A Flawed Person's Drug Problem Isn't a Moral Failing

By Dr. Lynn Webster, PNN Columnist

Rush Limbaugh was as controversial as he was politically influential. In fact, Nicole Hemmer, a research scholar at Columbia University, called Limbaugh "the man who created Donald Trump" and opined that Limbaugh created the political foundation that catapulted Trump to power.

In 2020, President Trump returned the favor by awarding Limbaugh the Medal of Freedom, our highest civilian honor, for his "decades of tireless devotion to our country."

But the Independent points out that Limbaugh also left behind a legacy of "divisiveness, cruelty, racism, homophobia, bigotry, and sexism." And Rolling Stone said the radio host "trafficked in bigotry and cruelty."

RUSH LIMBAUGH

RUSH LIMBAUGH

It's hard to argue with either of those statements. To me, Limbaugh was a deeply flawed human being who caused harm. But some statements about him go too far.

When Limbaugh died this week after a lengthy battle with lung cancer, Mark Frauenfelder, editor of The Magnet, tweeted: "Rush Limbaugh, the sex tourist and drug addict whose four marriages, mockery of people after their deaths, and overt racism and misogyny made him a beloved icon of American conservatism, is dead at 70." 

That statement is troubling. Overt racism and misogyny are character flaws. Drug addiction, however, is not. It's unfortunate to see Limbaugh's detractors point to his well-documented problems with painkillers as moral failings. This supports my firm belief that our culture holds deeply negative views of people with addiction.  

History of Back Pain and Drug Use 

Limbaugh began abusing prescription painkillers after his spinal surgery in the 1990s. He was eventually arrested on drug charges — specifically, charges of fraud to conceal information to obtain prescriptions, also known as "doctor shopping." In exchange for having the charges dropped, Limbaugh agreed to undergo drug treatment and pay $30,000 in court costs. He posted $3,000 bail and was released.

I wrote about Limbaugh's prescription drug problem in my book, "Avoiding Opioid Abuse While Managing Pain." What we knew about Limbaugh's problem, as I said at the time, was that he abused large quantities of prescription opioids for several years; kept his abuse secret from family, friends and colleagues; entered a rehabilitation program twice, but relapsed each time; remained successful without a visible reduction in functioning while he used drugs; and was suspected of buying drugs illegally. 

What we didn't know, and perhaps now can never ascertain, is whether Limbaugh had an addiction or an undiagnosed psychiatric disorder (although some may argue his professional conduct was evidence of a disturbed personality). We also can't know whether his main motivation for using drugs was to control physical pain, to mask emotional pain or stress, to seek a "high," or some combination of those reasons.  

The answers to these questions — about his history of drug abuse, mental health and motivation — would have told us whether his opioid use disorder (OUD) was treatable with better pain control or, tragically, was an incurable disease.  

Limbaugh exemplifies the type of patient most physicians face when treating serious pain conditions. Sometimes, opioids fail to provide adequate relief for them. And, increasingly, patients cannot access the opioids they need due to misguided polices and regulations.   

How Society Views Addiction 

Some people may agree with Limbaugh's political and social views, and others may not. But conflating his drug abuse and associated illegal activities with the opinions he expressed about social issues harms people who suffer from the disease of addiction. It also makes it more difficult for people with severe pain to receive the care they deserve, whether their abuse is caused by addiction or, as is often the case, a symptom of undertreated pain. 

Many of those with addiction may not have the power or influence to bail themselves out of prison or pay tens of thousands of dollars in court costs. They may remain in prison for years and suffer the loss of their careers, reputations, homes and even their families.  

Generally, our society views people with addiction as flawed, weak and hopeless. We distance ourselves from those who have the disease, and we allow the criminal justice system to have jurisdiction over them, making it difficult or even impossible for them to receive treatment.  

We may never know why Rush Limbaugh made the choices he did. But, just as we would never think of berating him for falling victim to lung cancer, we also shouldn't chastise him for misusing painkillers. We may have a right to judge Limbaugh's behavior, but we cannot, in decency, judge his disease. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book The Painful Truth, and co-producer of the documentary It Hurts Until You Die. Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences. You can find Lynn on Twitter: @LynnRWebsterMD.

Opioids Are Not the Only Pain Meds That Can Be Abused

By Dr. Lynn Webster, PNN Columnist

Contrary to popular opinion, opioids don't cause substance abuse. Opioids certainly may be abused, but it is human biology itself that drives drug abuse.

We often get the message that any other pain treatment would be better than using opioids. However, even non-opioids prescribed for pain can contribute to overdoses and suicides. The same genetic and environmental factors that cause opioid abuse can induce abuse of other drugs, too.

For several years the number of opioid prescriptions has declined significantly, due to public demand and political pressure. According to the IQVIA Institute, there was a 17 percent decrease in the number of opioids prescribed in 2018 alone.

We may have expected that to translate into fewer drug abuse problems. Instead, we have seen an increase in overdoses, hospitalizations and suicides involving non-opioids such as gabapentin, methamphetamines and muscle relaxants.

Less access to prescription opioids has driven some people in disabling pain to seek illegal alternative medications. That has led to a wave of use and abuse of drugs that doctors have not prescribed.

Between 2016 and 2017, the CDC reported a nearly 47% increase in fentanyl-related deaths. Overdoses related to methamphetamine and cocaine have also surged.  

According to Stateline, approximately 14,000 cocaine users and 10,000 meth users died in the United States in 2017, triple the number of deaths in 2012. Deaths involving have heroin also spiked since 2010.  

