the national explosion of opiate addiction — whether in the form of painkillers such as OxyContin or in the form of illegal street drugs such as heroin — is the dramatic increase in the use of opiate-based prescription drugs. Over the past 20 years, there has been a threefold increase in the number of prescriptions issued for opiate-based painkillers, as well as a major step-up in dosage, according to the Centers for Disease Control and Prevention (CDC). Healthcare providers wrote 259 million prescriptions in 2012 alone. Further, it has been well-documented that some people when they can no longer get access to prescription painkillers feed their opiate addiction by turning to heroin.
The costs in lost and ruined lives from what the CDC refers to as a “national epidemic” of opiate addiction continue to rise. Drug overdoses are the number one cause of accidental death in the United States. In 2010, nearly 20,000 people died from an overdose of opiates — nearly 17,000 from prescription painkillers and an additional 3,000 from heroin. It is time for a comprehensive approach that matches the scale of the problem and that begins at its source—the overprescribing of prescription painkillers and the underinforming of patients about the risks of this medication and possible alternatives
We are pleased to report that there is legislation moving through the New Jersey legislature that does exactly that. Senator Loretta Weinberg (D-37th) and Senator Joe Vitale (D-19th) are putting forward a proposed law (S-2366) requiring physicians and other health practitioners to discuss with a patient the risks of physical and psychological addiction and the availability of potential alternative medications, before issuing a prescription for an opiate-based painkiller.
In cases where the patient is under 18 years old, this discussion must take place with a parent or a guardian From the harm that too many of our children and families have experienced because a teenager becomes addicted to opiates, we know just how important providing this essential knowledge can be. To ensure compliance with the essential provisions of this legislation, the practitioner must obtain a written acknowledgement from the patient or the patient’s parent or guardian that this discussion has taken place.
The need for moving forward with this kind of approach is underscored by the American Academy of Neurology’s recent determination that the risks of powerful narcotic painkillers outweigh their benefits for treating chronic headaches, low back pain, and fibromyalgia. The Academy noted that 50 percent of patients who took opioids for at least three months are still on them five years later.
Further, more appropriate and limited prescribing of prescription painkillers will help reduce heroin use by reducing the number of people who crave opiates. AS CDC Director Tom Frieden, M.D., M.P.H., said, “Addressing prescription opioid abuse by changing prescribing is likely to prevent heroin use in the long term
Just as importantly, there is strong public support in New Jersey for this approach. In a recent FDU Public Mind Poll, more than two-out-of-three New Jersey parents indicated support for a law requiring that they be notified if their child’s prescription contained potentially addictive medication
We are pleased to report that this legislation, one component of a comprehensive package aimed at taking on New Jersey’s addiction problem passed the Senate recently, by a margin of 36 to 1. Still, there is a long way to go before final passage and it will require all of us to make our voices heard. It is particularly important for people to communicate their support to their Assembly members, since that is the next hurdle, we anticipate an open and fair discussion of this legislation in the Assembly Health Committee chaired by Assemblyman Herb Conaway (D-7th) soon after the New Year.
Senator Weinberg and Vitale’s legislation (S-2366 ) is a critical prevention measure which attacks the problem directly at its source. Treatment after the fact is still important to do, but because of the brain changes caused by opiate addiction, it is a hard, difficult road to recovery for too many and the results are hit or miss. We must put preventing addiction in the first place at the forefront and that begins with passing this essential measure.
Elaine and Steve Pozycki are board members of the Partnership for a Drug-Free New Jersey, with Elaine serving as co-chair. Steve Pozycki is the founder, chairman, and CEO of SJP Properties.
More than 40 addiction treatment, health care and consumer groups are urging the Food and Drug Administration (FDA) to reverse its decision to approve the prescription painkiller Zohydro ER (extended release), CNN reports.
The drug is a pure form of the painkiller hydrocodone. The FDA approved Zohydro ER in October for patients with pain that requires daily, around-the-clock, long-term treatment that cannot be treated with other drugs. Drugs such as Vicodin contain a combination of hydrocodone and other painkillers such as acetaminophen. Zohydro ER is set to become available in March, the article notes.
In December 2012, a panel of experts assembled by the FDA voted against recommending approval of Zohydro ER. The panel cited concerns over the potential for addiction.
Zohydro is designed to be released over time, and can be crushed and snorted by people seeking a strong, quick high. The opioid drug OxyContin has been reformulated to make it harder to crush or dissolve, but Zohydro does not include similar tamper-resistant features.
In a letter to FDA Commissioner Dr. Margaret Hamburg, the coalition of health groups, wrote, “In the midst of a severe drug epidemic fueled by overprescribing of opioids, the very last thing the country needs is a new, dangerous, high-dose opioid. Too many people have already become addicted to similar opioid medications, and too many lives have been lost.”
