Opioid Abuse & Death: Nothing Close to a Good Answer

The term that best describes the opioid addiction predicament in the United States is not appropriate for publication. (Hint: It begins with "cluster." You figure out the rest.) Aside from the highly-addictive nature of these narcotics, there are other pieces to this puzzle, many of which overlap, and augment an already-bad problem. The increase in opioid overdose deaths is discussed in this edition of MedPage Today. As expected, the situation is worsening. But rather than summarize the article, I thought it would be more interesting to examine some of the factors that contribute to what is currently an insurmountable problem one that is unlikely to change anytime soon.

1. It's been more than 100 years since the invention of aspirin and heroin, yet, there are still no good pharmacological ways to manage chronic, severe pain. Every method has drawbacks. Tylenol is not even remotely strong enough to manage severe pain, and also has considerable liver toxicity at doses that are not much higher than the therapeutic dose. Chronic use of the drug exacerbates this. Non-steroidal anti inflammatory drugs (NSAIDs) work well for moderate pain, but have significant gastrointestinal side effects, can cause bleeding and some of them also carry a cardiovascular risk. There are also certain drugs that are used off-label for pain (especially nerve pain), but they are only marginally effective much of the time. After that comes the big boys Vicodin and Percocet. And often, trouble follows.
2. Government efforts to crack down on prescription of opioids haved worked to some degree, but there is also a downside: These efforts have already made it much harder for people with legitimate needs severe, chronic pain, such as that asociated with terminal cancer to get the relief they need. They must now physically obtain a prescription from a physician, which can be a real hardship. Phone calls and faxes are no longer permitted. Neither are refills. In rural areas, where a patient may need to drive an hour to see his or her doctor, these restrictions are cruel and barbaric.
3. The number of opioid prescriptions that have been written has tripled over the past 25 years. This is, in part, due to a shift in medical perceptions about treating pain. Over the past two decades, a movement to treat pain more aggressively developed. Undertreatment of pain, which still persists, was viewed as counterproductive to

patient health and well being. 4. It is now recognized that a significant number adolescents, who were prescribed narcotics, later became addicts. Additionally, the number of prescriptions written for teenagers doubled between 1994 and 2007. 5. There is a very strong relationship between the difficulty of obtaining narcotic pills and the proliferation of heroin use. This was made clear in 2010 when Purdue Pharma, the maker of OxyContin perhaps the biggest single contributor to narcotic addiction finally came up with a new formulation for the drug to make it "abuse proof." The old formulation, which contained a whopping 40 mg dose of oxycodone, could be crushed and snorted or injected. The new formulation turned into a gum when addicts tried to grind or crush it, so they switched, in droves, to heroin. It is possible that this reformulation inadvertently did more harm than good, since heroin is not only more dangerous than oxycodone, but also involves needle sharing, which has led to clusters of HIV and hepatitis C infection. 6. Heroin is now far cheaper than the pills. A bag of heroin costs about $5. A single Vicodin pill can cost $20. 7. Heroin is not necessarily heroin anymore. As pills became harder to get, heroin became the obvious drug of choice for addicts. Demand soared. But, so did "technology." There is a legal (but highly restricted) heroin-like drug called fentanyl, which is about 100-times more potent than morphine. It is so powerful that only 2 mg about the weight of a few grains of salt is fatal to humans. So, even a small weighing error while adding fentanyl to either heroin or an inert carrier, can result in a lethal dose. Much of the "heroin" that is sold on the street is, in fact, fentanyl. 8. Fentanyl is very easy to make in a lab. Any organic chemist with even average skills can synthesize enough to provide thousands (even millions) of doses of it. A good deal of the fentanyl that is now killing people comes from illegal labs. 9. The "War on Drugs" has been a miserable failure by any measure. If anything, it seems to be "working" even worse than ever. Given these factors, plus the innate desire of many people to get "high," it is not surprising that we have a pharmaceutical train wreck on our hands. Unfortunately, I have yet to see any evidence that this problem can be tamed. Addictive drugs, legal or otherwise, will always be available, and most addicts will do almost anything to get their "fix." Do not expect a "magic pill" for this problem anytime soon.