The Real Reasons People Become Addicted

By Dr. Lynn Webster, PNN Columnist

The Atlantic recently published an article, “The True Cause of the Opioid Epidemic,” that shares an underreported view of the complexities of the opioid crisis. The article acknowledges the epidemic is a multi-faceted drug problem that is largely driven by economic despair.

Yet most of the media remains focused on the large volume of opioids being prescribed, while ignoring the fact that opioids fill a demand created by deeply rooted, unaddressed societal problems.

As PNN reported, a recent study found that auto plant closures in the Midwest and Southeast created a depressed economic environment where drug abuse thrived. Poverty and hopelessness, more than overprescribing, were the seeds of the opioid crisis.

But those factors are only part of the issue. The prevalence of mental health disorders, the lack of immediate access to affordable treatment of addiction, and inadequately treated chronic pain — along with poverty and despair — have caused and sustained the continuing drug crisis.

One of the challenges in beginning to solve the crisis is to change how we view people with the disease of addiction. Rather than provide them with access to affordable healthcare, we stigmatize and criminalize them. This creates recidivism rather than rehabilitation. It affects people who use drugs for the wrong reasons, as well as people who use opioids for severe chronic pain.

Debunking Myths About Addiction

Many people make another false assumption. They claim that opioid addiction develops solely because of exposure to the drugs. That is untrue. Genetic and environmental factors determine who will become addicted. Exposure to an opioid — or any drug of abuse — is necessary for the expression of the disease, but by itself it is insufficient to cause it.

Most Americans are exposed to opioid medication at some point in their lives. In fact, the average person experiences a total of nine surgical and non-surgical procedures in a lifetime. An opioid analgesic is administered during most of these procedures and is often prescribed afterward for pain control. The lifetime risk for developing an opioid addiction is less than one percent of the population.

If exposure alone were responsible for addiction, then the 50 million Americans who undergo an operation every year, or those who undergo nine procedures in a lifetime, would develop an addiction.

Commonly, people who investigate and discuss opioid overdoses believe the deaths are exclusively due to the disease of addiction. But here again, they are mistaken.

An estimated 30 percent or more of overdoses are believed to be suicides. Why do some people choose to intentionally overdose? One driver is the despair that develops from inadequately treated pain. People in pain are almost three times as likely as the general population to commit suicide. They often use drugs rather than violent acts to end their lives.

In addition, efforts to curb opioid prescribing have pushed many people to the streets to purchase illegal and more lethal drugs. This is even true for people without a substance abuse disorder who are seeking pain relief.

Despite a more than 30 percent decline in opioid prescriptions over the past decade, there has been a continued surge in drug overdose deaths. We are seeing a shift in the reasons why people are dying from overdoses. Since 2018, the number of overdose deaths from methamphetamines has exceeded the number of deaths from prescription opioids. This underscores the fact that the problem is less about the supply of opioids and more about the demand for relief of psychological or physical pain.

Clearly, America’s drug crisis involves more than just the overprescribing of opioids — and this helps explain why interventions to reduce prescriptions have not succeeded. Understanding the actual causes of the problem may help us find real solutions. It also would change the focus from people in pain who find more benefit than harm in opioids to those who clearly are at risk of harm from them.   

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 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.

Questioning the New Cannabinoids

By Roger Chriss, PNN Columnist

A new cannabinoid similar to THC was announced last month in Scientific Reports. Dubbed tetrahydrocannabiphorol, or THCP for short, it is being hailed as a “breakthrough discovery” that is 30 times stronger than THC, the chemical compound in cannabis that causes euphoria.

Discovered by a group of Italian researchers, THCP has been shown to have a high affinity for the cannabinoid receptor (CB1) in the brain. Cinzia Citti from the Institute of Nanotechnology told Medical Cannabis Network that THCP likely has pain relieving effects, but pharmacological studies are needed to confirm it.

“Once all pharmacological profile of THCP has been established, I can imagine that THCP-rich cannabis varieties will be developed in the future for specific pathologies,” Citti said.

THCP’s chemical structure makes it nearly optimal for activity at the CB1 receptor. Studies on mice showed that THCP has psychoactive effects at low doses, but research is required to confirm how strongly THCP acts on the human brain.

‘Potential Game Changer’

There is already great enthusiasm for THCP, as well as cannabidiphorol (CBDP), another newly identified cannabinoid compound.

Vice states that “it’s possible these chemicals could treat certain conditions better than their counterparts,” THC and CBD.

Leafly went even further, predicting the new cannabinoids could have “immense therapeutic implications,” with THCP being a “potential game changer.”

Looking beyond the media hype, there appears to be no critical consideration of what a cannabinoid 30 times more potent than THC might mean. THC Is known to have significant negative effects on the human body. The National Institute on Drug Abuse lists side effects such as impaired breathing, increased heart rate, and mental effects such as hallucinations, paranoia and schizophrenia.

Moreover, THC is addictive. Health Canada reports that 1 out of 10 people who use cannabis will develop an addiction. The addiction odds increase to 1 out of 2 for people who use cannabis daily.

In other words, is THCP going to be 30 times more additive than THC? Will it cause 30 times more cognitive impairment? A 30-fold increase in ER visits and hospital admissions?

If THCP acts much more strongly on the CB1 receptor, then it may not really be a good thing for cannabis users or public health. These questions may seem absurd, but potent synthetic cannabinoids like K2/Spice have been a public health concern for many years. THCP may also have unknown side effects.

The difference between THC and CBD comes down to one chemical bond, but their respective effects are quite different. The apparent similarities between THCP and THC cannot be used to draw conclusions about effects in humans, good or bad.  

At present, very little is known about THCP. As Live Science points out, "while THC offers some medicinal effects, including pain and nausea relief, no one knows if THCP has these qualities."

It would be nice if even just one media outlet had mentioned the THCP could have some of the same problems that THC does, and at far lower concentrations.

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. 

Cost of MS Drugs Nearly Tripled

By Pat Anson, PNN Editor

The cost of prescriptions for disease-modifying multiple sclerosis (MS) drugs nearly tripled in the last decade, even with the introduction of cheaper generic versions, according to a new study funded by the National Multiple Sclerosis Society.

Researchers found spending on 15 MS drugs in the Medicaid program increased from $453 million in 2011 to $1.32 billion in 2017.

