Taking On the Scourge of Opioids | National Affairs

Taking On the Scourge of Opioids | National Affairs | Summer 2017 By Sally Satel

This article is especially noteworthy because this political publication, “its founding editor, Yuval Levin, and authors are typically considered to be conservative.” 

The author describes the origin and current state of the “opioid issue” in great detail and reasonably concludes that “factors beyond physical pain are most responsible for making individuals vulnerable to problems with opioids”

An estimated 2.5 million Americans abuse or are addicted to opioids — a class of highly addictive drugs that includes Percocet, Vicodin, OxyContin, and heroin.  

The roots of the [opioid] crisis can be traced to the early 1990s when physicians began to prescribe opioid painkillers more liberally. In parallel, overdose deaths from painkillers rose until about 2011.

Since then, heroin and synthetic opioids have briskly driven opioid-overdose deaths; they now account for over two-thirds of victims. Synthetic opioids, such as fentanyl, are made mainly in China, shipped to Mexico, and trafficked here. Their menace cannot be overstated.

The nation has weathered drug epidemics before, but the current affliction — a new plague for a new century, in the words of Nicholas Eberstadt — is different. Today, the addicted are not inner-city minorities, though big cities are increasingly reporting problems. Instead, they are overwhelmingly white and rural, though middle- and upper-class individuals are also affected. The jarring visual of the crisis is not an urban “gang banger” but an overdosed mom slumped in the front seat of her car in a Walmart parking lot, toddler in the back.

Today, in the small towns where so much of the epidemic plays out, the crisis is personal. Police chiefs, officers, and local authorities will likely have at least one relative, friend, or neighbor with an opioid problem.

Yet the much-touted promise of treatment — and particularly of anti-addiction medications — as a panacea has already been proven wrong.

Perhaps “we can’t arrest our way out of the problem,” as officials like to say, but nor are we treating our way out of it.

This is because many users reject treatment, and, if they accept it, too many drop out. Engaging drug users in treatment has turned out to be one of the biggest challenges of the epidemic — and one that needs serious attention.

ROOTS OF A CRISIS

The chief risk of liberal prescribing was not so much that the patient would become addicted — though it happens occasionally — but rather that excess medication fed the rivers of pills that were coursing through many neighborhoods.

And as more painkillers began circulating, almost all of them prescribed by physicians, more opportunities arose for non-patients to obtain them, abuse them, and die. OxyContin formed a particularly notorious tributary. Available since 1996, this slow-release form of oxycodone was designed to last up to 12 hours (about six to eight hours longer than immediate-release preparations of oxycodone, such as Percocet).

Packing a large dose into a single pill presented a major unintended consequence. When it was crushed and snorted or dissolved in water and injected, OxyContin gave a clean, predictable, and enjoyable high.

By 2000, reports of abuse of OxyContin began to surface in the Rust Belt — a region rife with injured coal miners who were readily prescribed OxyContin, or, as it came to be called, “hillbilly heroin.”

Ohio along with Florida became the “pill mill” capitals of the nation.

These mills were advertised as “pain clinics,” but were really cash-only businesses set up to sell painkillers in high volume. The mills employed shady physicians who were licensed to prescribe but knew they weren’t treating authentic patients.

Around 2010 to 2011, law enforcement began cracking down on pill mills.

In 2010, OxyContin’s maker, Purdue Pharma, reformulated the pill to make it much harder to crush.

In parallel, physicians began to re-examine their prescribing practices and to consider non-opioid options for chronic-pain management.

More states created prescription registries so that pharmacists and doctors could detect patients who “doctor shopped” for painkillers and even forged prescriptions.

Last year, the American Medical Association recommended that pain be removed as a “fifth vital sign” in professional medical standards.

Controlling the sources of prescription pills was completely rational. Sadly, however, it helped set the stage for a new dimension of the opioid epidemic: heroin and synthetic opioids.

Heroin — cheaper and more abundant than painkillers — had flowed into the western U.S. since at least the 1990s, but trafficking east of the Mississippi and into the Rust Belt reportedly began to accelerate around the mid-2000s

As prescription painkillers became harder to get and more expensive, thanks to alterations of the OxyContin tablet, to law-enforcement efforts, and to growing physician enlightenment, a pool of individuals already primed by their experience with prescription opioids moved on to low-cost, relatively pure, and accessible heroin.

Indeed, between 2008 and 2010, about three-fourths of people who had used heroin in the past year reported non-medical use of painkillers — likely obtained outside the health-care system — before initiating heroin use.

The progression from pills to heroin was abetted by the nature of addiction itself. As users became increasingly tolerant to painkillers, they needed larger quantities of opioids or more efficient ways to use them in order to achieve the same effect.

Moving from oral consumption to injection allowed this. Once a person is already injecting pills, moving to heroin, despite its stigma, doesn’t seem that big a step.

…in economically and socially depleted environments where drug use is normalized, heroin is abundant, and treatment is scarce, widespread addiction seems almost inevitable.

The last five years or so have witnessed a massive influx of powder heroin to major cities such as New York, Detroit, and Chicago. From there, traffickers direct shipments to other urban areas, and these supplies are, in turn, distributed further to rural and suburban areas.

It is the powdered form of heroin that is laced with synthetics, such as fentanyl.

Most victims of synthetic opioids don’t even know they are taking them. Drug traffickers mix the fentanyl with heroin or press it into pill form that they sell as OxyContin.

Whereas heroin requires poppies, which take time to cultivate, synthetics can be made in a lab, so the supply chain can be downsized. And because the synthetics are so strong, small volumes can be trafficked more efficiently and more profitably.

In some regions of the country, roughly two-thirds of deaths from opioids can now be traced to heroin, including heroin that medical examiners either suspect or are certain was laced with fentanyl.