Gabapentin and Baclofen 

Prescription drugs, too, have fueled the negative statistics. Doctors have felt forced to taper or discontinue opioids. In an attempt to find alternatives for pain management, they have increased the number of gabapentin and baclofen prescriptions. 

As PNN has reported, a recent study published in Clinical Toxicology found a “worrying” increase in calls to U.S. poison control centers about gabapentin (Neurontin) and the muscle relaxer baclofen, coinciding with a decrease in opioid prescriptions. The study analyzed more than 90,000 cases of exposure to gabapentin and baclofen, many of which were coded as suicides or attempted suicides.

“Gabapentin and baclofen are two medications that have seen increased availability to patients as alternatives to opioids for the treatment of acute and chronic pain. With greater accessibility, poison center exposures have demonstrated a marked increase in toxic exposures to these two medications,” wrote lead author Kimberly Reynolds of the University of Pittsburgh.

“As poison center data do not represent the totality of cases in the United States, the steep upward trends in reported exposures reflect a much larger problem than the raw numbers would suggest.”  

Gabapentin is one of the most commonly prescribed drugs in the United States. It is prescribed for epilepsy, hot flashes, migraines, nerve damage, and more. It is also used to treat the symptoms of drug and alcohol detoxification, and to treat pain for patients at higher risk of addiction to opioids.  

Baclofen is a muscle relaxant that has also been substituted for opioids. Other non-opioid drugs such as pregabalin and NSAID’s are being increasingly prescribed as well.  

All Medications Have Risks 

Non-opioids have a role to play in pain management, but it is just as important to understand their dangers. While we need effective alternatives to opioids, it is important to know that alternatives also have risks. That is unavoidable, because all medications carry potential benefits and consequences.  

To decide whether a medication is appropriate for an individual, it is critical to determine whether the potential benefit outweighs potential harm. Gabapentin and baclofen are not bad drugs, but they are not harmless replacements for opioids, either.  

No pain medication, whether it is an opioid or non-opioid, is right for everyone under all circumstances. The next time a physician or nurse practitioner suggests replacing an opioid with gabapentin, baclofen, or another medication, it would be appropriate to ask for a comparison of the risks and benefits. 

Talking with your healthcare provider about your preference for a particular medication does not make you a drug seeker. It helps you become an informed patient. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is the author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences. 

Criminalizing Pregnant Women for Drug Abuse Is a Terrible Idea

By Dr. Lynn Webster, PNN Columnist

According to Guttmacher Institute, nearly half the states in the United States are willing to punish pregnant women in order to spare their babies the agony of being born with Neonatal Abstinence Syndrome (NAS). Ironically, their efforts are having the opposite effect.

Twenty-three states and the District of Columbia have passed legislation that criminalizes substance abuse during pregnancy. Additionally, 25 states and the District of Columbia require healthcare providers to report expectant mothers who may be illegally using substances. In 8 states, pregnant women who are suspected of substance abuse must also undergo drug testing.

The huge number of babies born to mothers dependent on opioids has driven policymakers to find ways to deter pregnant women from abusing opioids.

But new research points out there are unintended consequences to criminalization. And it provides lawmakers insight on how to create more effective policies that result in positive, not punitive, outcomes.

A study published recently in the journal JAMA Network Open examined 4.6 million births in the U.S. from 2000 to 2014. During this time, the diagnosis of NAS increased seven fold.

The study was conducted by the RAND Corporation, a nonprofit research institute that analyzed 8 states with punitive policies for drug-abusing pregnant women. The research was funded by the National Institute of Drug Abuse.

According to a RAND press release, Arkansas, Arizona, Colorado, Kentucky, Massachusetts, Maryland, Nevada and Utah adopted either punitive penalties for drug use during pregnancy or policies that required health care providers to report pregnant women with suspected illegal substance use.

RAND researchers found that the annual rate of NAS increased in the 8 states, from 46 cases per 10,000 live births to 60 cases per 10,000 after punitive policies were enacted. That is an alarming 30% increase in NAS cases.

This is not the first study that has shown political efforts to curb opioid addiction and overdoses have not had a positive impact. We have seen the harm associated with forced tapers and dose limits adversely affecting millions of pain patients.

It is hard to understand why these destructive policies are put in place, but it may be because policymakers are misinformed or biased. Regardless, it reflects a systemic flaw for governments to fail to evaluate the efficacy and outcomes of the very policies they create.

Addiction Is a Disease, Not a Crime

How best to address addiction has long been the subject of debate. For example, a state hospital in South Carolina illegally obtained the diagnostic tests of pregnant women in an effort “to obtain evidence of a patient's criminal conduct for law enforcement purposes” (this was the case of Ferguson v. Charleston).

Unfortunately, some people still believe that addiction is a volitional or character flaw that should be recognized as criminal behavior rather than a disease.

Indisputably, addiction is a complicated, life-threatening disease. Treating people with the disease as criminals is the worst possible approach. Most experts in the substance abuse treatment community have known this for years. Fortunately, the RAND Corporation has now provided evidence of how this applies to babies born to women who abuse opioids. 

Typically, lawmakers do not evaluate the impact of the policies they pass. There have been many policies over the past few years that were implemented by state legislatures, healthcare organizations and insurance companies that were intended to reduce harm from opioids. Almost no one has attempted to measure their effectiveness or unintended consequences.

Fortunately, in this case, we have an exception. We have a unique opportunity as a result. The RAND study should provide policymakers with insights on how to more effectively address the problem of substance abuse during pregnancy.

Threatening to punish a pregnant women does not decrease the number of women who abuse drugs. However, it does scare many of them away from seeking the treatment they need and can deter pregnant mothers from seeking prenatal care.