The health groups include the American Society of Addiction Medicine, Public Citizen Health Research Group, Phoenix House, the Hazelden Foundation, and Physicians for Responsible Opioid Prescribing.
In December, 28 attorneys general wrote to Commissioner Hamburg, saying they believe the approval of Zohydro ER “has the potential to exacerbate our nation’s prescription drug abuse epidemic because this drug will be the first hydrocodone-only opioid narcotic that is reportedly five to ten times more potent than traditional hydrocodone products, and it has no abuse-deterrent properties.”
The life of a heroin addict is not the same as it was 20 years ago, and the biggest reason is what some doctors call “heroin lite”: prescription opiates. These medications are more available than ever, and reliably whet an appetite that, once formed, never entirely fades.
The actor, who quit heroin more than 20 years ago, reportedly struggled to break a prescription painkiller habit last year. Experts in addiction say that the use of medications like Vicodin, OxyContin and oxycodone — all opiates like heroin — has altered the landscape of addiction and relapse, in ways that affect both current users and former ones.
“The old-school user, pre-1990s, mostly used just heroin, and if there was none around, went through withdrawal,” said Stephen E. Lankenau, a sociologist at Drexel University who has surveyed young addicts. Today, he said, “users switch back and forth, to pills then back to heroin when it’s available, and back again. The two have become integrated.”
Rates of prescription opiate abuse have risen steadily over the last decade, while the number of people reporting that they used heroin in the past 12 months has nearly doubled since 2007 to 620,000, according to government statistics. That’s no coincidence, researchers argue: more people than ever now get a taste of opiates at a young age, and recovering addicts live in a world with far more temptations than there were a generation ago.
“You can get the pills from so many sources,” said Traci Rieckmann, an addiction researcher at Oregon Health & Science University. “There’s no paraphernalia, no smell. It’s the perfect drug, for many people.”
Millions of people use these drugs safely, and doctors generally prescribe them conscientiously. But for some patients, prescription painkillers can act as an introduction — or a reintroduction — to an opiate high. The pills set off heroin craving in recovering addicts, doctors say, every bit as well as they soothe withdrawal in current users.
Dr. Jason Jerry, an addiction specialist at the Cleveland Clinic’s Alcohol and Drug Recovery Center, estimates that half of the 200 or so heroin addicts the clinic sees every month started on prescription opiates.
“Often it’s a legitimate prescription, but next thing they know, they’re obtaining the pills illicitly,” Dr. Jerry said.
In many parts of the country, heroin is much cheaper than prescription opiates. “So people eventually say, ‘Why am I paying $1 per milligram for oxy when for a tenth of the price I can get an equivalent dose of heroin?’ ” Dr. Jerry said.
Investigators do not yet know whether Mr. Hoffman was taking prescription opiates at the time of his death. Toxicology tests are pending, and the purity and content of the heroin found in his apartment will certainly be a focus.
While the deluge of prescription painkillers is new, other risk factors for overdose have not changed in decades.
“These are common danger zones,” said Dr. Nicholas L. Gideonse, the medical director of O.H.S.U. Richmond Community Health Center in Portland.
Even a change in where a person uses his or her drug of choice can increase the likelihood of an overdose, studies suggest. “If you habitually use in your car, for example, the body prepares itself to receive the drug when it’s in that environment,” Dr. Rieckmann said. “It’s called conditioned tolerance. When people using are in an unfamiliar places, the body is less physically prepared.”
The risk of dying from an overdose is higher when people are using alone. “Another person, sober or not, can notice when someone nods off, or just say, ‘Hey man, slow down,’ ” Dr. Lankenau said. “And users act as a gauge for each other of when they’re doing something dangerous.”
Many needle exchange programs and clinics now have overdose prevention courses, teaching users to notice danger signs and administer the drug naloxone, an opiate blocker that E.M.T.s use to revive addicts who have overdosed.
None of which might have spared Mr. Hoffman. One thing that has not changed for heroin addicts over the past 20 years is the certainty that this next shot will not be deadly.
“You have to understand that addicts inject three or four times a day for years and years on end,” Dr. Gideonse said. “They don’t perceive any one shot to be dangerous or potentially deadly, because in their experience, there’s no reason to.”
By Rick Nauert PhDSenior News Editor Reviewed by John M. Grohol, Psy.D. on February 19, 2014
Teen prescription drug abuse programs have experienced mixed levels of effectiveness, ranging from big drops in drug abuse to no measurable effect.
The finding comes from a study of 11,000 teenagers by researchers at Duke and Pennsylvania State universities.
The best results came from pairing a school-based program with a home-based intervention, resulting in a 10 percent decrease in abuse rates.