THE BASICS

Terminology is important in discussions about drug use.

A 2016 Surgeon General report on addiction, “Facing Addiction in America,” defines “misuse” of a substance as consumption that “causes harm to the user and/or to those around them.” Elsewhere, however, the term has been used to refer to consumption for a purpose not consistent with medical or legal guidelines.

Thus, misuse would apply equally to the person who takes an extra pill now and thenfrom his own prescribed supply of Percocet to reduce stress as well as to the person who buys it from a dealer and gets high several times a week

The term “abuse” refers to a consistent pattern of use causing harm, but “misuse,” with its protean definitions, has unhelpfully taken its place in many discussions of the current crisis.

In the Surgeon General report, the clinical term “substance use disorder” refers to functionally significant impairment caused by substance use.

Finally, “addiction,” while not considered a clinical term, denotes a severe form of substance-use disorder — in other words, compulsive use of a substance with difficulty stopping despite negative consequences.

Much of the conventional wisdom surrounding the opioid crisis holds that virtually anyone is at risk for opioid abuse or addiction — say, the average dental patient who receives some Vicodin for a root canal. This is inaccurate, but unsurprising.

Exaggerating risk is a common strategy in public-health messaging: The idea is to garner attention and funding by democratizing affliction and universalizing vulnerability.

But this kind of glossing is misleading at best, counterproductive at worst. To prevent and ameliorate problems, we need to know who is truly at risk to target resources where they are most needed.

In truth, the vast majority of people prescribed medication for pain do not misuse it, even those given high doses.

A new study in the Annals of Surgery, for example, found that almost three-fourths of all opioid painkillers prescribed by surgeons for five common outpatient procedures go unused.

In 2014, 81 million people received at least one prescription for an opioid pain reliever, according to a study in the American Journal of Preventive Medicine; yet during the same year, the National Survey on Drug Use and Health reported that only 1.9 million people, approximately 2%, met the criteria for prescription pain-reliever abuse or dependence (a technical term denoting addiction).

Those who abuse their prescription opioids are patients who have been prescribed them for over six months and tend to suffer from concomitant psychiatric conditions, usually a mood or anxiety disorder, or have had prior problems with alcohol or drugs.

Notably, the majority of people who develop problems with painkillers are not individuals for whom they have been legitimately prescribed — nor are opioids the first drug they have misused.

Such non-patients procure their pills from friends or family, often helping themselves to the amply stocked medicine chests of unsuspecting relatives suffering from cancer or chronic pain. They may scam doctors, forge prescriptions, or doctor shop. The heaviest users are apt to rely on dealers. Some of these individuals make the transition to heroin, but it is a small fraction.

One study from the Substance Abuse and Mental Health Services Administration found that less than 5% of pill misusers had moved to heroin within five years of first beginning misuse.

These painkiller-to-heroin migrators, according to analyses by the Centers for Disease Control and Prevention, also tend to be frequent users of multiple substances, such as benzodiazepines, alcohol, and cocaine. The transition from these other substances to heroin may represent a natural progression for such individuals.

Thus, factors beyond physical pain are most responsible for making individuals vulnerable to problems with opioids

Princeton economists Anne Case and Angus Deaton paint a dreary portrait of the social determinants of addiction in their work on premature demise across the nation.

Beginning in the late 1990s, deaths due to alcoholism-related liver disease, suicide, and opioid overdoses began to climb nationwide. These “deaths of despair,” as Case and Deaton call them, strike less-educated whites, both men and women, between the ages of 45 and 54.

While the life expectancy of men and women with a college degree continues to grow, it is actually decreasing for their less-educated counterparts. The problems start with poor job opportunities for those without college degrees.

Absent employment, people come unmoored. Families unravel, domestic violence escalates, marriages dissolve, parents are alienated from their children, and their children from them

Work by Alex Hollingsworth and colleagues found that residents of locales most severely pummeled by the economic downturn were more susceptible to opioids.

As county unemployment rates increased by one percentage point, the opioid death rate (per 100,000) rose by almost 4%, and the emergency-room visit rate for opioid overdoses (per 100,000) increased by 7%. It’s no coincidence that many of the states won by Donald Trump — West Virginia, Kentucky, and Ohio, for example — had the highest rates of fatal drug overdoses in 2015.

Of all prime-working-age male labor-force dropouts, nearly half — roughly 7 million men — take pain medication on a daily basis. “In our mind’s eye,” writes Nicholas Eberstadt in a recent issue of Commentary, “we can now picture many millions of un-working men in the prime of life, out of work and not looking for jobs, sitting in front of screens — stoned”

When it comes to beleaguered communities, one has to wonder how much can be done for people whose reserves of optimism and purposefulness have run so low. The challenge is formidable, to be sure, but breaking the cycle of self-destruction through treatment is a critical first step.

LOOKING FORWARD

At least at this point, if not for the duration of this crisis, we need to allow medical professionals, law-enforcement officials, community organizations, and the loved ones of those affected to attempt different, even radical, solutions and evaluate their effectiveness.

Policymakers should support such experimentation, and fund it, but must resist the urge to pretend that better funding alone will end the scourge of opioids.

Indeed, the lingering lesson of the opioid crisis is that nothing ever changes. This time around, the casualties are largely white drug users with little education dying young in communities that are “hemorrhaging jobs and hope,” in the words of J. D. Vance. But this bleak fact is an instance of a larger truth.

No matter where people live or how much money they have, those in great pain will seek solace and oblivion through intoxicants, as they have done forever.

Indeed, the lingering lesson of the opioid crisis is that nothing ever changes.

Author: Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute. She would like to thank Christopher M. Jones at the U.S. Department of Health and Human Services for sharing his expertise.