“Most of these drugs cost more than $70,000 per year on average and costs for these drugs are among the highest drug cost areas for private insurers as well as Medicare and Medicaid,” said Daniel Hartung, PharmD, of Oregon State University in Portland. “Unfortunately for people with MS, the introduction of a generic drug had a minimal effect on prices overall.”

Hartung and his colleagues found that when a generic version of the drug glatiramer acetate (Copaxone) was introduced in 2015, it was only 15 percent cheaper than the brand name drug made by Teva Pharmaceuticals.

Teva also worked to maintain its market share by encouraging doctors and patients to switch from a 20 mg dose of Copaxone to a 40 mg dose, which was not interchangeable with the new generic.

A second company introduced a generic version of glatiramer acetate in October 2017. Only then did the cost start to come down and generic versions started to get a greater share of the MS market.  

“After our study was complete, the company that introduced the second generic drug dropped its costs significantly, making it the lowest cost disease-modifying drug for MS on the market,” Hartung said. “Despite this, there is an urgent need for more robust competition from generics within these MS drugs.”

A similar study published last year found that Medicare paid nearly $76,000 annually per patient for disease modifying therapy (DMT), which reduces the frequency and severity of MS flare-ups. MS is a chronic and progressive disease that attacks the body’s central nervous system, causing pain, numbness, difficulty walking, paralysis, loss of vision, and fatigue.

Many Patients Can’t Afford DMT Meds

A recent survey by the National Multiple Sclerosis Society found that 40% of MS patients who take a DMT drug altered or stopped taking their medication due to the high cost. Only 11% said they could afford the medication without financial assistance.

“People with MS are paying the price, not only financially, but also physically and emotionally,” Bari Talente, executive vice president of advocacy for the National MS Society said in a statement.

“When someone alters or stops the use of their DMT, it can lead to increased symptoms, relapses, stress and anxiety. We need to make these medications affordable and accessible so people already facing a chronic illness don’t have to deal with deciding between buying groceries for their families or paying for their medication.”

The FDA recently approved the first generic versions of Gilenya (fingolimod) for the treatment of relapsing forms of multiple sclerosis (MS). A 30-day supply of brand name Gilenya 0.5mg capsules currently costs about $8,482, according to Healthcare Bluebook, or nearly $102,000 a year.

Few people actually pay the full amount for a DMT drug. About 45% of MS patients do not pay anything out-of-pocket for their DMT. The average annual cost among those who do pay is about $2,300.

‘Opioid of the Future’ Abandoned

By Pat Anson, PNN Editor

A promising new pain medication once touted as the “opioid of the future” because of its low risk of abuse is being abandoned.

Nektar Therapeutics withdrew its new drug application for NKTR-181 (oxycodegol) after two FDA advisory committees voted 27 to 0 against approval of the drug because of lingering concerns about the potential for addiction.

“The Company is disappointed in the Committees' vote regarding oxycodegol and believes it is also disappointing for patients suffering from chronic pain and the physicians that treat those patients who are currently relying on existing opioid therapies,” Nektar said in a statement. “The Company has decided to withdraw the NDA for oxycodegol and to make no further investment into the program.”

The molecular structure of oxycodegol is designed so the drug enters the brain slowly, providing pain relief without the euphoria or “high” that can lead to abuse.

In clinical studies, recreational drug users reported less “drug liking” of oxycodegol compared to oxycodone. Patients with chronic back pain also reported significant pain relief taking the drug twice daily.  

The research was so promising the FDA gave oxycodegol “fast track” designation in 2017 to speed its development.

All that changed, however, when the FDA came under a wave of public and political pressure to tighten its regulation of opioids.  A 60 Minutes report last year claimed the FDA “opened the floodgates” to the opioid crisis by approving the use of OxyContin. The agency also received a petition from Public Citizen calling for a moratorium on new opioid approvals because the agency “can no longer be trusted” due to its “poor record” of regulating opioids.

The FDA advisory committees had concerns about oxycodegol being snorted or injected by drug abusers and its potential for liver toxicity. A staff briefing document also questioned whether Nektar’s clinical studies were adequate.

While the panels’ unanimous recommendation isn’t binding on the FDA, Nektar decided to withdraw its new drug application rather than invest further resources in oxycodegol. That will save the company $75 to $125 million in 2020, according to a news release.

Drug Distributor Stops Opioid Sales

Nektar’s decision came the same day a New York based drug distributor announced it will no longer sell opioid medications. The Rochester Drug Co-Operative (RDC) is the nation’s sixth-largest pharmaceutical wholesaler. It buys medicines directly from drug manufacturers and sells them to 1,300 pharmacies in the Northeast.

"The ever-increasing expenses associated with the legal and regulatory compliance for this segment of drugs are simply not sustainable," RDC said in a statement. "While these specific drugs represent a relatively small percent of total sales, they account for significant legal and compliance expenses." 

Two former RDC executives were charged last year with illegally distributing opioids and conspiring to defraud the government. The company paid a $20 million fine and accepted independent monitoring under a five-year deferred prosecution agreement with the government.

An RDC spokesman said the decision to stop selling opioids was a business decision and not related to the legal case.

The Truth About Chronic Pain

By Dr. Rachel Zoffness, PNN Columnist

I’ve never been an athlete, but I’ve always loved exercising because of how it makes me feel. One beautiful spring day, I went for a run. On the way downhill, I was stopped by a sudden pain in my knee. When I woke the next morning, I couldn’t step out of bed without burning pain radiating from my feet, up my leg and into my hip.

I was couch-bound for the better part of a year. I saw countless doctors, was prescribed many medications, and would’ve done anything to stop the pain. That was the beginning of a decade-long journey with chronic pain.

I’ve dedicated my life to understanding pain, and not just because of that injury.

I’m a pain psychologist and assistant clinical professor at UC San Francisco School of Medicine, where I teach pain neuroscience to medical residents. I also founded a private practice dedicated to people living with chronic pain.

One of my earliest patients was a teenager. He’d been bedridden with multiple medical diagnoses for four years, seen 12 physicians and tried 40 medications. But nothing worked.

Not surprisingly, he was depressed and anxious. He had no life, no friends and no hope.

DR. RACHEL ZOFFNESS

As a pain psychologist, I use cognitive behavioral therapy (CBT) as one of my primary treatment tools, so we started a CBT-for-pain program. In addition to other strategies, it involved “pacing” or resuming select activities one small step at a time.