By contrast, most school-based programs were ineffective when used by themselves, with just one exception.
While the results are sobering (no pun intended), the six-year study is among the first to measure the success and cost-effectiveness of prescription drug abuse prevention efforts.
Abuse of prescription opioids, a form of painkiller, is the fastest-growing form of illicit drug use in the country, affecting more than 12 million Americans and killing more people annually than heroin and cocaine combined, according to the Centers for Disease Control and Prevention.
As a result, the U.S. Food and Drug Administration has recommended restricting access to painkillers such as Percocet, Oxycontin, and Vicodin.
“These drugs are very available, and highly addictive,” said Max Crowley, Ph.D., an NIH Research Fellow at Duke’s Center for Child and Family Policy.
“There’s a growing national debate about whether we should restrict access to these drugs, but at the same time, the drugs are hugely important for pain management. What’s being left out of the debate is the role of prevention.”
Crowley and his co-authors found that only one school-based program was effective when used by itself.
The Life Skills Training program resulted in 4 percent lower drug abuse rates, compared with a control group. The 18-session course teaches social skills that build competence and encourage assertiveness.
“Life Skills Training was also among the most cost-effective programs studied, costing an average of $15 per child,” Crowley said. “By contrast, the study notes that prescription drug abusers cost society an average of $7,500 each for treatment and other expenses, by conservative estimates.”
Life Skills was among four prevention programs the researchers studied.
The team looked at 28 rural public school districts in Iowa and Pennsylvania, tracking students from grades 6 through 12. They examined a home-based program called Strengthening Families 10-14 and three school-based programs: Life Skills Training, Project Alert, and All Stars.
All four were “universal” programs that were offered to all teenagers in a given district.
The researchers analyzed pairs of demographically similar school districts. Within each pair, one community received a prevention program or programs, and the other did not.
The research team surveyed teenagers each year, asking teens to anonymously report whether they had ever used a prescription painkiller for nonmedical purposes. The authors then compared drug use levels in districts that received interventions versus those that did not.
In communities that received no intervention, a quarter of high school seniors reported having misused prescription painkillers.
The most substantial reductions in abuse rates occurred when the Life Skills program was combined with the Strengthening Families program. The All Stars intervention also yielded reductions when it was used alongside the Strengthening Families program.
Crowley said he hopes policymakers and educators will put the findings to use.
“Policymakers and other leaders are actively searching for efficient ways to curb prescription drug abuse,” Crowley said.
“These results give policymakers options regarding how to handle this growing epidemic.”
The Jersey Shore, famous for sun, fun and reality TV, now has a new and less welcome distinction. Deaths from heroin and prescription drug overdoses in Ocean County, N.J., already among the highest in the state per capita, more than doubled in 2013, and three residents have already overdosed in 2014.
“It is a suburban epidemic facing us throughout New Jersey,” said Angelo Valente, executive director of the Partnership for a Drug-Free New Jersey. “A lot of suburban counties are affected at dangerous levels.”
“This is no longer just an inner city issue,” said Al Della Fave, spokesman for the Ocean County prosecutor’s office.
In 2012, 53 people died of heroin and prescription drug overdoses in Ocean County, a boardwalked string of beach towns like Seaside Heights, home to the long-running reality series “The Jersey Shore.” Ocean County had already claimed the New Jersey state title for highest number of heroin-related emergency room admissions, ahead of urban counties like Hudson and Essex with larger populations. It led the state in 2011 with 11 percent of all admissions and again in 2012 with 11.4 percent of admissions, despite having less than seven percent of the state’s population.
Last year, the county death toll from overdoses soared to 112, with the majority heroin-related, roughly ten percent of a state total of 1,188 overdose deaths. Three locals have already died in 2014. Over the weekend, two men died of heroin overdoses in Point Pleasant and Seaside Heights. Local police have issued a warning about a possibly tainted brand of heroin being sold under the name “Bud Light.”
Della Fave said the popularity of heroin and related drugs has risen because of purity and price and that DEA reports show use is spreading in suburban and rural areas of New Jersey and Pennsylvania. Use of a needle is no longer a deterrent, said Della Fave, “because people are simply snorting the newer, purer product.”
Valente blamed the problem in part on young people’s access to medicine cabinets. “Prescription drugs are a gateway drug to heroin,” said Valente.
Ocean County prosecutors have even distributed warning cards to funeral homes so families understand the need to dispose of unused prescription medications, particularly those containing opiates, that may be left behind by the deceased. According to prosecutors, “It is our hope that these unused medications will be disposed of at the designated drop-off points so that they do not get into the hands of those who would use or sell them illegally.”
Della Fave also warned users that there’s still no consistency in how the product is cut. “Every time users take it,” he said, “they’re rolling the dice with their lives.