An Examination of the Opioid Crisis: Methods of Mitigating Pain

BY NANCY LU

On January 27, 2017, the image of the Florida couple passed out in their car with a 2-year old toddler in the backseat bore deeply into the hearts of parents, people nationwide, and even addicts themselves.¹ Here was one image with a clear representation of the havoc that addiction could wreak. The image would serve as one of many wake-up calls to the American people – the opioid epidemic was in full swing, and thousands of innocent children, family members, and friends were the ones suffering. In a world where people of developing countries often die due to the lack of painkillers, it is a cruel twist of irony that Americans die precisely of the opposite problem: an excess of opioid medication. The multifaceted solutions to the problem are necessarily complex, but will in many ways determine the trajectory of healthcare for years to come.

Opioids are drugs that interact with the nervous system to reduce pain. They fall into two broad categories: opiates which are derived from the opium plant and synthetic or semi-synthetic drugs. Examples of opiates includes morphine, and the latter category include oxycodone, hydrocodone, fentanyl, and many other drugs that may be even more potent. Though they were initially intended only to treat pain, opioids are widely abused because of the euphoria associated with high levels of the drug. Tolerance and eventual dependence on the drugs is often the result.

The United States is the world’s largest consumer of the global opioid supply. In fact, Americans consume approximately 80% of the world’s supply.² This is not necessarily surprising due to the American emphasis on pain management. The consequences, however, are dire. From 2010 to 2014, there was nearly a twofold increase in the number of overdoses from opioids, a statistic which remains constant across almost all races, ages, and income levels.³ On an average day in the United States, approximately 78 people die of an overdose. The staggering statistics beg for a solution to the problem.⁴

So how did the opioid epidemic spread to the epic proportions that it embodies today? Perhaps the first step is taking a look at the history of the drug and what led to its widespread use. Opioids have long been part of both American and world history. Touted originally as a “miracle drug” or “wonder drug,” Veterans, especially of the Civil War, had already been using the drug as a potent pain reliever, but commercial use skyrocketed in the early 1900s.⁵ This was partly as a result of Bayer’s invention of heroin in 1898. Users quickly became addicted and found that the drug’s effects could be amplified through injection. Kimberly Johnson, the former director of the Substance Abuse and Mental Health Services Administration notes that there was a need for these drugs: “They are effective pain relievers, and that’s what they were being used for,” Johnson said. “There weren’t many other options.”⁵ Soon after, however, people started to understand the drastic effects of the drug, and heroin was outlawed in 1924.

Outlawing heroin, however, was certainly not the end of the opioid problem. Throughout the 1940s and 1950s, physicians needed to treat an influx of severely injured World War II veterans.⁵ This demand led to an increase in the use of nerve blockers as an effective pain management method. It was not until the 70s, when Percocet and Vicodin, two extremely addictive painkillers, came into the marketplace, that doctors began to shy away from prescribing uncontrolled dosages of these drugs. Unfortunately, there were still those who believed otherwise. In the New England Journal of Medicine, for example, Dr. Hershel Jick and Jane Porter wrote that “the development of addiction is rare in medical patients with no history of addiction” after a thorough analysis of 11,882 patients.⁶ This conclusion, of course, implied that the opioid addiction was not something to be taken too seriously in those who had no history of addiction.

The introduction of OxyContin, an even stronger painkiller, into the marketplace in 1996, once again fueled the falsehood that opioids were not that dangerous. In fact, According to the statistics from the National Institute of Drug Abuse, the number of prescriptions for the drugs increased by 2 million every year during the first several years of OxyContin’s introduction.⁵ By then, when physicians realized the extremely dangerous nature of the drug and its potential to serve as a gateway into illicit drugs, it was too late: the normalization of such drugs had already been created.

Interestingly, while America has a widespread drug problem due to overuse, many people in developing countries face the opposite problem due to lack of proper medication. In such countries, people often spend the ends of their lives in excruciating pain from illnesses like cancer. According to the International Narcotics Control Board, approximately “92% of all morphine, an opioid commonly used to control the pain caused by cancer, in consumed in America, Canada, New Zealand, Australia, and part of western Europe.”⁷ These regions of the world contain less than one-fourth of the world’s population. As Canadian professor Benedikt Fischer, a prescription-drug misuse expert at the University of Toronto’s Center for Addiction and Mental Health said, “It’s an absurd situation…We’re spraying [opioid] from a fire-hose while the majority of the world doesn’t have them.”⁷

Obtaining opioids for people in the rest of the world is often tedious, and in some cases nearly impossible. Not only are pain-relieving medications and people authorized to provide such treatment scarce in rural areas, but also numerous other issues are at play. As Dr. Gayatri Palat, a researcher of pain medicine at the MNJ Institute of Oncology and Regional Cancer Center, notes, doctors themselves themselves not well-trained in pain medicine, and thus are understandably wary of the process. Dr. Palat even notes that there may be fear of stigma against prescription, saying that “[Doctors are] afraid it will cause addiction in healthier patients or respiratory depression in those with terminal illness.”⁷ Because of this prevailing attitude, patients in extreme pain, such as terminal cancer sufferers, often cannot even get access to morphine. Pain relief in such situations is not a priority for healthcare professionals and in a larger sense for the government. For developing countries, the emphasis is on life-threatening epidemics rather than dying comfortably. Meg O’Brien, the managing director of global cancer treatment at the American Cancer Society puts it succinctly: “No one gets in trouble if, at the end of the year, pain relief has not been procured.”⁸

Thus, the opioid problem seems to be a unique problem facing developed countries, especially the United States, and much of the rest of the world waits with bated breath to see if solutions will decrease access to important medications. Researchers are eagerly looking for solutions to the problem and are tackling the issue from many different angles, including education, medication to reverse overdoses, and drug rehabilitation centers.