Pregnant women who are opioid-dependent frequently use other illegal substances that risk the health of their babies. There should not be more barriers for pregnant women to receive prenatal care. Infants born after exposure to opioids often require prolonged hospitalizations to manage their needs, with those cumulative costs totaling more than $500 million, according to the RAND study. More importantly, babies with NAS suffer needlessly.

It should go without saying that every policymaker wants to solve problems and not create additional harm for new mothers or to babies born to them. Hopefully, this study will be used as it is intended: to help create policies that actually reduce harm from opioids. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is the author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences or Pain News Network. 

The New Norm for Chronic Pain Patients

By Rochelle Odell, PNN Columnist 

Come the new year, I will start my 28th year battling Complex Regional Pain Syndrome (CRPS). Like so many high impact pain patients, I have been experiencing a pain flare that isn't improving and prevents me from doing many tasks. I am praying it will get better and not become my new norm.  

I have been a palliative care patient for a couple of months now. Palliative care is not what many people think it is. My meds did not get increased and I still live at home. A home health RN visits me twice a week, takes my vital signs, asks how I am doing, how is my pain, and what doctor do I see next.  

I was evaluated this time last year for Transitional Care Management or TCM. It’s usually for patients getting out of the hospital and is short term -- only two to three months at the most. A medical doctor evaluated me and told me I was “high functioning” but needed assistance. High functioning? I have no help and only have me to depend on. I have to function to some degree just to survive. 

My RN tells me palliative care is meant to help patients be as comfortable as possible. They used to be able to give their patients pain meds, but now all they can give is Toradol, a non-steroidal anti-inflammatory drug, which does me no good because I am deathly allergic to NSAID's and aspirin. She is compassionate and caring and says what is happening to me and others in pain is "Just not right." I have to agree with her. 

Perhaps part of this new norm is reading so much negativity coming from our not so illustrious leaders in DC, along with blurbs from the CDC and the FDA. To me it appears to be getting worse as opposed to getting better.  

Is my increased pain clouding what I am reading? I don't believe so. Many of us suffering from high impact pain -- about 20 million Americans – are unable to get opioid medication. Even those suffering from life ending cancer are being turned away. That is nothing but plain cruelty. 

There is a core group of pain patients, probably numbering a few thousand, that is trying to change things. We call and write our elected officials and various government offices that have deemed it their duty to destroy our lives piece by piece.

Those that are physically able can attend a Don't Punish Pain Rally. There is another DPP rally coming up October 16. I have only been able to attend one rally. It's hard when one is in extreme pain and with limited funds to be able to travel to the rallies.  

Why Are We Being Treated This Way?

What is happening to us? Why are our physicians, those trained to treat and care for us, turning their backs on us? Why are we being shunned? Why are we being treated like we did something wrong?  

Why are people who abuse drugs being treated with compassion and care but not us? They hurt their families, they steal, they destroy their bodies, they seemingly don't care. We don't do any of that. Our pain is caused by diseases we never asked for. We care, we want to live and we want to participate in life.   

They get clean needles, clean rooms to shoot up in, free Narcan, and in Canada they are giving Dilaudid (hydromorphone) to those who abuse drugs. Dilaudid is an opioid used for treating severe pain. I was on Dilaudid three years ago. Not anymore.  

I just read about a county in England that is going to provide medical grade heroin twice a day to drug addicts. Why? The police are hoping it will lower crime in the area. I bet they have lines form they never expected.  

So now those who abuse are getting free heroin. Yet pain patients are kicked to the curb. How can physicians care for one who abuses their body but refuse to treat a human being suffering from intractable pain? I don't mean to sound so cold when it comes to those who abuse, but people in pain are suffering unrelenting pain because of them.   

If we ask for meds, ask for referrals or refuse a treatment we know will have adverse effects, we are accused of being non-compliant and dropped by our doctors. I believe the loss of compassion from our physicians is why many of us are having these unexplained pain flares that are becoming our new norm.  

I have been reading on social media that patients on opioids who move or are dropped are finding it impossible to get a new primary care physician. I saw my PCP last week and asked her about it. She emphatically told me "they" would not accept new patients who are on or had been on opioids. I was afraid to ask who “they” were, but am assuming it's all or most of the doctors in this area. 

I am sorry for all my friends in pain and for those I don't know who are in pain. I am sorry we are being treated like addicts. That those in healthcare would turn a blind eye to us. My heart breaks for those who feel the only solution is to take their life to end the pain. That is so wrong. Human beings are being pushed to that point by those elected to represent us and those in healthcare who are supposed to care but don't. I am so very sorry. 

Rochelle Odell lives in California.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org

This column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Addiction and the 2020 Presidential Race

By Dr. Lynn Webster, PNN Columnist

I found the recent story about Hunter Biden's drug and alcohol problems disturbing, not because he has an addiction — there's no shame in that — but because of the way the media tiptoes around the problem.

There seems be some reluctance to discuss Hunter's problem because of the way it may affect his father – former Vice President Joe Biden – and Biden’s bid for the presidency in 2020. To me, this illustrates a serious barrier to addressing the terrible disease of addiction.

Drugs, Politicians and Their Families

Marijuana is not considered a hard drug today, but it was considered a serious drug of abuse 27 years ago, when President Bill Clinton admitted he had used it. The stigma attached to using marijuana at the time was such that he disingenuously claimed he didn't inhale.

Of course, Clinton wasn't the only president who used or abused chemicals. Nor was he the only president whose reputation took a hit when his drug use was exposed to the public:

President Richard Nixon was reported to have an alcohol problem that worsened as his presidency neared its end.