It was hard work, but little by little, he got healthier. As his functioning and mood improved, his pain did, too. Within 6 months he resumed school and rejoined his soccer team. His pain wasn’t gone – but it was significantly reduced and he knew how to manage it. He says pain will never control his life again.

Many of us have noticed this link between how we feel emotionally and how we feel physically. That’s because pain is never purely physical. This is confirmed by neuroscience research indicating that pain is produced by multiple parts of the brain, including the cerebral cortex (responsible for thoughts), prefrontal cortex (which regulates attentional processes), and the limbic system – your brain’s emotion center.

Dialing Back Pain

Imagine that you have a “pain dial” in your central nervous system that controls pain intensity. The function of this dial is to protect you from danger or harm. It can be turned up or turned down by many factors, including:

1. Stress and anxiety

2. Mood

3. Attention (what you’re focusing on)

When you’re feeling stressed and anxious – your thoughts are worried, your muscles are tense and tight, and the pain volume is turned up.  

When your mood is low, you’re miserable and depressed, and your brain similarly amplifies pain volume. 

This is also true when your attention is focused on pain. When you’ve stopped going to work, seeing friends and engaging in hobbies, your prefrontal cortex (which controls attention) sends a message to your pain dial, turning it way up. 

However, the opposite is also true. 

When stress and anxiety are low – your body is relaxed, your thoughts are calm and you’re feeling safe. Your cerebral cortex and limbic system send messages to your pain dial, lowering the volume so that pain feels less bad. 

When your mood is high, your thoughts are positive, you’re feeling happy and you’re engaged in pleasurable activities. Your brain determines that little protection is needed, so pain volume is reduced. 

And finally, when you’re distracted – you’re absorbed in activities, like watching funny movies with friends. The pain dial is turned down, so pain is less bad. 

In summary, when you’re relaxed, happy, distracted, and feeling safe, your pain volume is lower. The pain is still there -- it hasn’t magically disappeared -- but it’s quieter. Softer. Less. 

The truth about chronic pain is this: Your thoughts, beliefs, emotions and attention can all adjust pain volume. 

This does not mean that pain is “all in your head.” It isn’t. Your pain is real, as real as mine, and no one should ever tell us otherwise. It does mean that there are many ways to change pain. One is medication. Multiple medications have been shown to effectively turn down the pain dial.  

There are other methods for lowering pain volume, too. CBT, mindfulness and biofeedback are three biobehavioral approaches to pain management that research suggests can be helpful. They aren’t magic cures and they take time. But if you’ve never tried to manage your pain with these techniques, consider them. They’ve helped me immensely on my chronic pain journey. 

When I was learning about mindfulness, I remember thinking, “What could mindfulness possibly have to do with physical pain?”  

And then something fascinating happened.  

During the first year of my practice, my pain changed. It didn’t go away entirely and I wasn’t cured. But the pain changed. It became less intense, less frequent, less distracting, and got less in the way of the rest of my life. 

Rachel Zoffness, PhD, is a pain psychologist and assistant clinical professor at the UCSF School of Medicine. Rachel serves on the Steering Committee of the American Association of Pain Psychology, where she founded the Pediatric Division. She is the author of The Chronic Pain and Illness Workbook for Teens. You can find Rachel on Twitter @DrZoffness.  

Obamacare Prevented Thousands of Opioid Overdose Deaths

By Pat Anson, PNN Editor

The expansion of Medicaid under the Affordable Care Act – widely known as Obamacare -- was associated with a six percent lower rate of opioid overdose deaths, according to a new study that estimates thousands of overdoses may have been prevented by expanding access to healthcare for millions of Americans.

Researchers also found a significant and unexpected increase in overdoses involving methadone, an addiction treatment drug sometimes used to treat chronic pain.

Thirty-two states and the District of Columbia opted to expand Medicaid eligibility under the Affordable Care Act (ACA), providing healthcare coverage to uninsured low-income adults. ACA requires that individuals who receive coverage be provided with mental health and substance use disorder treatment.

Researchers at the NYU Grossman School of Medicine and University of California, Davis looked at death certificate data from 49 states and the District of Columbia between 2001 and 2017— looking for changes in overdose rates in counties that expanded Medicaid under ACA compared to those that did not.

Their findings, published online in JAMA Network Open, suggest that Medicaid expansion prevented between 1,678 and 8,132 opioid overdose deaths from 2015 to 2017.

Overall, there was a 6% lower rate of opioid overdose deaths, an 11% lower rate of heroin overdoses, and a 10% lower rate of death involving fentanyl and synthetic opioids other than methadone in states that adopted the ACA.

"The findings of this study suggest that providing expanded access to health care may be a key policy lever to address the opioid overdose crisis," said senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the Department of Population Health at NYU Langone Health.

Methadone Overdoses Rose

Cerdá and her colleagues also found a concerning 11% increase in methadone overdose rates in states that expanded Medicaid under the ACA. Methadone is an opioid that has long been used to treat addiction, but it is also prescribed by some doctors to treat chronic pain.

“Although the rate of methadone-related mortality is relatively low compared with other opioid classes, our finding that Medicaid expansion was associated with increased methadone overdose deaths deserves further investigation,” researchers said.

“Past research has found high rates of methadone use to treat pain among Medicaid beneficiaries and that the drug is disproportionately associated with overdose deaths among individuals in this population, underscoring the importance of ongoing local, state, and federal actions to address safety concerns associated with methadone for pain in tandem with Medicaid expansion.”

In 2014, the methadone prescribing rate among Medicaid patients was nearly twice that of commercially insured patients. Medicaid patients were also slightly more likely to be prescribed methadone for pain (1.1% vs. 0.85%) as opposed to addiction.

Expansion Reduced Opioid Deaths

The ACA became law at a time when opioid overdose deaths were rising sharply. Some critics of Obamacare claimed that expanding access to low-cost opioid pain relievers would create an incentive for low-income Medicaid beneficiaries to sell their drugs.

“It stands to reason that expanding the program — particularly to people most susceptible to abuse — could worsen the problem,” a 2018 report by Sen. Ron Johnson (R-WI) claimed. “The epidemic has indeed spiraled into a national crisis since the Obamacare Medicaid expansion took effect in 2014. Drug overdose deaths have risen rapidly, at a much faster pace than before expansion.”

The NYU and UC Davis study found that theory to be false.