One promising lead has been the invention of naloxone, or Narcan, its brand name. Administration of naloxone to someone who has overdosed will often help him or her regain consciousness within several minutes. Thousands of people are revived by naloxone every single day, and many consider it a “wonder drug.” Naloxone cannot be abused and has no ramifications if mistakenly administered to someone who has not overdosed on opioids.⁹ People revived by naloxone often wake up woozy, disoriented, and craving more drugs. Still, naloxone gives emergency responders the time to advise treatment options.

Naloxone was originally used exclusively in medical settings, but the drug has gradually been moved out into rural areas, where access to immediate medical care is more costly and time-consuming for an issue where time is of critical importance. Lawmakers have paid attention as well. Forty-seven states–all except Montana, Kansas, and Wyoming–have laws that make obtaining naloxone easier. The accessibility of such drugs “reflects the relatively humane response to the opioid epidemic, which is based largely in the nation’s white, middle-class suburbs and rural areas, a markedly different response from that of previous urban-based drug epidemics.”⁹ Instead of using mass incarceration and a punishment-based system which was common when drugs were considered a problem of African American communities, officials are instead taking a more compassionate approach.

This was even reflected in the July 2016 Democratic National Convention. Senator Jeanne Shaheen (D-New Hampshire) made an impassioned plea, noting how the opioid epidemic has ravaged communities in her state.The statistics have worsened exponentially: in 2013, there were 192 overdoses; in 2014, 326 overdoses; and in 2015, overdoses. Shaheen’s main message of potentially requiring all emergency responders to carry naloxone received thunderous applause from the present delegates.¹⁰

Critics of naloxone note that what appears to be a panacea to the problem of overdose is really an illusion. Naloxone does not treat the core problem of addiction. While there is no doubt that the death toll from opioids would be higher without it, naloxone may provide a false sense of security to users. In fact, naloxone may even increase the risk of users trying to get high in the first place. Melissa Tucci, a heroin user, has been revived seven times through naloxone and she is not alone.⁹ As Governor Paul LePage of Maine writes, “Naloxone does not truly save lives; it merely extends them until the next overdose….[We have] created a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other, which produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction.⁹” But Tucci notes that naloxone is not pleasant for someone revived from an overdose. Withdrawal symptoms begin almost immediately, and Tucci, in an interview with the New York Times says, “I hate it…When I start withdrawing, I vomit, you get diarrhea, you sweat profusely, your nose will run, you sneeze and have runny eyes, and you ache so bad you can’t even walk.”⁹ When revived, some addicts are even angry that they have been treated with naloxone–while naloxone reverses the overdose, it also eliminates the euphoria and leads immediately into withdrawal.

Another possible solution to pain management includes medical marijuana. Some evidence suggests that medical marijuana is effective for chronic pain. Prescribing medical marijuana instead of opiate-based painkillers may be a viable solution. Dr. James Feeney, a surgeon in Connecticut, firmly believes that this substitution would be much safer in the long run, and more pleasant for patients as well. He is conducting his own study at Saint Francis Hospital and Medical Center in Hartford, Connecticut.¹¹ One of the the big obstacles that researchers face is that marijuana is still classified as a Schedule I drug, which makes obtaining the drug extremely difficult.¹² Currently, the best place for researchers to obtain it is from the University of Mississippi which grows limited amounts. Licensing requirements for researchers are also extremely strict. Yasmin Hard, a researcher licensed to study marijuana, is specifically interested in THC, the active component of marijuana, and whether isolating the compound can help create a potent pain reliever.¹¹ She is also running a study determining whether this substance can help heroin users stop using heroin. The continued research into this field should be able to provide some answers.

The politics of medical marijuana are certainly very complicated, but many states, such as West Virginia which has been hit hardest by the opioid epidemic, have taken a rational and algorithmic view of the issue.¹³ Because many healthcare professionals are not well-versed in pain management, an advisory board of both specialists, non-specialists, and health insurance experts was set up which codifies a step-by-step approach to treating pain. At the lowest level of risk, there are topical creams with acetaminophen. The four categories of treatment then proceed from least potent to most potent. This algorithm directly tackles the issue of lack of education amongst the community. In addition, the inclusion of health insurance providers encourages them to not deny coverage to practices that may not be considered “standard.” For example, alternative pain methods to painkillers are often denied coverage currently due to unproven efficacy. Having a state-approved algorithm system could possibly change this situation.

The multifaceted approaches to treating the national opioid problem will most likely need to be applied to other nations as well. One current crisis in the developing world is tramadol, an addictive synthetic painkiller that remains largely unstudied and unregulated.¹⁴ As an inducer of hallucinations and delusions, the drug is extremely damaging to users’ nervous systems. Tramadol is the developing world’s counterpart to heroin, and will likely need to be regulated by governments in the same way. However, these governments tend to succumb easily to bribery and are generally less organized, making such regulations difficult to enforce.

Ultimately, in order to provide adequate care and truly solve the opioid epidemic, we must remember and follow the words of the current Surgeon General, Vivek Murthy: “…we must stop seeing addiction as a moral failing and start treating it as the chronic illness it is, one that demands our skill, urgency, and compassion.”¹⁵ Educating those who find themselves in the ever-tightening grip of addiction is certainly the first step. Continuing to administer naloxone and finding other innovative treatments, like medical marijuana, is also crucial. Identifying solutions to this problem with compassion and understanding is of utmost importance not only because the rest of the world is watching, but also because we have a duty to help those who cannot help themselves.

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References:

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2. Gusovsky, Dina. Americans still lead the world in something: Use of highly addictive opioids. CNBC. (n.d.). Retrieved from http://www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html.
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