Starting in the 1980’s and 1990’s, doctor’s began to change their views regarding opioid use. Articles were published that stated the risk of addiction was < 1%. A frequently quoted editorial was published in the New England Journal of Medicine in 1980 which stated the risk of addiction was < 1%. Another article in 1986 in the Journal of Pain states “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.”
Later in the 90’s governmental agencies to include the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the Veterans Administration (VA) began to push for pain as a vital sign. Normally, doctors and nurses pay attention to four vital signs; pulse, blood pressure (BP), respiratory rate and temperature. The push for better pain control changed the thinking to pain control as a right and under-treatment of pain as punishable.
The pharmaceutical industry capitalized on the more lenient views towards narcotics with marketing directed towards doctors and the public extolling the virtues of opioid use. Advertising campaigns in medical journals, conferences and visits to doctor’s offices led to a significant increase in prescriptions written.
This perfect storm of:
The mistaken belief that opioids were rarely addictive
The concept of pain control as a right and under-treatment as inhumane
Big pharma marketing opioids as safe
These 3 factors led to an increase in prescriptions written and increased opioids on the street.
Abuse & Drug Overdose
Unfortunately, while opioids can help physical pain; mental pain is hard to quantify and lends itself to abuse. Oftentimes, benzodiazepines (Valium & Xanax) were also prescribed with the opioids which increased the risk of addiction. With the increase in available opioid medication, addiction increased as did drug overdoses.
An unexpected result associated with the increase in Opioid addiction was the increase in heroin use. In 1996, OxyContin was released. OxyContin was meant to be a delayed release pain pill to be used twice a day. OxyContin (Oxycodone) was different than Percocet (Oxycodone + Tylenol) in that Tylenol was not added. This meant that the pill could be crushed and allow for exposure to all of the drug dosage at once instead of over a delayed time period. With the Tylenol removed, there was no risk of liver injury from exposure to high doses. As addiction increased, snorting and injecting OxyContin became other routes to consume the drug. The difference between injecting OxyContin vs Heroin is minimal. It has been often quoted that OxyContin is the gateway drug between low dose opioids and Heroin. Severe withdrawal from high doses of OxyContin mimics that of heroin withdrawal.
New Mexico we have a problem
Currently, we are dealing with opioid addiction that affects all races, all classes and all ages. New Mexicans die of drug overdoses at nearly twice the rate of the U.S. average. The impact of opioid and heroin abuse has preferentially hit New Mexico the hardest.
To fix the problem will require a combination of public and patient awareness, smarter use of opioids among healthcare providers and creation of rehab centers. Adolescents are particularly susceptible to addiction and often their first exposure is stealing their parent’s meds.
The judicious use of narcotics by doctors is important as well as minimizing combining opioids with benzo’s. Recognizing potential abuse and acting on the problem will be important in preventing overuse and potential overdose. Working together will be the only way to get the problem under control.
Paul Saiz, M.D.
Diplomate of the American Board of Orthopedic Surgery