War on heroin can start with better control over prescription drug availability

John was brilliant and funny. He entered the room and every one smiled. We were wowed by his quirky humor and his quest for life. John was also an accomplished athlete. If there was a ball involved, he could do it. It was during his junior year, when in the last throes of a tight game, he received a pass from Pete, the quarterback. He was tackled to the ground, hard. John had immediate low back pain. Any movement was agonizing. Just the simple task of waking up in the morning was surreal. Though he was reassured by his longtime family doctor that all was ok, his MRI was normal; his low back pain was ever present. He received hydrocodone, then oxycodone and finally was placed on Oxycontin. The pills did not eradicate his pain, but they also made him cope with the failure of that terrible game night. He got injured and they lost! Also, he was unable to play as a senior, dashing his hopes for an athletic scholarship in a Big 10 college. He was angry, and without football and the other sports, he had lost his bearings. He did go to a community college, not what he wanted, and his anger persisted. He discovered heroin in a frat party, first snorting it, and then, injecting it. He was found with a needle in his arm, in the bathroom of a popular college bar, dead.

What a waste! What a loss! What pain for his family and friends.

According to the Substance Abuse and Mental Health Services Administration, initiations to heroin by prescription drugs increased 80 percent among 12- to 17-year-olds since 2002. In 2009, 510 young adults between the ages of 15 and 24 died of a heroin overdose. That figure was 198 in 1999, meaning the rate of young adult deaths caused by heroin more than doubled in one decade. Close to 90 percent of teen heroin addicts are white. In 2012 in Lycoming County, we had 18 heroin overdoses!

But the problem is not only Heroin, it is prescription narcotics. Prescription drugs have been associated with those that misuse or abuse prescription drugs. In fact, U.S. overdose deaths involving prescription narcotics increased to 17,000 deaths a year in 2010, almost double the number in 2001. This increase coincided with nearly a fourfold increase in the use of prescribed opioids for the treatment of pain. These fatalities now outnumber deaths from heroin and cocaine combined, that same report found. More than 12 million people said they abused prescription drugs in 2010. The only other drug people abuse more is marijuana, the White House noted in a 2011 report.

The dramatic rise in prescription drug deaths corresponds with a concerted effort in the late 1990s to find ways to treat chronic pain. In 1997, two expert panels issued guidelines encouraging doctors to prescribe more prescription pain meds to promote “compassionate care,” according to an article in the Journal of the American Medical Association.

In the next few years, the number of prescriptions for pain medications shot up. Between 1997 and 2007, per capita retail purchases of methadone, hydrocodone, and oxycodone increased 13 times, four times, and nine times respectively according to a JAMA article, which was cited by Health Policy Solutions. Indeed, the U.S. consumes 90% of the worldwide production of hydrocodone. The majority of prescription drugs that are abused were legitimately prescribed by a doctor, according to the CDC.

People may think they’re safe because doctors can prescribe them, but they’re wrong. Prescription opioids act on the same brain receptors as heroin and can be very addictive. These drugs make people euphoric. They can slow down breathing. When people take more of an opioid to achieve the same level of euphoria, the CDC says, it can stop their breathing altogether. This is aggravated by simultaneous use of alcohol, Soma, Valium, clonazepam and other benzodiazepines which people use as to obtain a “benzo boost”. This will accelerate death!

A study performed by Roger Chow, M.D. at the Oregon Health & Medicine University in Portland, shows that physicians increased narcotic drug prescriptions by 73% between 2000 and 2010 despite relatively little change in patient characteristics or how sick they are. These findings suggest that trends in increased prescription drugs were not driven by new understanding in diseases as demonstrated by new research or by other patient factors, but rather by other individual practice patterns not grounded in evidence or science.

But are prescription narcotics effective in the treatment of chronic pain? Information on the effectiveness of narcotics in chronic pain largely consists of conflicting observational data, as reviews have shown. The few existing randomized trials suggest a benefit from opioids but follow-up is often short, leaving unclear the effects of long-term treatment with these medications. In the absence of clear evidence amidst concerns about the addiction potential of opiates, management of chronic pain patients with narcotics may become susceptible to conscious or unconscious value judgments on the part of physicians. When we look at the total literature we find that there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic pain is effective.

What this means, is that we must realize that prescription narcotics must not be used as sole therapy for the treatment of chronic pain. They should only be used in conjunction with other treatment modalities such as physical therapy, chiropractic therapy, acupuncture, weight control, increased physical activity and the strategic use of “blocks” or surgery. They should only be used in a setting in which these medications and their effects are closely monitored and where multiphasic therapy can be done.

Alex, a first year student in a local college, and an honors graduate from his high school was at a local party. He took 20 mgs of Oxycontin, given to him by a “friend” (here, have a good time! )and chased it down with a beer. He continued drinking and having a good time. He was found the next morning, in the living room couch, dead.

Data is overwhelming, prescription drugs are the portal of entry for abuse with heroin. So what should we do?

It is critical that physicians recognize that therapy with narcotics alone is deemed to fail in the treatment of chronic pain. If narcotics are required, physicians must subscribe to published safe practices in the prescriptions of narcotics. Hopefully, the House and Senate will pass, and the Governor will sign, a prescription drug monitoring database. When this occurs, then physicians can access the prescription drug database and avoid abuse.

Does your physician have access to an experienced Pain Physician? Does your doctor have access to drug toxicologies and understand how to use this tool for my benefit?

As patients, we must insist in treatments for the “whole person.” Let’s not jump to narcotic pills immediately. If narcotics are necessary, then let’s take them in small amounts for short periods. It is not appropriate to seek treatment for chronic pain in the emergency room. Let’s make sure we understand why we have pain. Go to your primary care physicians and insist on treatment for the “whole person”: Should I go into physical therapy? Can I progress from there into a swimming program? If I lose weight and increase my activities, will I improve? Am I depressed, stressed out without hope? Where can I get help, and how do I get help? Will a referral to an experienced pain physician be of benefit? Do I need surgery? We must insist physicians’ base treatments on scientific evidence that can be validated with good outcomes.

Prescription drug and heroin abuse is our problem. “It’s hard to talk about the heroin problem without talking about the prescription drug problem,” said Rafael Lemaitre, of the White House Office of National Drug Control Policy. Let’s start by controlling the improper use of prescription narcotics.

Dr. Regal is a local physician.