We are in the midst of an opioid epidemic. Prescription opioids are being over-prescribed and misused. People have become addicted when taking opioids prescribed for them by doctors for acute, chronic, or post-surgical pain; or when inappropriately taking meds prescribed for others; or when buying illegal drugs on the street. Many prescription drug addicts switch to heroin because it is easier to get, and heroin overdoses are also on the rise. More than 11 million people abused prescription opioids in 2016. 42,000 Americans are dying every year from opioid overdose, 40% from prescription opioids. For comparison, 33,636 Americans die of firearm injuries, 37,133 from traffic accidents, and 480,000 from cigarettes every year. President Trump has declared opioid addiction a national Public Health Emergency.
According to New York Magazine’s Intelligencer, “No other developed country is as devoted to the poppy as America. We consume 99 percent of the world’s hydrocodone and 81 percent of its oxycodone. We use an estimated 30 times more opioids than is medically necessary for a population our size.”
Are the drug companies to blame?
27 states have sued Purdue Pharma, the creator of OxyContin, accusing them of two things:
- False advertising
- They downplayed the dangers and exaggerated the benefits.
- They misrepresented newer, stronger opioids as less addictive.
- They failed to disclose information they were aware of from their clinical trials.
- They claimed that because of the time-release formulation, OxyContin posed a smaller risk of abuse and addiction than other, shorter-acting opioids.
- They promised 12-hour relief based on a flawed initial study, but follow-up studies showed that for up to 95% of patients, it didn’t last that long.
- Producing and distributing the pills on a massive scale.
- In some areas, more bottles of OxyContin were sold than there were people.
- This despite the fact that they knew there was a high risk of abuse.
- They knew the drugs were being diverted onto the black market, yet they failed to monitor usage or do anything to stop it.
In a 2007 case, Purdue and three executives pleaded guilty to criminal charges. Purdue paid $600 million and the three executives paid $19 million, $8 million, and $7.5 million in individual fines.
An article in The Atlantic asked, “Did Free Pens Cause the Opioid Crisis?” It described the aggressive marketing tactics of the drug companies and cited a study showing that while prescriptions decreased across the country in response to much-publicized abuse, “among physicians who continued to receive gifts from opioid makers, prescriptions continued to see a modest rise.”
Opioids can be used responsibly or irresponsibly
A report by the Surgeon General says:
there are certain populations who rely on prescription opioids and are taking them responsibly under the care of a trusted provider. These include, but are not limited to: individuals in hospice care; individuals who are undergoing cancer treatment; people who recently experienced a traumatic injury; or those with long-term disability and chronic pain…Opioid pain medications are generally safe when taken for a short time and as prescribed by a health care professional, but because they produce euphoria in addition to pain relief, they can be misused.
A Cochrane review found that:
OxyContin is one of the most commonly abused prescription drugs. The drug’s controlled-release formula provides chronic pain relief for up to 12 hours. Many people bypass the time-release action by crushing and snorting OxyContin, or by dissolving the tablets in water and injecting the solution. This allows the user to achieve the full effect of the drug all at once.
The addiction process
The Surgeon General’s report said:
Well-supported evidence suggests that the addiction process involves a three-stage cycle: (1) Binge/Intoxication, the stage at which an individual consumes an intoxicating substance and experiences its rewarding or pleasurable effects; (2) Withdrawal/Negative Affect, the stage at which an individual experiences a negative physical and emotional state in the absence of the substance; and (3) Preoccupation/Anticipation, the stage at which one seeks substances again after a period of abstinence. This cycle becomes more severe as a person continues substance use and as it produces dramatic changes in brain function that reduce a person’s ability to control his or her substance use.
A study that compared therapeutic use to street use found that:
CNCP [opioids prescribed for chronic non-cancer pain] patients started therapy in the low dose range for oral morphine (</=60 mg/day) and most (83%) did not move into a higher dose range once adequate levels of analgesia were attained. Street users started smoking heroin intermittently, before daily use. Most escalated their dose by increasing the amount used and by switching from smoking to injecting. Unlike CNCP patients, street users demonstrated patterns of compulsive drug use, social problems and intoxication. Only 3/31 (9.5%) pain patients that discontinued opioid therapy reported withdrawal symptoms on abstaining from the drug compared to 35 (89.5%) of street users.
Definitions
Not all individuals who abuse drugs are addicts. Drug abuse is defined as the habitual taking of addictive or illegal drugs. Drug dependence is defined as experiencing withdrawal symptoms when the drug is withdrawn. Withdrawal symptoms can be avoided or managed by gradually reducing the dose. Addiction is a chronic relapsing brain disorder characterized by compulsive drug seeking.
Just how addictive are opioids, anyway?
It’s very difficult to get a straight answer to that question.
Many websites ask “Why is OxyContin so addictive?” or say it is a “highly addictive drug.” But even they admit that “very few people who take OxyContin as prescribed become addicted to the drug.” There are animal studies, but no well-designed controlled human studies. And there are many possible confounders.
The confusion started in 1980, when a letter published in The New England Journal of Medicine said addiction is rare (less than 1%) in patients treated with narcotics. It was widely cited and believed, and Big Pharma relied on it for their advertising. But it was only a one-paragraph letter about data collected from records of hospitalized patients in highly regimented settings and it was misrepresented and misused to justify widespread outpatient use.
The experience of the Viet Nam war seemed to confirm that opioids were not very addictive. About 15% of servicemen became addicted to heroin while stationed in Viet Nam. 95% of them stopped using it and did not resume when they returned stateside.
A systematic review of studies found a prevalence of drug abuse, drug dependence, and drug addiction in the range of 3.2-18.9% but said there is little evidence that addictive behaviors are common within the chronic pain population.
A study published in 2011 found that:
Although preclinical measures of opioid antinociception, tolerance, addiction and dependence need to be interpreted with caution, overall they appear to have good predictive validity for human responses to opioids. The primary problem in making this connection is the lack of randomized controlled human studies.
A better question
While we don’t have a straightforward answer to “just how addictive are opioids?” especially OxyContin, the available evidence seems to point to this: when taken as directed, opioids are not especially addictive. In practice, OxyContin is more addictive than other drugs because of the way it is abused.
The drug itself is only part of the problem. Psychological factors, socioeconomic factors like joblessness and hopelessness, mental illness, drug company misinformation, doctors who overprescribe, patients who share their prescribed meds with others, and patients who disregard instructions are also to blame.
So a better question is not “how addictive?” but “what can we do to prevent addiction and overdose?”
What can be done to stop the opioid epidemic?
There have been many suggestions: alteration of opioid formulations to make them less subject to abuse, better monitoring of prescription and addiction rates, early identification of drug abusers, better treatment programs for addicts, better insurance coverage, supplying first responders with naloxone to reverse overdoses, programs to educate doctors, better identification of risk factors, and more.
We know many of the risk factors for addiction: a family history of addiction, a personal history of alcoholism or other substance abuse disorders, mental illness (especially major depression), etc. A combination of five risk factors is known to increase the risk of dependence by a factor of 56.36. Doctors can check for risk factors, prescribe with caution, prescribe smaller quantities, and closely monitor patients for abuse and for suicidal potential. They could also try to find out if the patient is part of a high-risk peer group and is exposed to drug abusers and illegal drugs.
Success will require a joint effort of doctors, patients, families, drug companies, legislators, and the media. Fingers crossed.