President George W. Bush reportedly used cocaine in his youth and admitted “drinking too much.” ABC News even polled voters to find out whether his cocaine use might affect their willingness to vote for him.

President Barack Obama admitted that he used marijuana and cocaine. He was also a cigarette smoker with a nicotine addiction, and dealt with media inquiries about his attempts to quit throughout his presidency.

Hunter Biden is not the only family member of a presidential candidate with addiction.

Jeb Bush's daughter, Noelle Bush, had a drug problem. New York City Mayor Bill de Blasio’s daughter, Chiara de Blasio, abused alcohol and drugs while dealing with depression. Sen. Amy Klobuchar's father has struggled with alcohol his whole life. And President Trump’s brother, Fred Trump, Jr., died of complications related to alcoholism, which contributes to an estimated 88,000 deaths per year.

What Do Candidates Know?

Clearly, the endemic nature of addiction in our culture means that we should be interested in how the candidates deal with the presence of drugs in their lives. Are they able to talk openly about drug use instead of letting it remain a dark and shameful secret? Are they compassionate and supportive of family members who struggle?

To what extent do they personally use drugs and alcohol in daily life? And by extension, how well do they cope with stress? These are relevant, appropriate questions for candidates auditioning for a job that impacts the entire world.

It would be inappropriate to vote for a candidate solely on the basis of whether or not their loved ones struggle with addiction. But one criteria we can use for voting is a candidate’s positions on the critical issue of addiction in America. Here is how I would evaluate a candidate:

1) How much awareness do they demonstrate on the basic issues, including:

  • Do they know the difference in the prevalence of prescription opioid vs. illicit opioid abuse?

  • Do they know that addiction is not determined by the drug, but by genetic and environmental factors?

  • Do they know that the volume of pills prescribed to people in various parts of the country does not determine the number of overdose deaths?

  • Do they know that the prevalence of overdose deaths correlates with the loss of jobs and lack of income opportunity?

2) Will they de-stigmatize the disease of addiction by:

  • Decriminalizing the use of drugs?

  • Acknowledging addiction is a disease?

  • Understanding that babies cannot be born addicted?

  • Educating people that physical dependence and withdrawal can occur without addiction?

3) Do they favor access to substance abuse treatment in a timely fashion for everyone who needs it, regardless of their ability to pay?

4) Will they advocate for people in pain to receive opioid therapy when appropriate at the dose determined by their provider, rather than by the government?

5) Will they acknowledge the unintended consequences of the CDC opioid prescribing guideline?

Shining a Light on Addiction

The ideal candidate should recognize the tragedies associated with all addictions, not just with prescription opioids. He or she must recognize that addiction is part of being human, and that some people are more vulnerable to addiction than others, just as some people are more vulnerable to developing cancer or heart disease.

Whoever becomes or remains our president must shine the light of information on addiction, rather than hide it in the darkness of misinformation, shame and denial. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth” and co-producer of the documentary, “It Hurts Until You Die.”

You can find him on Twitter: @LynnRWebsterMD.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study Debunks Myths About Origins of Opioid Abuse

By Pat Anson, PNN Editor

It’s become a popular myth – and for some, a propaganda tool – to claim that opioid pain medication is a gateway drug to heroin and other street drugs.

An opioid education campaign called The Truth About Opioids – funded with taxpayer dollars from the White House Office of National Drug Control Policy — declares in big bold letters on its website that “80% of heroin users started with a prescription painkiller.”

The 80% figure stems from a 2013 study that found four out of five new heroin users had previously abused prescription opioids by using them non-medically.

Importantly, the heroin users were not asked if they had a valid prescription for opioids or even where they got them – but that doesn’t stop federal agencies from citing the study as proof that illegal drug use often starts with a legal opioid prescription.

The Drug Enforcement Administration last year used the 80% figure to justify steep cuts in the supply of prescription opioids, claiming in the Federal Register that addicts often get hooked “after first obtaining these drugs from their health care providers.”

“The 80% statistic is misleading and encourages faulty assumptions about the overdose crisis and medical care,” Roger Chriss explained in a PNN column last year.

A new study by researchers at Penn State University debunks the myth that the opioid crisis was driven primarily by doctors’ prescriptions. The researchers conducted a series of surveys and in-depth interviews with opioid abusers in southwestern Pennsylvania -- a region hard hit by opioid addiction -- asking detailed questions about their drug use.

The study was small – 125 people were surveyed and 30 of them were interviewed – but the findings provide a an important new insight into the origins of opioid abuse and the role played by painkillers.

"What emerged from our study -- and really emerged because we decided to do these qualitative interviews in addition to a survey component -- was a pretty different narrative than the national one,” said lead author Ashton Verdery, PhD, an assistant professor of sociology, demography and social data analytics at Penn State. "There's a lot about that narrative that I think is an overly simplistic way of thinking about this."

‘Opioids Were Never the First Drug’

Verdery and his colleagues found that over two-thirds of those interviewed (66.7%) first abused a prescription opioid that was given, bought or stolen from a friend or family member. Another 7% purchased the drugs from a stranger or dealer. Only one in four (26%) started by abusing opioid medication that was prescribed to them by a doctor.

“We found that most people initiated through a pattern of recreational use because of people around them. They got them from either siblings, friends or romantic partners," said Verdery. “Participants repeatedly reported having a peer or caregiver in their childhood who had a substance use problem. Stories from childhood of witnessing one of these people selling, preparing, or using drugs were very common. Being exposed to others’ substance use at an early age was often cited as a turning point for OMI (opioid misuse) and of drug use in general.”