"Past research has found Medicaid expansion is associated with not only large decreases in the number of uninsured Americans, but also considerable increases in access to opioid use disorder treatment and the opioid overdose reversal medication naloxone," said lead author Nicole Kravitz-Wirtz, PhD, an assistant professor in the Department of Emergency Medicine at UC Davis.

"Ours was the first study to investigate the natural follow-up question: Is the expansion associated with reductions in local opioid overdose deaths? On balance, the answer appears to be yes." 

Current and Former Smokers Have More Pain

By Pat Anson, PNN Editor

There are many good reasons to stop smoking. Within hours, your heart rate and blood pressure will drop, you’ll cough less and feel more energy. Within a few months your lung function will start to improve. And after 20 years, your risk of dying from lung disease or cancer will be about the same as someone who never touched a cigarette.

Unfortunately, one thing that may not improve is your pain. According to a large new study in the UK, former smokers report higher levels of pain than people who never smoked, and their pain levels are similar to people who still continue to smoke.

Researchers at University College London (UCL) analyzed health data from over 220,000 people in the UK who were asked to report how much pain they experienced during the previous 4 weeks and whether it interfered with their work.  

After adjusting for other health factors such as anxiety and depression, current and former daily smokers were more likely to report bodily pain compared to people who never smoked. The difference was small, but considered significant. Surprisingly, the association between smoking and pain was highest in the youngest group of smokers (aged 16 to 34).

The study was observational and did not establish a cause-and-effect relationship between smoking and pain. But researchers say their findings, published in the journal Addictive Behaviors, suggest that regular smoking at any age results in more pain.

“We cannot rule out that there is some other difference between former smokers and never smokers that is causing these surprising results, but we have to consider at least the possibility that a period of daily smoking at any time results in increased pain levels even after people have stopped smoking,” said lead author Olga Perski, PhD, a research associate in UCL’s Department of Behavioural Science & Health.

“This may be due to negative effects of smoking on the body’s hormonal feedback loops or undiagnosed damage to body tissues. This is certainly an issue that needs looking into.” 

Another possibility is differences in personality. People who take up smoking may handle the psychological stress of illness differently than non-smokers or have a lower level of pain tolerance, which makes them feel pain more acutely. A large study in Norway, for example, found that smokers and former smokers were more sensitive to pain than non-smokers, who had a higher pain tolerance.

Regardless of the reason, smoking is linked with many negative health consequences.

“The possibility that smoking may increase lifelong pain is another important reason not to take up smoking in the first place,” said Perski.

Studies have also found that smoking increases your chances of having several types of chronic pain conditions, such as degenerative disc disease.

A 2011 study of over 6,000 Kentucky women found that those who smoked had a greater chance of having fibromyalgia, sciatica, chronic neck pain, chronic back pain and joint pain than non-smokers. Women in the study who smoked daily more than doubled their odds of having chronic pain.

Back to the Future in Pain Care

By Carol Levy, PNN Columnist

The start of another year started me thinking about my 42-year fight against trigeminal neuralgia (TN) and how things have changed in its diagnosis and treatment.

I was 26 when the pain started. It came out of the blue, like a lightning bolt inside the skin of my left temple. It was horrendous, lasting maybe 20 seconds or so, and then it subsided. After a clinic doctor diagnosed it as trigeminal neuralgia, I was repeatedly told it could not be TN because I did not meet the criteria for the diagnosis.

At that time, it was very simple: TN pain had to be in a specific anatomical area. Mine was. The pain also had to be spontaneously triggered by touch, no matter how slight. Mine was. But you had to be at least 60 years old or, if you had multiple sclerosis, over age 40 to have TN. I was only 26. Too young.

So, regardless of the pain being in the right place and occurring in the proper fashion, it had to be something else, although they had no idea what that might be. It took more than a year before someone finally recognized it as trigeminal neuralgia, despite my youth.

Over the years the definition and diagnostic criteria for TN have changed. There are now two recognized types of TN:

• Trigeminal Neuralgia 1: Intense, stabbing pain attacks affecting the mouth, cheek, nose, and/or other areas on one side of the face.

• Trigeminal Neuralgia 2: Less intense but constant dull aching or burning pain.

You can have both types of TN. I have constant pain, as well as spontaneous and triggered pain. Neither type includes an age factor. This makes it easier for a young person to be diagnosed with TN today. 

Changing Treatments

Not only has the definition changed, but so too have the treatment options. When mine started, there were less anti-convulsants to try, the first line of treatment for TN. Now there are many new medications, including botulinin (Botox) injections.  

Over the years I had many operations, some of them no longer in use. Now there are gamma knife and cyber procedures, things not even a glimmer in someone's eye when I was first diagnosed or being treated. 

Reflex Sympathetic Dystrophy (RSD) is another pain disorder which has come a long way. Even the name was changed, from RSD to CRPS (Complex Regional Pain Syndrome).

In 1981, I entered a residential pain program. There were only 8 of us. One was named Joanne, who had very weird, unbelievable symptoms and complaints, so weird even the doctor had trouble believing her.

Joanne said she had tremendous pain throughout her body, and trouble controlling her bowels and bladder. She insisted it all started right after a statue had fallen on her foot. It sounded fanciful at best. She seemed a perfect example of pain being psychological. 

If that happened today, Joanne’s complaints might be taken more seriously and she could be diagnosed with CRPS. But at that time, it was a disorder that did not appear on anyone's radar. 

Since then many new medications and treatment options have been devised or added to the armamentarium against CRPS, such as ketamine infusions, intrathecal pain pumps, hyperbaric oxygen therapy and bisphosphonates. The same is true for many of the other pain disorders. Research is ongoing, new medications and surgeries are being developed. 

We often lament that nothing new is being done for us. Where is the research? Where is the treatment that will finally give us relief? 

It can be hard to see sometimes where we have been vs. where we are now, much less where we may be going. But history shows that more progress is being made than most of us may realize. And that is a good thing. We have to look to the past to see not only how far we have come, but how much farther we still have to go.   

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The Devil We Know

By K. Grahame, Guest Columnist

I was on opioid medication for over 10 years as treatment for acute and chronic pain in 27 diagnosed pain conditions, including herniated lumbar discs, arthritis, spinal stenosis, and torn muscles and tendons in my lower back. 

Now I've been involuntarily taken off opioids by my pharmacy. Guess what? There is NOTHING available that treats pain like opioids.

I am 66. The pain has driven my blood pressure up into the 200/90 range, and since I've already had both heart surgery and malignant melanoma surgery, I'm on so much blood pressure medication that I cannot walk.

