Opioid painkiller addiction - the Stealth bomber in the living room

by Charlene Smith

Americans addicted to opioid painkillers have all but killed the cocaine trade as the citizens of the United States, just four percent of the world’s population, consume half the global output of prescription drugs.  And 80 percent of its painkillers.

Marijuana is no longer the gateway drug for teens - it is prescription drugs.

Cocaine is no longer the party thrill - it is prescription drugs.

And for kids who are persuaded by parents and teachers that they can’t study or concentrate appropriately without Ritalin, they switch to Adderall at college when writing papers – both drugs are ranked as narcotic as cocaine by the Drug Enforcement Administration, and both are cardio-toxic, which means they can cause potentially lethal heart problems.

The profile of prescription drug addicts is different to that of street addicts – your classic prescription drug addict is a white male aged 30 to 60. He is educated, employed, and probably a family man. His wife and children also probably use a higher ratio of prescription drugs than necessary.  And the more prescription drugs children are exposed to as they grow up, the more likely they will become addicted. Prescription drugs and not marijuana are the new gateway drugs to addiction and hard-core illegal drugs like heroin, the granddaddy of opioids.

And talking of senior citizens, grandma or grandpa also probably consume 10, 15, 20 or more drugs a day as globally the most rapidly growing age group is that aged 80 and older – with the assumption, not always correct, that as they age they need more and more drugs to function.[i]

Prescription drug addiction is not confined to the U.S., Britain, Australia and Canada are all reporting alarming increases in prescription drug consumption and addiction, but the problem is worst here.

Why are so many Americans in such pain[ii], so troubled and finding it so difficult to cope with life?  One of the reasons may be that, according to research from Harvard economists and others, this country has become one of the most over-worked nations in the world. Americans tend to work longer hours than the global norm with less labor protection. American productivity ranks among the top three in the world but the excessive consumption of pharmaceutical products to sleep, perform (at school, college, work and in bed) and retain a calm disposition would suggest that high rates of workplace performance are achieved at a cost that is disabling the country.

Dr. David Martin head of the Washington-based Drug and Alcohol Testing Industry Association receives daily reports of drug test results taken of employees in corporations and federal institutions. He says[iii] the U.S.A. is “facing a tsunami of severely addicted people.” He also gets to see drug test results for children and comments: “We are sacrificing a generation of children. We give them pills that look like vitamins. When I was growing up about six percent of 12-year-olds had some exposure to drugs, now over 60 percent are exposed to some form of drug abuse. I can’t think of a scarier science fiction plot … ”

What the United States needs to get out of the global recession is not for Americans to work harder – you can’t keep flaying a dying horse – it is for legislators and corporate bosses to become smarter about a risk that is rising up behind them like a Stealth bomber.  While everyone has their faces to the balance sheets, they’re ignoring the fact that the American worker can no longer cope, whether on the trading floor or on the manufacturing line.  They’re exhausted and are consuming chemicals in such high quantities that it is starting to paralyze innovation (the U.S. now ranks bottom in a ranking of 40 nations [iv]); destroy educational outcomes (U.S. educational scores are at record lows[v]) and collapse the health system.

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[i] World Population Ageing 1950 to 2050, Population Division, Department of Economic and Social Affairs, United Nations, 2002: “In the more developed regions, the proportion of older persons already exceeds that of children, and by 2050 it is expected to be double that of children.”

[ii] More than 33 million Americans, age 12 and older, misused extended-release and long-acting opioids during 2007—up from 29 million just five years earlier. In 2006, nearly 50,000 emergency room visits were related to opioids, by 2009 that figure had leapt to 1,2 million emergency room admissions. (Federal Drug Administration, April 2011)

[iii] Telephone interview with Dr. Martin, June 7, 2011

[iv] GPS Innovation Special, Fareed Zakaria, CNN, June 13, 2011

[v] The three-yearly Organization for Economic Cooperation and Development Program for International Student Assessment (PISA) report, which compares the knowledge and skills of 15-year-olds in 70 countries around the world, ranked the United States 14th out of 34 OECD countries for reading skills, 17th for science and a below-average 25th for mathematics, US Falls in World Education Rated Average, Huffington Post, July 12, 2010.