And prescription opioids were not the gateway drugs they are often portrayed to be. Polysubstance abuse was common and usually began with drugs such as alcohol, marijuana, cocaine, methamphetamine, prescription sedatives and prescription stimulants.

“It is important to note that interviewees universally reported initiating OMI only after previously starting their substance use career with another drug (e.g., alcohol, marijuana, cocaine). Opioids were never the first drug used, suggesting that OMI is likely associated with being further along in one’s drug using career,” Verdery reported in the Journal of Addictive Studies.

Verdery says additional studies are needed on the origins of drug abuse and that researchers should focus on the role that other substances play in opioid addiction. Only then can proper steps be taken to prevent abuse and addiction before they start.

"We think that understanding this mechanism as a potential pathway is worth further consideration," said Verdery. "It's not just that people were prescribed painkillers from a doctor for a legitimate reason and, if we just crack down on the doctors who are prescribing in these borderline cases we can reduce the epidemic.”

The Complexity of Rx Opioid Misuse

By Roger Chriss, PNN Columnist

The misuse of prescription opioids is a complex phenomenon. Recent research has found that non-medical opioid use almost always involves a variety of other substances -- not just exposure in the course of routine medical care.

The risks of non-medical prescription opioid use developing into addiction need to be better understood to develop more effective measures to prevent misuse and to ensure that patients who use opioids responsibly are not wrongly targeted.

A new study in The American Journal on Addictions looked closely at the 2016 National Survey on Drug Use and Health, which found that that about 2.5% of respondents had misused prescription opioids in the previous 30 days. Almost half (43.9%) obtained opioid analgesics from a friend or relative for free and most were using other substances, such as cigarettes, alcohol, marijuana or street drugs.

“So much of the public discussion focuses on the opioid epidemic as though it is happening in a vacuum when, in fact, so many people misusing prescription opioids are also engaging in other substance use,” says lead author Timothy Grigsby, PhD, an assistant professor at The University of Texas at San Antonio.

“If we want to end the opioid epidemic, and stop another similar one from taking its place, then we need to consider the entire clinical picture of the patient including their use of other substances.”

Grigsby and his colleagues found that prescription opioid and polydrug users were also more likely to engage in stealing, selling drugs, have suicidal thoughts, suffer from major depression and need substance use treatment.

A similar study recently published in the journal Pediatrics examined non-medical prescription opioid use by parents and teenagers. The study found that parental misuse of opioid analgesics was associated with teenagers doing the same, with mothers’ use having a stronger association than fathers’ use.

Parental smoking, low parental monitoring and parent-adolescent conflict were also associated with teenage prescription opioid misuse, as were adolescent smoking, marijuana use, depression, delinquency and schoolmates’ drug use.

Despite what you may have heard, non-medical prescription opioid use does not usually lead to heroin. The National Institute on Drug Abuse reports that only 4 to 6 percent of people who misuse prescription opioids transition to heroin.

But trends in this transition have been shifting. A new study in PLOS One found that people who injected illicit drugs who were born after 1980 were more likely to initiate drug use with prescription opioids and non-opioids, and had higher levels of polydrug use. This study was limited to Baltimore, but similar findings have been reported for other parts of the U.S.

Importantly, most non-medical prescription opioid use occurs in the context of more general substance use. U.S. News recently reported that most patients treated in emergency rooms for misuse of prescription medications get into trouble because they mixed different substances.

"Most of the time there may have been only one pharmaceutical involved, but there were other non-pharmaceutical substances or psychoactive drugs or alcohol involved as well. When people get into trouble with misusing medicines, they're usually taking more than one substance," Dr. Andrew Geller of the CDC told U.S. News.

This is a long-standing trend in the opioid crisis. The 2014 Overdose Fatality Report in Kentucky found that the top five drugs in drug-related deaths were morphine, cannabis, heroin, alcohol and alprazolam (Xanax), with more than one drug present in many overdoses.

Moreover, a new study in the Journal of Substance Abuse Treatment compared 2013 and 2017 data on patients seeking opioid addiction treatment. Researchers found that many patients had employment, psychiatric, alcohol and drug problems, and were more likely to have depression, anxiety, hallucinations and suicidal thoughts. In other words, the overdose crisis is far more complex and dangerous than just opioids alone.

Fortunately, these long-standing trends are now starting to be appreciated. Public and private health officials in Ohio have started looking at data from multiple sources to better address mental health and substance abuse. 

The overdose crisis is a fast-moving target that is rapidly evolving. Overdoses now more than ever involve multiple drugs, and may not even occur among people who use opioids non-medically or people who have a substance use disorder. Understanding these features of the crisis is essential for developing better responses.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Teen Misuse of Rx Opioids at Historic Lows

By Pat Anson, Editor

Misuse of opioid pain medication by American teenagers is at an historic low, according to a nationwide survey that also found prescription painkillers have become increasingly harder for teens to obtain.

Nearly 44,000 students in 8th, 10th or 12th grade were questioned about their drug use in the University of Michigan’s annual Monitoring the Future (MTF) survey. Overall, the number of teens drinking, smoking and abusing drugs is at the lowest level since the 1990’s, although marijuana use spiked upward in 2017.

While the so-called opioid epidemic continues to make national headlines, misuse of prescription painkillers by teenagers has been steadily falling for over a decade.

The survey found that 4.2% of 12th graders used “narcotics other than heroin” in the past year, down from 9.4% in 2002.

Only 35.8% of high school seniors said the drugs were easily available in the 2017 survey, compared to more than 54 percent in 2010.