The government would not let a human treat a dog like this. The rest of my life looks, at this point, to be short and a piece of hell, thanks to the media blitz on 67,000 annual overdose deaths -- of which only 17,000 were overdoses from prescription opioids. That’s fewer deaths than happen from common falls in the home.

While I'm at it, there were 72,000 alcohol related deaths in 2017. And the Surgeon General estimates that 440,000 people die every year from tobacco-related health conditions. Where are you, FDA and CDC on that?

The reason I care about this so much is not only how it affects my life. In 1978, my mother died in mortal agony from bone cancer, without much in the way of painkillers. The hospital refused repeatedly to give her opioids for pain relief because they were afraid she’d become addicted!

I watched the angel of my life pass away looking like a victim of Nazi Germany death camps, after she begged me to find something that she could poison herself with.

God in heaven, nobody should have to watch someone they love beg them for death! It simply boggles my mind that this is happening in America.

I'm going to die soon, most likely of a heart attack or stroke, and that's what will show on my death certificate. It won't show that I was doing just fine, taking care of myself and the pets who are the joy of my life, while I was taking opioids. The only side effect I had to deal with was constipation, and a GI doctor fixed that for me with simple OTC meds.

I don’t really want to die before my pets, but this ain’t living, people!

The government should be outed as the killers they are, because it sure as hell isn't the legally prescribed and supervised opioids. As for the 17,000 people that died from prescription opioids in 2017, the stats aren't available on how many were deliberate overdoses, if alcohol or other substances were involved, or even if they had a prescription.

Those stats should be provided, because that information should make a BIG difference in how the governments, state and federal, make their decisions.

Please don’t tell me that cognitive behavioral therapy or hypnosis are going to cure the pain in my much-damaged back. Or the arthritis, tendonitis and bursitis. Or the pain from my cancer surgery-severed nerves.

There is just so much to tell people that isn’t known or hasn’t been communicated. It’s the devil you know versus the devil you don’t. I really do think the devil we know is trying to reduce the expensive medical costs associated with the Boomer generation. What happens when death is made cost-effective for the government?

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

Alcohol Deaths Double in U.S.

By Pat Anson, PNN Editor

Alcohol related deaths in the U.S. have doubled in the past two decades, according to a new study that highlights an under-reported aspect of the overdose crisis: while deaths involving prescription opioids are declining, alcohol abuse appears to be increasing.

Researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) found the number of death certificates mentioning alcohol more than doubled from 35,914 in 1999 to 72,558 in 2017.

By comparison, 17,029 deaths in 2017 involved a prescription opioid, according to CDC estimates.

“The current findings suggest that alcohol-related deaths involving injuries, overdoses and chronic diseases are increasing across a wide swath of the population. The report is a wakeup call to the growing threat alcohol poses to public health,” said NIAAA Director Dr. George Koob.

Nearly 1 million alcohol-related deaths were recorded between 1999-2017. About half the deaths resulted from chronic liver disease or overdoses on alcohol alone or with other drugs.

Researchers noted that alcohol-related deaths were increasing among people in almost every age, race and ethnic group. Their study is published in Alcoholism: Clinical & Experimental Research.

“Taken together, the findings of this study and others suggests that alcohol-related harms are increasing at multiple levels – from ED visits and hospitalizations to deaths. We know that the contribution of alcohol often fails to make it onto death certificates. Better surveillance of alcohol involvement in mortality is essential in order to better understand and address the impact of alcohol on public health,” said Koob.

Other drugs besides alcohol are increasingly involved in overdoses. A recent analysis of over one million urine drug tests conducted by Millennium Health found that positive results for illicit fentanyl rose by 333% since 2013, while positive rates for methamphetamine increased by 486 percent.

That study, published in JAMA Network Open, found that positive rates for heroin and cocaine peaked in 2016 and appear to be declining.

The analysis is similar to a 2019 report from the National Institute on Drug Abuse, which found that drug deaths involving prescription opioids and heroin have plateaued, while overdoses involving methamphetamine, cocaine and benzodiazepines have risen sharply.

Unreliable Data

Just how reliable is the federal data on drug use and overdoses? Not very, according to another study published in Drug and Alcohol Dependence.

Troy Quast, PhD, an associate professor at the University of Florida’s College of Public Health, compared overdose data from the Florida Medical Examiners Commission (FMEC) to drug deaths in a CDC database. Quast found the federal data significantly undercounted overdose deaths in Florida linked to cocaine, benzodiazepines, amphetamines and other drugs.

Florida medical examiners are required by law to wait for complete toxicology results before submitting an official cause of death to FMEC. It often takes weeks or months to identify the exact drug or drugs that cause an overdose. By contrast, the CDC data is based on death certificates filed by coroners and other local authorities, which often don't include detailed toxicology reports. This causes significant differences between the two databases.

Between 2003 and 2017, roughly one-in-three overdose deaths in Florida involving illicit or prescription opioids were not reported by the federal government. The discrepancy wasn’t limited to opioids. Quast also found that nearly 3,000 deaths in Florida caused by cocaine were not included in the CDC database. Overdose deaths involving benzodiazepines and amphetamines were also significantly under-reported.

"The CDC data are widely reported in the news and referenced by politicians, which is problematic since those estimates significantly undercount the true scope of the epidemic for specific drugs," said Quast. "The rate of under-reporting for all overdose deaths in Florida is near the national average, so the problem is not to the state."

This isn’t the first time the reliability of CDC data has been questioned. In 2018, CDC researchers admitted that many overdoses involving illicit fentanyl and other synthetic black market opioids were erroneously counted as prescription drug deaths. As result, federal estimates prior to 2017 "significantly inflate estimates" of prescription opioid deaths.

Even the adjusted estimates are imprecise, because the number of deaths involving diverted prescriptions or counterfeit drugs is unknown and drugs are not identified on 20% of death certificates. When the drugs are listed, many overdoses are counted multiple times by the government because more than one substance is involved.

The federal government is working to improve the collection of overdose data. Over 30 states are now enrolled in the CDC's Enhanced State Opioid Overdose Surveillance program, which seeks to improve overdose data by including toxicology reports and hospital billing records.

In 2017, the program reported that nearly 59 percent of overdose deaths involved illicit opioids like fentanyl and heroin, while 18.5% had both illicit and prescription opioids. Less than 18% tested positive for prescription opioids only.