The morning fix - methadone before work

By Charlene Smith
Huntington, West Virginia – It’s 4am and cars snake around three blocks. People stand outside their vehicles chatting. If it wasn’t for the hour you would think they were waiting to get into a sports stadium, instead it’s a methadone clinic, they’re getting their fix before getting the kids ready for school and going to work.
Seventy percent of those standing outside the Huntington Treatment Center, a private methadone clinic, are employed, they are all white. They pay $12 a day for a hit of methadone or suboxone, supposedly to wean themselves off opioid painkillers. For the man in the new SUV next to me, it’s a way to get an added high. He smoothes a piece of paper before sprinkling a crushed pill onto it, probably Oxycontin, the opioid painkiller which is the drug of choice for most, and inhaling.

At $80 for the average 80mg Oxycontin, you can’t be poor, you need to have a good job and the medical insurance with it or receive Medicaid (the US’s crumbling national health insurer).

Three miles away, Professor Ahmet Ozturk, a clinical professor at the Marshall University School of Medicine agrees with the assessment of a nurse at the clinic that methadone or suboxone is little more than “a bandaid.”
Edith Urner, supervisor of the Chemical Dependency Recovery Center at Huntington Memorial Hospital across the country in wealthy Pasadena, California is more cutting: “It’s easier to go through four to seven days of withdrawal from heroin than the absolute hell of three weeks to get off methadone or subaxone so-called treatment. They are potent and long acting.” But Urner says, not enough doctors know enough about helping addicts. “It’s not dangerous to stop opioids abruptly, but it is dangerous to try the same with benzodiazepans (eg Valium) or barbiturates.”

And while there are many out-patient clinics, an inpatient facility like the CDRC in Pasadena costs $1 000 a day, average treatment needed? Ten days for opioid addiction. In that time they start a process of teaching patients non-drug alternatives.

The two hospitals, one in a wealthy area, and the other in an economically depressed zone have nothing in common but for the challenge of dealing with what the White House in April called “an epidemic” of prescription drug abuse.
This epidemic, Ozturk, Urner and others agree is making all other drug addiction scenarios look like childs play. Already 27,000 Americans are dying every year because of prescription drug overdoses – in Florida where pill-mills are common, there are seven overdose deaths a day and around 20 percent of babies are born addicted.

Prescription drug addiction in the USA is so extensive it has all but killed the cocaine trade and has ousted marijuana as the gateway drug for teens. The National Survey on Drug Use and Health reported in 2010, “a marked decrease in the use of some illegal drugs like cocaine.” The quantity of cocaine seized in El Salvador and destined for the United States plummeted for the second consecutive year, from 4,074 kg in 2007 to 394 kg in 2009, according to the International Narcotics Control Board.

The INCB expressed concern about the rapid increase in prescription drug abuse in the U.S.A. and observed that in 2009, 4.8 million Americans used cocaine compared to 12.4 million Americans who abused prescription pain relievers. The number of emergency room visits involving legal drugs more than doubled from 2004 to 2008, mainly as a result of the abuse of hydrocodone, methadone and oxycodone.

But its good for job creation around this legal drug trade. Around the Huntington Treatment Center are two pawn shops, a 24-hour MacDonald’s, a large Walgreens drive-thru pharmacy and loads of free parking. This Treatment Center, one of a few in this small town that borders Ohio and Michigan, sees an average of 700 patients a day while its parent company, CRC Health Group, has 150 clinics that sees 30,000 nationwide. National spokesperson Kristen Hayes, rejected an interview request and slammed the phone down when questions were asked.
Dr Ozturk shrugs, “CRC don’t take referrals from physcians and they won’t tell us if a patient is on methadone… If they don’t tell us we cannot co-ordinate treatment. Section 42CRF under federal law the Addiction Act says that patient history or current treatment is strictly protected, but the law also says that when medically necessary patient information should be released. They won’t it give to us but then again everyone is afraid of getting sued… “
There is little doubt that the primary dealers are doctors, yet when they are arrested, often after multiple overdoses among patients, their jail terms are low, most often they will get a $15 000 fine and a suspended sentence.

