By Robert E. Field, Co-Founder and Co-Chair, Common Sense for Drug Policy.
Much has changed since 2005 when Common Sense for Drug Policy (CSDP) devoted two of its monthly ads in national publications to the issue of inadequate pain treatment. At that time, experts consulted by CSDP contended that physicians, out of ignorance or fear of prosecution where often under medicating pain from trauma, resulting in that pain becoming chronic and patients sometimes becoming dependent or even addicted.
Two of the hundred public service informationals included “Suffering From Chronic Pain?” and “CHRONIC PAIN AND OPIOIDS: Debunking the Myths “. They were published in 2005;
Last Sunday the New York Times published a major opinion piece by Sam Quinones entitled “Serving All Your Heroin Needs” which did not necessarily contradict what we had been contending but gave reason to revisit and further research our contentions.
According to Quinones:
“FATAL heroin overdoses in America have almost tripled in three years. More than 8,250 people a year now die from heroin. At the same time, roughly double that number are dying from prescription opioid painkillers, which are molecularly similar. Heroin has become the fallback dope when an addict can’t afford, or find, pills. Total overdose deaths, most often from pills and heroin, now surpass traffic fatalities…
“In the ’90s, some doctors came to believe that opioid painkillers were virtually nonaddictive when used for pain, and they prescribed them freely — not just for terminal cancer patients, but for chronic pain sufferers, too. Many patients were in pain. But instead of pursuing more complicated pain solutions, which might include eating better, exercising more and, thus, feeling better, too many saw doctors as car mechanics endowed with powers to fix everything quickly.
“Too often, opioid painkillers were prescribed to excess; after I had my appendix removed a few years back, I received 60 Vicodin, when four might have been enough.
“A result has been a rising sea level of prescription painkillers that continues today, of opioids such as Percocet, Vicodin and OxyContin. Sales of these drugs quadrupled between 1999 and 2010. Addiction followed. And this has given new life to heroin, which had been declining in popularity since the early 1980s…”
In response to the article, CSDP commenced a discussion among board members Drug War Facts editor Doug McVay; our chair Ernest Drucker, PhD; our president Kevin Zeese; and David Borden, editor of Drug War Chronicle.
I wrote:
“…Please carefully study the New York Times article for the link below.
“Although the NYT has long been in the rear when it comes to drug policy reform, the public needs to be able to judge the credibility of the articles assertions. And perhaps CSDP was misled two decades ago concerning the efficacy and relative harmlessness of opiate medication for those suffering trauma.”
Doug McVay responded:
“Quinones is a journalist. He was a freelance for several years, working in Mexico
http://www.journalism.columbia.edu/page/419-sam-quinones/9
“And spent 2004-2014 working for the LA Times
http://www.laobserved.com/archive/2014/03/sam_quinones_moves_on_fro.php
“He’ll be on C-SPAN 2 answering calls about his new book at 3pm Eastern time
http://www.c-span.org/video/?325092-3/open-phones-sam-quinones
“Lately he’s been spending a good bit of time talking about the “Mexican Mafia”
http://www.lataco.com/taco/gangs-los-angeles-2015-sam-quinones
“He’s something of a sensationalist, and arguably his work promotes a vision that’s popular among some – that big pharma and the Mexicans have created an opioid epidemic. This, for example, is from the advertising blurb for his book:
http://www.amazon.com/Dreamland-True-Americas-Opiate-Epidemic/dp/1620402505/ref=sr_1_1?s=books&ie=UTF8&qid=1422455112&sr=1-1&keywords=dreamland+sam+quinones
” ‘In fascinating detail, Sam Quinones chronicles how, over the past 15 years, enterprising sugar cane farmers in a small county on the west coast of Mexico created a unique distribution system that brought black tar heroin–the cheapest, most addictive form of the opiate, 2 to 3 times purer than its white powder cousin–to the veins of people across the United States. Communities where heroin had never been seen before–from Charlotte, NC and Huntington, WVA, to Salt Lake City and Portland, OR–were overrun with it.’ ”
McVay continues: “I’d have to do more checking to debunk a couple of those cities but as far as Portland, Oregon is concerned, heroin has been a major concern in this city since well before the 1980s… I started to look at the punk scene before I left Portland in 1987, and met several other heroin users at that time. The movie Drugstore Cowboy was very much a slice of life here in the northwest…
Dave Borden commented:
“Is the concern you’re seeking to probe about the need to increase access to opioid medications for pain control? The situation is a complex one. More people today are able to obtain pain medications. Because more people are getting these prescriptions, the statistically inevitable situation of an overdose occurs more frequently, as does the statistically inevitable situation of some patients developing a dependence on the medications. However, not everyone who needs these medicines is able to get them; opiophobia is alive and well.
“I’ve read that the assertion once made that pain patients get addicted only rarely has come into question, maybe even has been repudiated. There are also some reform-minded health scholars, who are aware of opiophobia and who oppose it, but who believe that some types of prescribing are not being done well or considered well, thereby increasing problems like addiction and overdose, which in turn create more opiophobia and fuel punitive legislating.
“Part of the solution is harm reduction measures that our movement and others are involved in promoting — the overdose antidote naloxone, “911 Good Samaritan” non-prosecution policies for people seeking help with overdose situations, opioid maintenance with methadone or buprenorphine or (despite the author’s too quick dismissal) clinically-provided heroin, and or course syringe exchange.
