The study of pain and how opioid painkillers created a new generation of prescription drug addicts

        By Charlene Smith (c)

The study of pain, was, remarkably long neglected. But in the 1940’s a young Italian immigrant, John Bonica began studying pain management to assist the thousands of U.S. soldiers under his care in Washington State.  After his wife nearly died during the birth of their first child he began examining ways to reduce pain in childbirth and developed the epidural analgesia, now used in millions of births.  In 1953, he produced a classic script on the management of pain. “Bonica said pain is a disease by itself, not a disease prolonged,” 

Professor Ahmed Ozturk, a pain expert from Huntington Hospital, West Virginia with three decades of pain management experience relates. “Bonica started the first pain clinics with the idea of getting people off drugs, he saw drugs as an impediment, rather than an aid to recovery. This attitude continued through the ‘50s but in the 1960s because of the liberal use of drugs and the arrival of methadone clinics attitudes began changing. Suddenly three out of four people would say they were addicted because of pain.  Then in the 1990’s a group in New York mainly from Sloan Kettering [a cancer institute] developed the idea that chronic pain patients, like cancer patients, would benefit from opioid usage. They promoted high dose opioids for chronic pain patients. They promoted it cautiously, but once the genie was out of the bottle a great increase was seen in opioid usage, doubling almost every year in the 1990s, especially after the strong opioid OxyContin came onto the market.”

     

              But there were other factors converging, the Diagnostic and Statistical Manual of Mental Disorders became increasingly influential in diagnosing new disorders that often coincided with new products from pharmaceutical manufacturers. The word ‘cure’ left the lexicon and ‘management’ of illness became the preferred term.  

Then the Food and Drug Administration took the controversial step in 1999 of allowing prescription drug manufacturers to advertise over radio and television to consumers, the only other country in the world to allow this is New Zealand.  Those ads have now replaced tobacco as by far the most lucrative form of advertising in the broadcast media. During his presidential campaign in 2000[i], President George W. Bush began suggesting the most radical changes to Medicare in six decades, the most notable of which was a powerful prescription drug clause. He personally drove it until it became law in 2003.  

Ironically, perhaps, one of the countries the United States would go to war with in 2003 was Afghanistan a major producer of poppy, the plant from which opium is extracted. A decade of war has seen Afghanistan go from being a lowly opium producer to the worlds biggest and most successful opium producer. All these motley ingredients and more, fed into a pipe that would see prescription drug profits and addiction soar.

        And so today we hear or know of pathetic stories of successful Americans who are hopelessly addicted to prescription opioids, or died because of their overuse, the roll call of deaths is long and includes entertainers Michael Jackson (propofol and the anti-anxiety drug, Lorazepam), Amy Winehouse,  Heath Ledger (six kinds of painkillers), and New York Rangers hockey player Derek Boogaard (oxycodone). Those who admitted to being addicted and sought help in time include talk show host and political commentator Rush Limbaugh, actress Melanie Griffiths and many more.  

Rapper Eminem[ii] confessed to taking: “Vicodin, Valium and Ambien, and toward the end, which caused my overdose, methadone. I didn’t know it was methadone. I used to get pills wherever I could. I was just taking anything that anybody was giving to me.”

    

      He at least could afford to get help, most Americans can’t.

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[i] On the Issues 2000, George Bush, Health Care http://www.ontheissues.org/George_W__Bush_Health_Care.htm

[ii] The Real Marshall Mathers by Deborah Solomon, New York Times Magazine, June 16, 2010

Michael Jackson’s message from the grave

by Charlene Smith (c)

It was an accident, just a stupid accident, but when sparks from a fireworks display set fire to 25-year-old Michael Jackson’s hair in 1984, each carried a message about what would cause his death exactly 25 years later.

Only eight years before, then Merck chief executive officer Henry Gadsen was famously quoted in a 1976 Fortune article as saying: “I want to sell drugs to everyone. I want to sell drugs to healthy people. I want drugs to sell like chewing gum.”

Gadsen died in 1980, but by then his dream was coming true. Around the time that he made his statement, some scientists at Sloan Kettering cancer research centre were suggesting opioid painkillers might be effective for more than just terminal cancer pain. This saw a rapid escalation in doctors and dentists prescribing opioids for problems as insignificant as a pulled tooth or stubbed toe.