Most doctors overprescribe because of ignorance. Dr David Kloth of the American Society of Interventional Pain Physicians says a lack of training in pain management at medical schools is to blame.

For example, “most spinal surgeons have no formal training in pain management, nor do radiologists. Of those who are extremely qualified and certified to do intervention pain management, there are maybe only 7 000 to 8 000 across the USA.
“There are a lot of doctors prescribing medications that do not have proper expertise, I am not trying to put the doctors down, but these are highly addictive substances that interact with other medications.”
The world prescription drug market was worth $856 billion in 2010 – it has almost doubled in value in a decade. In the United States prescription drugs netted a cool $307.4 billion for pharmaceutical companies in 2010 ($270.3 billion in 2006). By far the biggest seller is hydrocodone/acetaminophen, a Schedule Three painkiller and cough syrup. It netted $131.2 million in legal sales in 2010.
Hydrocodone is a semi-synthetic opioid derived from codeine and thebaine and is often compounded with paracetamol or ibuprofen. Codeine and cough syrups are routinely abused in South Africa and the INCB has expressed concern that “In Africa, the illicit manufacture of psychotropic substances for local abuse takes place mainly in South Africa…The illicitly manufactured drugs are predominantly methamphetamine, methcathinone and methaqualone (Mandrax). The precursor chemicals … are usually imported into South Africa legally but then diverted from domestic distribution channels.”
Prof Charles Parry, director of the Alcohol & Drug Abuse Research Unit at the South African Medical Research Council says prescription drug abuse in South Africa is “absolutely” a problem. “And one that is somewhat hidden. The prime prescription drugs of abuse are benzodiazepines (e.g. Valium, Ativan, Alzam), analgesics (containing codeine – though many can be bought without prescription) and stimulant drugs such as Ritalin (methylphenidate) used to treat ADHD. Among physicians, abuse of pethidine (an analgesic) has been an issue in the past.”
Whereas the profile of those most addicted in the USA is white educated, working men aged 30 to 60, “In South Africa women feature more heavily than men in the abuse of over-the-counter (OTC) and prescription drugs… and middle and upper classes are more likely to abuse prescription medicines. A recent study in Cape Town found that abusers of OTCs and prescription medicines were primarily from the White population followed by Coloureds and Indians.
“A lot depends on what steps are taken to address the potential for the abuse of products , for example, real time prescription registers that prevent people filling scripts fraudulently across multiple pharmacies (this is starting to happen now with pharmacies that are linked, like the Clicks network, but we need to link pharmacies together that are not in the same networks). We also need to work with medical aid companies to look into why certain clients remain on benzodiazepines for long periods of time following an acute incident. Doctors need to prescribe where needed but to be mindful of the abuse potential when giving repeat scripts.”

And that is in part, where some of the problem lies, it can be so profitable for a doctor to have addicted clients.

The US Drug Enforcement Administration says that, “Hydrocodone is the most frequently prescribed opiate in the United States with more than 139 million prescriptions for hydrocodone-containing products dispensed in 2010 and more than 36 million in the first quarter of 2011.” In Oklahoma, as an example, where the number of deaths annually due to accidental overdose of prescription drugs has nearly tripled in the past decade, according to Oklahoma Medical Examiner’s office, hydrocodone is most often involved, followed by the anti-anxiety drug alprazolam, and two other painkillers: oxycodone and morphine.
The US has adopted drug-takeback days and launched a variety of initiatives, not one of which yet, does anything meaningful to address an epidemic that cuts to the heart of its working population at a time of economic crisis.