A recent study of drug deaths in Massachusetts found that only 1.3% of overdose victims who died from an opioid painkiller had an active prescription for the drug – meaning the medication was probably diverted, stolen or bought on the street.  

Do Pain Patients Really Get High on Rx Opioids?

By Roger Chriss, PNN Columnist

The standard narrative of the opioid crisis is built on the idea that people feel euphoria or get “high” when exposed to opioids and almost immediately become addicted. Some assert that opioid medications should have no role outside of trauma, surgical, palliative and end-of-life care due to their high risk and side effects.

But reality is more complex.

Euphoria is widely believed to be inevitable with opioids, and increases the risk for misuse and addiction. But in fact, euphoria is not common.

"I think that the notion that opioids [always] cause pleasure is a myth," Siri Leknes, principal investigator at the University of Oslo in Norway, told Live Science.  "I think it's especially important to point out that opioids do not reliably cause pleasure or relief of subjective stress and anxiety in the lab or in stressful clinical settings."

Leknes’ research found that patients receiving remifentanil – a potent, short-acting synthetic opioid -- felt high, but the experience was unpleasant.

"Not everyone experiences the same level of euphoria from opioids, and not everyone that uses opioids will develop an addiction or opioid use disorder,” says Brian Kiluk of Yale School of Medicine.

Major cognitive side effects are often thought to be inevitable with opioids. But a review of 10 clinical studies on older adults with chronic pain found that most “demonstrated no effect of opioid use on cognitive domains.” Only at high daily doses did opioids worsen memory, language and other cognitive skills.

In other words, long-term opioid therapy may cause side effects at doses well above what most people ever receive and beyond thresholds recommended by the CDC and state governments.

The risks of overdose are similarly nuanced. For instance, a study on opioids and mortality looked at a nationally representative sample of over 90,000 people, among whom 14% reported at least one opioid prescription. There were 774 deaths during the study period, with the death rate slightly higher among those taking opioid prescriptions.

However, after adjusting for demographics, health status and utilization, the authors concluded there was “no significant association” between opioids and sudden death. “The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination," they said.

On the efficacy of opioid therapy, a major review in Germany looked at 15 studies with 3,590 patients with low back, osteoarthritis and neuropathic pain. The quality of evidence was low, but the authors concluded long-term opioid use was appropriate for patients who experience “meaningful pain reduction with at least tolerable adverse events."

Pain Patients Used As ‘Guinea Pigs’

Instead, we have an intense focus on prescribing statistics. States like Minnesota tout a 33% decrease in opioid prescribing for Medicare patients, while ignoring how those poor and disabled people are faring.

“My cat gets better pain management than I do after surgery,” one man wrote to state health officials.

In Ohio, opioid prescriptions have declined by 41% since 2012. Some wonder if the cutbacks went too far.

“There needed to be an adjustment and maybe it did go overboard a bit. I feel bad for the people in chronic pain because they're going to be the guinea pigs for how we get it back to the middle," Ernest Boyd, executive director of the Ohio Pharmacists Association, told the Akron Beacon Journal

So the medical needs of people with cancer, sickle cell disease and other chronic painful conditions are going unmet. And some doctors are even avoiding such patients entirely.

Naturally, there is a need to safeguard the entire opioid supply chain, and to carefully screen and monitor people on any form of opioid therapy. But we also need to track the rapidly evolving policy landscape surrounding prescription opioids to make sure that pain patients with chronic medical needs are being not harmed.

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.

Pain Relief Hard to Find for Sickle Cell Patients

By Sam Whitehead, WABE

India Hardy has lived with pain since she was a toddler — ranging from dull persistent aches to acute flare-ups that interrupt the flow of her normal life.

The pain is from sickle cell disease, a group of genetic conditions that affect about 100,000 people in the U.S., many of them of African or Hispanic descent.

Sitting in the afternoon heat on her mom’s porch in Athens, Georgia, Hardy recollected how a recent “crisis” derailed her normal morning routine.

“It was time for my daughter to get on the bus, and she’s too young to go on her own,” Hardy recalled. “I was in so much pain I couldn’t walk. So, she missed school that day.”

Sickle cell disease affects red blood cells, which travel throughout the body carrying oxygen to tissues. Healthy red blood cells are shaped like plump and flexible doughnuts, but in people with sickle cell disease, the red blood cells are deformed, forming C-shaped “sickles” that are rigid and sticky.

These sickle-shaped cells can cause blockages in the blood vessels, slowing or even stopping normal blood flow. An episode of blockage is known as a sickle cell “crisis” — tissues and organs can be damaged because of lack of oxygen, and the patient experiences severe spells of pain.

‘It’s Like Torture’

Hardy tries to manage these crises on her own. She’ll take a hot bath or apply heating pads to try to increase her blood flow. Hardy also has a variety of pain medications she can take at home.

When she has exhausted those options, she needs more medical help. Hardy would prefer to go to a specialized clinic for sickle cell patients, but the closest is almost two hours away, and she doesn’t have a car.

So, Hardy often goes to the emergency room at nearby St. Mary’s Hospital for relief. Until recently, the doctors there would give her injections of the opioid hydromorphone, which she says would stop her pain.

Then, some months ago, the emergency room changed its process: “Now they will actually put that shot in a bag which is full of fluids, so it’s like you’re getting small drips of pain medicine,” Hardy said. “It’s like torture.”

INDIA HARDY (JOHNATHON KELSO FOR WABE)

It’s the same for her brother, Rico, who also has sickle cell disease and has sought treatment at St. Mary’s. The diluted medicine doesn’t give the same pain relief as a direct injection, they say.

Concerns About Addiction

St. Mary’s staffers explain that they’re trying to strike a balance with their new treatment protocol between adequate pain treatment and the risk that opioid use can lead to drug dependence.

It’s a local change that reflects a national concern. More than 47,000 Americans died in 2017 from an overdose involving an opioid, according to the Centers for Disease Control and Prevention. Most of those deaths involve an illicit opioid such as heroin, but the rising death toll prompted many hospitals to rethink how they administer opioid medications, including how they treat people, such as Hardy, who suffer from episodes of severe pain.

“We have given sickle cell patients a pass [with the notion that] they don’t get addicted — which is completely false,” said Dr. Troy Johnson, who works in the emergency room at St. Mary’s. “For us to not address that addiction is doing them a disservice.”