“We’re observing some of the lowest rates of opioid use that we have been monitoring through the survey. So that’s very good news,” said Norah Volkow, MD, director of the National Institute on Drug Abuse. "The decline in both the misuse and perceived availability of opioid medications may reflect recent public health initiatives to discourage opioid misuse to address this crisis."

The misuse of the painkiller Vicodin continues a decade long decline, falling to 2.9% of high school seniors in 2017. That’s down from 10.5% of seniors in 2003. Similar declines were reported in the misuse of OxyContin.

Marijuana use by teenagers rose by 1.3% to 24 percent in 2017, the first significant increase in seven years.

“This increase has been expected by many,” said Richard Miech, lead investigator of the study. “Historically marijuana use has gone up as adolescents see less risk of harm in using it. We’ve found that the risk adolescents see in marijuana use has been steadily going down for years to the point that it is now at the lowest level we’ve seen in four decades.”

For the first time, the survey asked students about vaping.  Nearly 28 percent of high school seniors said they had used a vaping device in 2017. A little over half said the mist they inhaled was "just flavoring," about a third said they inhaled nicotine, and 11% said they vaped marijuana or hash oil.

After years of steady decline, binge drinking appears to have hit bottom. Nearly 17 percent of 12th graders said they had five or more alcoholic drinks in a row sometime in the last two weeks. That’s a lot, but it's down from 31.5% in 1998.

Addiction Treatment Initial Focus of Opioid Commission

By Pat Anson, Editor

President Trump’s commission on drug addiction and the opioid crisis held its first public meeting today, a two-hour session focused largely on expanding access to addiction treatment.

Chaired by New Jersey Governor Chris Christie, the commission is expected to make interim recommendations to the president in the next few weeks on how to combat drug abuse, addiction and the overdose epidemic, which is blamed for the deaths of nearly 60,000 Americans last year. A final report from the commission is due by October 1.

It is not clear yet how much of a role opioid prescribing and pain medication will play in the commission’s work. Most of its five members have publicly blamed overprescribing for causing the opioid epidemic.

“No offense, but that is where this came from,” said Massachusetts Gov. Charlie Baker, a commission member.

“The opioid crisis is ruining lots of people’s lives and lots of families across America," David Shulkin, Secretary of Veterans Affairs told the commission. "At the VA, my top priority is to reduce veteran suicides. And when we look at the overlap between substance abuse and opioid abuse, it’s really clear.

“We’ve been working on this for seven years and we’ve seen a 33 percent reduction in use of opioids among veterans, but we have a lot more to do.”

Shulkin did not mention that veteran suicides have soared during that period, and are now estimated at 20 veterans each day.

“We also need to look at pharmaceutical companies making generic drugs more tamper resistant and looking at making drugs that do not cause addiction,” said North Carolina Gov. Roy Cooper, a commission member.

Commission member Patrick Kennedy, a former congressman who has battled substance abuse himself, said there has been a “historic discrimination” against mental health and addiction treatment.

“I’m excited by the chance to kind of push for ways that we can hold insurance companies more accountable, so that the public sector doesn’t have to pick up the tab. Because its taxpayers that are picking up the tab when insurance companies continue to push folks with these illnesses off into the public system,” Kennedy said. “This is a cost shift that is a windfall for insurance companies if they can get rid of people who have mental health or addiction issues.”

Limits on Opioid Medication Not Working

“Let me be blunt. Today there is not nearly enough drug treatment capacity in America to help most of the victims of the epidemic,” said Mitchell Rosenthal, MD, who founded Phoenix House, a nationwide chain of addiction treatment centers.

“Most terrifying is the reality that nothing we are doing today has been able to halt the spread of opioid addiction. Controlling prescription opioid medication has not done so. Prescription monitoring programs, strict limits on the number of pills physicians can prescribe, and the CDC pain management guidelines seem to have capped usage of prescribed opioid medications. But overdose deaths from heroin and highly potent synthetics like fentanyl have gone through the roof.”

One activist called for wider adoption of the CDC opioid guidelines and rigid enforcement if doctors don’t follow them. Gary Mendell, the CEO and founder of Shatterproof, a non-profit focused on preventing addiction, said each state should be held accountable and federal funding reduced to states if their prescribing exceeds a certain level.

“If every primary care doctor in this country followed the CDC guideline, you would cut by more than half, instantly, the number of new people becoming addicted,” said Mendell, whose son committed suicide after years of struggle with addiction. “We need a goal for the country. Divide it up by 50 states, a proper goal developed by the CDC, and then we need to publicize it and hold people accountable. Just like you would do in any business.”

Patrick Kennedy is a member of Shatterproof's board of advisors, and Andrew Kolodny, MD, founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP) is a member of its "opioid overdose advisory board."

No pain patients or pain management experts testified before the commission or were appointed to the panel.

Watch below for a replay of today's meeting:

Surge in Fake Painkillers as Opioid Prescribing Drops

By Pat Anson, Editor

A decline in the abuse and diversion of prescription pain medication is being offset by a “massive surge” in the use of heroin and counterfeit painkillers, according to a comprehensive new report by the U.S. Drug Enforcement Administration.

The DEA’s 2016 National Drug Threat Assessment paints a stark picture of the illicit drug trade in prescription medication, fentanyl, heroin, marijuana, methamphetamine and cocaine.  Interestingly, the 194-page report doesn’t even mention kratom, the herbal supplement the DEA attempted to ban in August before postponing its decision after a public outcry.

"Sadly, this report reconfirms that opioids such as heroin and fentanyl - and diverted prescription pain pills - are killing people in this country at a horrifying rate," said DEA Acting Administrator Chuck Rosenberg. "We face a public health crisis of historic proportions. Countering it requires a comprehensive approach that includes law enforcement, education, and treatment." 