“There are some references that I can look up to be of help with this, but I wanted to write this first to make sure I have correctly inferred what you are getting at. I’m about to get on the highway for our annual DPA grantees meeting, but can follow up on this tonight or in the morning.
“Generally my sense is that this author has made some valid points about today’s opioid problems and what some of the causes are (although Ernie [Drucker) undoubtedly knows much more about this than I do, and if I’m wrong I’d be very interested in learning how). But the author has missed what some of the most important solutions are, and worse has been dismissive (though to what degree it’s hard to tell from the wording) of what some of the most important solutions are.”
Borden later continued: Some additional references, with paraphrasing text from my Cardozo paper:
Another dire consequence of current drug policies is the under-treatment of chronic pain. A 2011 report by the Institute of Medicine found that while “opioid prescriptions for chronic noncancer pain [in the U.S.] have increased sharply . . . [t]wenty-nine percent of primary care physicians and 16 percent of pain specialists report they prescribe opioids less often than they think appropriate because of concerns about regulatory repercussions.” 57 As the report noted, having more opioid prescriptions doesn’t necessarily mean that “patients who really need opioids [are] able to get them.” 58 In 2010 Senator Herb Kohl threatened to hold up the nomination of acting DEA administrator Michele Leonhart over DEA’s policies that hindered timely access to pain medications for nursing home patients. 59
But even that is a luxurious situation compared with much of the world. INCB itself reports that “more than 90 percent of the global consumption of . . . opioid analgesics occurred in Australia, Canada, New Zealand, the United States of America and several European countries. This means that their availability was very limited in many countries and in entire regions.” 60 Here again, regulatory and legal restrictions contribute to the problem, as does underestimation by governments of the quantities of opioids their populations will need, and consequent underproduction in the (INCB-administered) global quota system. 61
57 Comm. on Advancing Pain Research, Care, & Education; Inst. of Med., Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, THE NATIONAL ACADEMIES PRESS 143-144 (2011), http://www.nap.edu/catalog.php?record_id=13172 (last visited Feb. 17, 2014).
58 Id. at 144.
59 Kohl Threatens to Hold Up DEA Nominee Over Nursing Home Drug-dispensing Issue, MCKNIGHT’S (Dec. 2, 2010) http://www.mcknights.com/kohl-threatens-to-hold-up-dea-nominee-over-nursing-home-drug-dispensingissue/ article/192036/ (last visited Feb. 17, 2014).
60 INTERNATIONAL NARCOTICS CONTROL BOARD, REPORT OF THE INTERNATIONAL NARCOTICS CONTROL BOARD ON
THE AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS: ENSURING ADEQUATE ACCESS FOR MEDICAL AND
SCIENTIFIC PURPOSES 2 (2010), available at http://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf ; [hereinafter INCB Pain Report] (last visited Feb. 17, 2014); with respect to INCB’s administration of the global opiate quota system.”
Kevin Zeese observed: “Good discussion so far. I look forward to hearing more about whether this is sensationalist journalism or accurate reporting. It feels like the former to me. I would not take any action on it until it is checked out.
“This could have been written at multiple times in our history when there were phases of increased heroin use. We are in that cycle again, no doubt for lots of reasons well beyond what is described in the Times article. I look forward to hearing more.”
One of the issues at work in this problem is that crackdowns on pain pill availability have contributed to increased heroin usage. On one level, that suggests that making pills harder to get is counterproductive, or at least neutral to the degree it merely substitutes one problem for another.
On another level, some argue (perhaps Phil and his coauthor in this piece, if I remember correctly) that too liberal usage of pain pills for some conditions has contributed to greater addiction, with those patients potentially turning to heroin when their access to pills dries up. I don’t know how the numbers of the different types of cases would stack up against one another.
I think our answer is that the main response to the overdose problem should be measures that directly seek to prevent overdoses or their consequences: Naloxone, 911 Good Samaritan policies, increased and less laborious access to opioid maintenance programs, authorizing more types of opioid maintenance.
Dave Borden, Drug War Chronicles
The heart of the new story here is the dramatic increase in opiate related overdose deaths in the last 6 years – tripling up to 24,000 – and the shift from heroin to prescription pharmaceuticals as the principal culprit. The persistent and wholly legitimate needs for pain medications and the roll that properly prescribed medication can play in relieving pain and suffering has traditionally been poorly met – with widespread refusal to treat pain and insufficient dosages being the norm Our failure to effectively address serious pain problems has always been linked to doctors justifiable fears about DEA retaliation – especially if they are too “liberal” in their prescribing practices.
This situation was worsened by the aggressive marketing of highly potent new opioid painkillers aggressively marketed by their manufacturers – most famously OxyContin – generating many new addicts and creating new markets for heroin in the US – most notably among the white working class.
Ernest Drucker, PhD
One more example of prohibition stifling research and medical practice with disastrous consequences. In the next few years we are going to see a lot of new information coming out about the medical value of cannabis as it is finally breaking free of the taboo of prohibition and can now be looked at more honestly in the first time during the era of modern medicine.
It is going to be recognized as a miracle drug as this information comes out.
KZ