Johnson proposed the ER’s shift to intravenous “drip delivery” of opioids for chronic pain patients because of personal experience. His son has sickle cell disease, and Johnson said he has seen firsthand how people with the disease are exposed to opioids when very young.

“We start creating people with addiction problems at a very early age in sickle cell disease,” Johnson said.

He brought his concerns to the director of the ER, Dr. Lewis Earnest, and found support for the change. Hospital officials say they also consulted national guidelines for treating sickle cell crises.

“We’re trying to alleviate suffering, but we’re also trying not to create addiction, and so we’re trying to find that balance,” Earnest said. “Some times it’s harder than others.”

St. Mary’s says the new IV-drip protocol is for all patients who come to the emergency room frequently for pain, and most of their sickle cell patients are fine with the change.

Caught in the Crossfire

The national guidelines cited by St. Mary’s also say doctors should reassess patient pain frequently and adjust levels of opioids as needed “until pain is under control per patient report.”

Some people who work closely with sickle cell patients, upon hearing about the new approach to pain management at St. Mary’s, called it “unusual.”

“When individuals living with sickle cell disease go to emergency departments, they are living in extreme amounts of pain,” said Dr. Biree Andemariam, chief medical officer of the Sickle Cell Disease Association of America.

It’s more common for ERs to give those patients direct “pushes” of pain medication via injection, she noted, not slower IV drips.

“If anything, individuals with sickle cell disease in our country have really been caught in the crossfire when it comes to this opioid epidemic.”

— Dr. Biree Andemariam

People with sickle cell disease aren’t fueling the opioid problem, Andemariam said. One study published in 2018 found that opioid use has remained stable among sickle cell patients over time.

“If anything, individuals with sickle cell disease in our country have really been caught in the crossfire when it comes to this opioid epidemic,” Andemariam said.

She suggested that ER doctors and nurses need more education on how to care for people with sickle cell, especially during the painful crisis episodes, which can lead to death.

A study of some 16,000 deaths from 1979 to 2005 related to sickle cell found that men in the group lived to be only 33, on average. Women didn’t fare much better, living to an average age of 37. The same study suggested that a lack of access to quality care is a factor in the short life spans of people with sickle cell disease.

Researchers who study sickle cell say the opioid epidemic has made it harder for patients with the condition to get the pain medication they need. The American College of Emergency Physicians is focusing on the problem, asking federal health officials to speak out about sickle cell pain and fund research on how to treat it without opioids.

“We in the physician community are looking for ways to make sure they get adequate pain relief,” said Dr. Jon Mark Hirshon, vice president of the group. “We recognize that the process is not perfect, but this is what we’re striving for — to make a difference.”

‘They Treat Us Like We’re Not Wanted’

In the meantime, India Hardy said she feels those imperfections in the process every time she suffers a pain crisis, and she’s not alone.

In addition to her brother, Hardy said she has another friend in Athens with sickle cell disease, and that friend has also reported difficulty in finding pain relief at the St. Mary’s emergency room.

“It’s just really frustrating, because you go to the hospital for help — expecting to get equal help, and you don’t,” Hardy said, her voice breaking. “They treat us like we’re not wanted there or that we’re holding their time up or taking up a bed that someone else could be using.”

Hardy filed a complaint with the hospital but said nothing has changed, at least not yet. She still gets pain medication through an IV drip when she goes to the St. Mary’s emergency room.

At this point, she’s considering leaving her relatives and friends behind in Athens to move closer to a sickle cell clinic. She hopes doctors there will do a better job of helping to control her pain.

This story is part of a partnership that includes WABE, NPR and Kaiser Health News, a national health policy news service.

Flushing Out the Truth About Disposing of Unused Pain Medication

By Dr. Lynn Webster, PNN Columnist

According to a 2016 survey, most Americans choose not to dispose of their leftover opioid pain medication because they want to keep it for potential future use. This is entirely understandable.

People have little incentive to dispose of their unused pain medication. It is expensive to replace drugs, and the person who owns the prescription has already paid for it. Also, a growing number of people are concerned that, should they someday need pain treatment, they will find it difficult to obtain opioid medication. They may even be accused of being a drug seeker if they ask for it.

So people don't necessarily have nefarious reasons for holding onto unused medication. However, leftover pain medication has been blamed for causing much of the opioid crisis because it can be easily diverted.

Leftover drugs can end up on the streets or in the wrong hands, such as family members or friends. In all cases, they can cause harm. Let's look at some numbers.

In 2013, nearly 9 billion pills containing hydrocodone were produced for prescription purposes. Other opioids added to the supply. Although this was several years ago and opioid production quotas have significantly reduced the supply of opioids, leftover pills are still a potential problem. Of those that are prescribed after surgery, more than 40% percent go unused.

Opioid drugs lose only about 1 percent of their potency per year. This means prescription opioids have a half-life of more than 50 years. These potent medications can remain viable (or toxic) for nearly a lifetime. 

At any given time, billions of opioid pills that still retain their potency are available for diversion and non-medical use. That is a problem.

Conflicting Information About Safe Disposal

A public education campaign may convince some people who are reluctant to give up their extra medication that it would be better for society if they get rid of the drugs. However, even if people were persuaded to dispose of their unused medication, they may not know how to do so safely.

A recent report by Time suggests that even pharmacists do not know how patients should dispose of their leftover drugs. Of 900 pharmacists surveyed, only 23 percent correctly told callers how to safely dispose of opioids according to FDA guidelines.

The pharmacists' confusion is understandable. Various authorities have delivered different messages over the years about the best way to dispose of unused drugs.

The FDA recognizes that there are environmental concerns about flushing medicines down the toilet. However, the agency also believes that the risks associated with narcotic medicine outweigh any potential risks associated with flushing. The FDA includes hydrocodone, oxycodone, methadone and other opioids on a lengthy list of medicines that should be flushed down a toilet if no other safe disposal options are available.

The FDA even recommends flushing unused fentanyl lozenges (ACTIQ). The disposal instructions are very complicated. They require both a pair of scissors and wire-cutting pliers, and are roughly as convoluted as Walter White's method of making crystal meth in television's "Breaking Bad." I suspect that not everyone who is prescribed ACTIQ would be willing or able to follow all of those steps.

Evidently, the FDA believes that the risk of harm from overdose is greater than the danger the drugs present to the environment and to our water supply. 

The Time story cites a 2017 U.S. Geological Survey and EPA report that found hundreds of drugs, including prescription opioids, in 38 streams across the country.