The diversion of prescription opioids has fallen dramatically, according to the DEA report, from 19.5 million dosage units in 2011 to 9.1 million in 2015. Less than one percent of the opioids legally prescribed are being diverted to the black market.

The agency says the prescribing and abuse of opioid medication is also dropping, along with the number of admissions to treatment centers for painkiller addiction.

“With the slightly declining abuse levels of CPDs (controlled prescription drugs), data indicates there is an increase in heroin use, as some CPD abusers have begun using heroin as a cheaper alternative to the high price of illicit CPDs or when they are unable to obtain prescription drugs,” the report states.

The increased use of heroin coincided with federal and state efforts to reduce the prescribing of opioids. So did the appearance of counterfeit pain medication made with illicit fentanyl – a synthetic opioid that is 50 to 100 times more potent than morphine.  

“In 2015, there was a marked surge in the availability of illicit fentanyl pressed into counterfeit prescription opioids, such as oxycodone. In many cases, the shape, colorings, and markings were consistent with authentic prescription medications and the presence of fentanyl was only detected after laboratory analysis,” the DEA said. “The rise of fentanyl in counterfeit pill form exacerbates the fentanyl epidemic. Prescription pill abuse has fewer stigmas and can attract new, inexperienced drug users, creating more fentanyl-dependent individuals.”

As Pain News Network has reported, the number of fentanyl related deaths has surged around the country. In Massachusetts – where there has been a marked effort to reduce opioid prescribing -- three out of four opioid overdoses are now being linked to illicit fentanyl.

In Ohio’s Cuyahoga County, the problem is even worse. The medical examiner there estimates 770 people will die from either fentanyl or heroin overdoses by the end of the year, ten times the number of overdose deaths from prescription opioids.

The DEA predicts the problem will only grow worse.

“Fentanyl will remain an extremely dangerous public safety threat while the current production of non-pharmaceutical fentanyl continues,” the agency warns. “In 2015 traffickers expanded the historical fentanyl markets as evidenced by a massive surge in the production of counterfeit tablets containing the drug, and manipulating it to appear as black tar heroin. The fentanyl market will continue to expand in the future as new fentanyl products attract additional users.”

Those who do manage to get their hands on prescription painkillers for recreational use are mostly getting them from friends or relatives. Less than 25% of the painkillers that are used non-medically are obtained directly from doctors.

Over two-thirds of the painkillers that are abused are bought, stolen or obtained for free from friends and relatives.

Despite the shifting nature of the opioid epidemic, government efforts to stop it continue to focus on punishing doctors who overprescribe and reducing patient access to opioids.

“I have several chronic pain conditions that I was managing with a doctor’s care and Norco,” one reader recently emailed Pain News Network. “The DEA closed his office out of the blue. I was left with no doctor, no medical records, and the responsibility of weaning myself off what meds I had left on my own. 

SOURCE OF PAINKILLERS USED NONMEDICALLY

SOURCE: DEA

“My life is in shambles and I live in constant pain with no mercy. How much medical proof of real pain does it take? They just run me around to see different doctors. All the money and time wasted. I can't imagine living the rest of my life like this.”

The Centers for Disease Control and Prevention says 52 Americans die every day from overdoses of prescription opioids, although the accuracy of its estimates has been questioned. Some deaths caused by heroin and illicit fentanyl are wrongly reported as prescription drug overdoses. Other deaths may have been counted twice.

Untreated Pain Raises Risk of Drug & Alcohol Abuse

By Pat Anson, Editor

Nearly nine out of ten people who abuse drugs or alcohol have chronic pain and most are using the substances for pain relief, according to the findings of a new study at Boston University School of Medicine.

The study seems likely to stir further debate about the nation’s opioid abuse problem and whether taking patients off pain medication or lowering their doses will only lead to more substance abuse.

Researchers surveyed nearly 600 primary care patients who screened positive for illegal drug use, misuse of prescription drugs or heavy alcohol use and found that 87 percent of them had chronic pain. About half rated their pain as severe.

Over half (51%) of the patients who admitted using marijuana, cocaine, heroin or other illegal drugs said they did it to treat pain.

And about eight out of ten who abused prescription pain medication (81%) or alcohol (79%) said they did it to manage pain.

"While the association between chronic pain and drug addiction has been observed in prior studies, this study goes one step further to quantify how many of these patients are using these substances specifically to treat chronic pain,” said lead author Daniel Alford, MD, an associate professor of medicine at Boston University School of Medicine.

“In this study, it was common for patients to attribute their substance use to treating symptoms of pain. Over half of the cohort using illicit drugs, two thirds misusing prescription drugs without a prescription, and one-third using their prescription in greater amounts than prescribed, reported doing so to treat pain. Among those with any recent heavy alcohol use, over one-third drank to treat their pain, compared to over three-quarters of those who met the criteria for current high-risk alcohol use.”

Alford said it was important for primary care doctors and addiction counselors to recognize the link between pain and substance abuse, because counseling efforts are likely to fail if a patient’s pain is not addressed.

“If drugs are being used to self-medicate pain, patients may be reluctant to decrease, stop or remain abstinent if their pain symptoms are not adequately managed,” Alford wrote.

“Addressing pain symptoms is complicated for the most experienced physician and is outside the skill set of most allied health staff performing brief intervention counseling. Brief interventions focusing solely on the harmful effects of an illicit or misused drug may be ignored or disregarded if the patient perceives the drug as necessary to treat a symptom.”

The study is published in the Journal of General Internal Medicine.