And another bonus came along for pharmaceutical industries that had quietly paved the way for it. In the year Gadsen died the American Psychiatrists Association, which had long been plagued by controversy around the lack of science to back diagnoses fought back, not with science but with public relations and huge drug company grants.

They came out with DSM-III – the third edition of the Diagnostic and Statistical Manual - which enumerates psychiatric disorders. This manual saw these disorders leap from 182 disorders in 1968 to 265 by 1980. At the time homosexuality was labeled as a ‘sexual orientation disturbance’ but in 1980, while continuing to see homosexuality as a disorder, DSM labeled it as ‘ego-dystonic homosexuality.’ It would take another seven years for homosexuality to be removed as a disorder along with premenstrual dysphoric disorder (the perfectly normal premenstrual tension women experience each month – this has recently again become a disorder by those who seek to create pills and profit from the normal) and masochistic personality disorder became totally normal.

Today psychiatry would have us believe that shyness is a disorder, so is grief, they say, and too those who jiggle their legs when impatient are not quite normal.  In the award-winning Broadway play, Next to Normal, Diana Goodman is pushed into 16 years of prescription drug addiction after the death of her eight-month-old son. In the play she recounts how a psychiatrist told her that any grief that lasts longer than four months is a disorder.

2.4 million schizophrenics in the U.S.

In his award-winning book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America, Robert Whitaker tells us that “Drug-induced chronicity has contributed to the rise in the number of disabled mentally ill. In 1955, there were 267,000 people with schizophrenia in state and county mental hospitals, or one in every 617 Americans. Today, there are an estimated 2.4 million people … ill with schizophrenia (or some other psychotic disorder), a disability rate of one in every 125 Americans.” Can it be true that so many people in the most prosperous nation on earth are so seriously disabled, and if so, why?

But let’s get back to Michael Jackson and his accident in 1984, it was the year that the Guinness Book of Records said that his new album, Thriller, was the top-selling album of all time. Jackson’s accident was the sort that has seen millions just like him become addicted to prescription drugs either because their doctors were ignorant of the side-effects of the drugs, or because some pharmaceutical companies and doctors knowingly trapped patients into a process they knew would lead to addiction and high profits. 

A badly burned Jackson began the first of a series of surgeries to correct the burns damage, and along the way threw in cosmetic surgery too. He was put onto painkillers to help reduce the pain from the burns and the surgeries, and so began an addictive spiral, aided by greedy doctors.

While researching prescription drug addiction in West Virginia, one of the poorest states in the U.S.A., I learned of a woman doctor who had lines of patients waiting outside her doors. She would practice until 3a.m. dispensing opioid painkillers by the thousands, and by the time the Drug Enforcement Administration got onto her tail; she jetted off to the island she had bought in the Caribbean.  Recently, as another example, 71-year-old Dr. Tyron Reece of Los Angeles was arrested because he wrote prescriptions in 2010 for some 920,000 hydrocodone pills [Vicodin or Lortab], and according to arresting officers was allegedly involved in smuggling opioids to Mexico (the trade is usually in the opposite direction).

 Dr. Irwin Dhalla of the University of Toronto recently wrote that: “The risk of addiction for patients who are being treated for chronic pain for several months or longer is 35 percent… Addiction is a much bigger problem than physicians think it is." 

Indeed, Dr. David Kloth, a leading member of the American Society of Interventional Pain Physicians told me in an interview for my upcoming book, America the Overmedicated, that 80 percent to 90 percent of those administering pain medications, including physicians, lacked appropriate qualifications.  Experts in the federal administration agree. That is a frightening realization especially when you realize that the top-selling drug, by far, in the United States is hydrocodone, the parent of Vicodin and similar drugs.

Ironically, however, opioid painkillers are easy to get off, you can stop them immediately and although you will go through withdrawal hell of stomach cramps, vomiting and three days to a week of feeling seriously ill, it is not as dangerous as psychiatric drugs which you cannot stop suddenly without endangering your life.

Addiction and profit

Between 1952 when DSM first came out to 2000 the number of psychiatric disorders soared 200%, and continue to increase in line with pharmaceutical company profits which have increased six times globally since 1999. That was also the year that the Federal Drug Administration allowed prescription drug advertising on television and radio, something only New Zealand also allows.  And in those eleven years since prescription drug advertising was allowed on television and radio stations addiction rates have soared in the United States. In April, the White House called prescription drug addiction an “epidemic” but ironically, it is not an epidemic it is marshaling significant resources to combat.

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.