“Many of the drugs identified in the 2017 study are known to kill, harm the health of, or change the behavior of fish, insects and other wildlife. This, in turn, can impact the food chain, and eventually harm humans as well,” Time reported.

The FDA’s guidance on how to safely dispose of drugs can be confusing. Some medication is flushable, while other leftover drugs should be put in a sealed container or plastic bag with an “unappealing substance such as dirt, cat litter, or used coffee grounds” before being thrown out in the trash.

Take Back Programs

Drug take-back programs are intended to reduce the supply of excess prescription opioids and destroy the pills in an ecologically safe way. The FDA has a list of permanent take-back sites where people can dispose of unused medication. The DEA also has Drug Take Back Days, temporary collection sites for the safe disposal of prescription drugs.

However, not all take-back programs collect controlled substances. And it is estimated that fewer than 2 percent of unused drugs are returned. Also, these take-back programs are costly to implement.

The messaging around disposal of pain medication is conflicting. In a perfect world, all unused medication would be easily disposed of without causing negative consequences to the environment or the community. Also ideally, people in pain would not have to worry they might not receive a prescription for medication if they need one. Unfortunately, neither of those propositions is true. 

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

Research Explores Cannabis as Treatment for MS, Alzheimer’s and Huntington’s Disease

By Pat Anson, PNN Editor

The University of Alberta is partnering with a Canadian cannabis company in three research projects exploring the use of medical cannabis for the treatment of multiple sclerosis, Alzheimer’s and Huntington’s diseases. 

Atlas Biotechnologies is investing nearly $300,000 over the next two years to fund the studies. Atlas operates a 38,000 square foot cannabis production facility near Edmonton and will supply customized blends of cannabis products to U of A researchers.

“People are touting (cannabis) for all kinds of things, but without solid scientific evidence,” said Ross Tsuyuki, PharmD, chair of the Department of Pharmacology at U of A. “But there likely are benefits for some conditions.”

The most well-known chemical compounds in cannabis are tetrahydrocannabinol (THC) and cannabidiol (CBD), but the plant has hundreds of other active biological chemicals, each with the potential of having therapeutic benefits. The goal of the research is to identify what specific compounds or combinations of compounds are effective.

“We've got to figure out the best combination of those compounds and how they're actually working in people,” Jeffrey Gossain, Atlas’ chief operating officer, told Folio, the University of Alberta's news site.  “A lot of people will tell you, 'My mom had cancer’ or, ‘My friend had an illness, and they took cannabis and it helped.’ But then for other people they don't have as effective results. 

“Part of the problem is that you don't really know what product they took, how they dosed it or the combinations of chemicals in the product that helped. It's not as simple as just saying, ‘The plant's got THC and CBD.’ You've got to get a lot more detailed than that.”

The research will examine whether CBD and other cannabinoids can relieve pain in patients with multiple sclerosis; if cannabis can reduce neuroinflammation and degeneration of the brain caused by Huntington's disease; and if cannabinoids have neuroprotective activity in models of Alzheimer’s disease.

“Alzheimer's disease, chronic pain, multiple sclerosis and Huntington's disease are all devastating conditions that don't have a lot of effective treatments,” said Tsuyuki. “If we find something, even if it works just a little, that could be an enormous advance for patients. But we have to do our homework first, and that is where we're starting.”

In addition to its partnership with the U of A, Atlas is collaborating with Harvard Medical School in developing cannabis products for pain and other neurological conditions.

A recent study found that medical cannabis is mildly effective in relieving pain and other symptoms in patients with multiple sclerosis (MS). Spanish researchers analyzed 17 clinical trials involving different combinations of THC and CBD, and found cannabis had limited effectiveness in relieving pain, muscle spasticity and bladder dysfunction.

MS is a chronic and incurable disease which attacks the body’s central nervous system, causing numbness in the limbs, difficulty walking, paralysis, loss of vision, fatigue and pain.

Research Links Auto Plant Closures to Opioid Overdoses

By Pat Anson, PNN Editor

A new study is adding to the growing body of evidence linking the opioid crisis to unemployment, depression, suicide and declining economic opportunities – the so-called epidemic of despair.

Researchers at the Perelman School of Medicine at the University of Pennsylvania and Massachusetts General Hospital looked at the closure of automotive assembly plants in the U.S from 1999 to 2016, primarily in the Midwest and Southeast. They found that opioid overdoses rose significantly in 29 counties where an auto plant shutdown.

Five years after the plants closed, opioid overdose rates among adults were 85 percent higher in counties where closures occurred compared to 83 counties where plants remained open.

"Major economic events, such as plant closures, can affect a person's view of how their life might be in the future. These changes can have a profound effect on a person's mental well-being, and could consequently influence the risk of substance use," said lead author Atheendar Venkataramani, MD, an assistant professor of Medical Ethics and Health Policy.

"Our findings confirm the general intuition that declining economic opportunity may have played a significant role in driving the opioid crisis."

The findings are published in JAMA Internal Medicine.

JAMA INTERNAL MEDICINE

The demographic group with the biggest increase in opioid overdose deaths after an auto plant closure was non-Hispanic white men between 18-34 years old, followed by non-Hispanic white men ages 35-65 years old. Opioid overdose rates also increased among young non-Hispanic white women.

Death rates involving heroin and other illicit opioids were higher for young white men and women than for prescription opioids, while older white men were more likely to die from prescription opioids.

"While we as clinicians recognize and take very seriously the issue of overprescribing, our study reinforces that addressing the opioid overdose crisis in a meaningful way requires concurrent and complimentary approaches to diagnosing and treating substance use disorders in regions of the countries hardest hit by structural economic change," Venkataramani said.

“Our findings should not be interpreted in such a way as to diminish the role of opioid supply, either from physician prescriptions or from illicitly made and supplied synthetic substances, in the US opioid overdose crisis.”

Princeton researchers Anne Case and Angus Deaton were the first to suggest in 2015 that the declining life expectancy of Americans was not caused by drug abuse alone, but linked to unemployment, poor finances, lack of education, divorce, depression and loss of social connections. They estimate that nearly half a million white Americans died due to a quiet epidemic of pain, suicide, alcohol abuse and opioid overdoses.

The epidemic of despair has also been cited as one of the reasons for the election of Donald Trump and for a “syndemic” of overdoses occurring in counties where the opioid crisis first erupted, particularly in mid-sized cities in Kentucky, Ohio and West Virginia.