Decline in Teen Opioid Abuse Continues

By Pat Anson, Editor

An annual survey that tracks teenage drug abuse continues to show a decline in the misuse of prescription opioid pain relievers, as well as heroin, alcohol, cigarettes, amphetamines and other substances.

The University of Michigan's Monitoring the Future Study (MTF) has tracked drug abuse among 8th, 10th, and 12th graders since 1975. This year’s survey included nearly 45,000 students at 382 public and private schools in the United States.

The MTF survey tracked the steady rise in teenage abuse of prescription opioids in the 1990's, before the trend reversed itself in the last decade. For the fifth year in a row, the survey found there was a significant decline in the misuse of opioids by teens (reported in the survey as “Narcotics Other Than Heroin”).

About 5% of 12th graders reported using an opioid pain medication in the last year, including 4.4% who used Vicodin and 3.7% who used OxyContin.

The number of teens reporting that prescription opioids were “fairly easy” or “very easy” to get also continues to drop.

Most teens abusing prescription opioids reported getting them from friends or family members. About one-third reported getting them from their own prescriptions.

"The recent declines in the abuse of prescription pain medicines among teens are encouraging. The Partnership has been working for quite some time through both our Above the Influence program and the Medicine Abuse Project to help educate teens, parents and communities about the risks of medicine abuse and we are glad to see continued progress," said Marcia Lee Taylor, President and CEO of the Partnership for Drug-Free Kids.

“While today's news about substance use among teens is mostly positive, we cannot let that take our focus off of the prescription drug and heroin crisis among other age groups.”

Despite widespread media reports about the so-called heroin “epidemic” in adults – heroin use among teens is at its lowest level since the MTF survey began. Past year use of heroin fell to 0.5% of 12th graders, an all-time low.

Use of several other illicit drugs – including MDMA (known as Ecstasy or Molly), amphetamines and synthetic marijuana – also showed a noted decline in this year's data. Use of alcohol and cigarettes reached their lowest points since the study began.

Marijuana, the most widely used illicit drug, did not show any significant change. After rising for several years, teenage marijuana use has leveled out since 2010, but still remains stubbornly high. In 2015, 12% of 8th ­graders, 25% of 10th­ graders and 35% of 12th­ graders reported using marijuana at least once in the past year. For the first time ever, daily marijuana use exceeds daily tobacco use among 12th graders.

"We are heartened to see that most illicit drug use is not increasing, non-medical use of prescription opioids is decreasing, and there is improvement in alcohol and cigarette use rates," said Nora D. Volkow, M.D., director of the National Institute of Drug Abuse, which funded the MTF survey.

"However, continued areas of concern are the high rate of daily marijuana smoking seen among high school students, because of marijuana’s potential deleterious effects on the developing brains of teenagers, and the high rates of overall tobacco products and nicotine containing e-cigarettes usage."

One growing area of concern is the abuse of Adderall and other prescription amphetamines, which are typically used to treat Attention Deficit Disorder (ADHD) but are widely perceived as a study aid.  About 7.5% of 12th graders used those drugs in the past year.

Study: Drug Abusers Responsible for Painkiller Misuse

By Pat Anson, Editor

A new analysis of a federal health survey has confirmed what many pain patients have been saying all along – that drug abusers, not patients, are largely responsible for the so-called epidemic of prescription painkiller abuse.

Researchers at the University of Georgia analyzed data from the 2011-2012 National Survey on Drug Use and Health. Over 13,000 Americans aged 12 and older were asked about their use of prescription drugs, illegal drugs, tobacco, and alcohol.

Less than 5% of those surveyed reported they had used a pain medication not prescribed for them or that they took it only for the "high" feeling it caused.

A further analysis of those abusers found that marijuana, cocaine or heroin use within the past year was the “only consistent predictor” of pain reliever misuse among all age groups.

"Male or female, black or white, rich or poor, the singular thing we found was that if they were an illicit drug user, they also had many, many times higher odds of misusing prescription pain relievers," said lead author Orion Mowbray, an assistant professor in the School of Social Work and the University of Georgia.

The findings are published in the journal Addictive Behaviors.

Asked where they obtained painkillers, the vast majority of the abusers said they did not get the drugs through a legitimate prescription, but had stolen them, acquired them from friends or relatives, bought them from a drug dealer, or used a fake prescription.

"If we know how people come to possess the pain relievers they misuse, we can design better ways to lower that likelihood," said Mowbray. "This study gives us the knowledge we need to substantially reduce the opportunities for misuse."

Adults aged 50 and older were more likely to acquire pain relievers through more than one doctor, although the rate of misuse in that age group was the lowest (1.7%).

People between the ages of 18 and 25 were most likely to misuse painkillers (10.2%) and more likely to get them from a friend, relative or drug dealer.

The study calls for greater coordination between medical care providers to reduce the possibility of over-prescription of painkillers, and for improving the communication between doctors, patients and the public.

"Doctors may conduct higher quality conversations with older patients about the consequences of drug use before they make any prescription decisions, while families and friends should know about the substantial health risks before they supply a young person with a prescription pain reliever," said Mowbray.

According to the Centers for Disease Control, over 16,500 deaths in the U.S. were linked to opioid overdoses in 2010.

More recent data suggest that the “epidemic” of painkiller abuse is abating.

Hydrocodone prescriptions fell by 8% last year and it is no longer the most widely prescribed medication in the U.S.

A recent report by a large national health insurer found that total opioid dispensing declined by 19% from 2010 to 2012 and the overdose rate dropped by 20 percent.

According to the National Institutes of Health, only about 5% of patients taking opioids as directed for a year end up with an addiction problem.