We're all addicted to something. Coffee. Video games. TV. Golf. Travel. Whatever. But usually our addictions aren't so intense as to wreck our lives. And rarely are they fatal.
Opioids, though, are both addictive and highly dangerous. They can do good, when used correctly. They also do a lot of harm, when used incorrectly.
Last Friday a Salem City Club talk, "The Opioid Epidemic: How We Got Here and the Way Forward," both fascinated me with facts I hadn't been aware of before, and depressed me with fairly familiar statistics about how opioids are ravaging our country.
Coelho and Holton
The speakers were Dr. Paul Coelho of the Salem Health Pain Clinic and Dwight Holton, CEO of Lines for Life (and a former US Attorney for Oregon). This isn't a very cheery photo of them that I took, but then, their topic was deadly serious. Literally.
Holton spoke first. He said that when he was US Attorney, he started to work on an effort to combat heroin use in Oregon. But he shifted gears after someone told him, "You're looking at the wrong drug." Indeed, opioids are a much bigger problem.
There are 42,000 car deaths per year. The Vietnam War killed 58,000 Americans, in total. And in 2017 it is estimated there were 72,000 drug overdose deaths. That number seemed so high, I worried that my notes were wrong. So I found a National Institute of Drug Abuse link that confirmed it.
Here's a figure from that web page. It shows that deaths from natural and semi-synthetic opioids, both prescription and black market, have been steadily increasing. Heroin deaths have been rising even more rapidly, now surpassing "regular" opioid deaths.
But deaths from synthetic drugs other than methadone have been really increasing in recent years.
In his remarks, Coelho said that $1,000 worth of Fentanyl can be worth $8 million on the black market, while $1,000 worth of heroin is only worth $4,000. So there's a huge incentive for drug dealers/cartels to push Fentanyl onto people addicted to opioids. Problem is, only a few grains of Fentanyl can be fatal.
So how did we get into this opioid mess?
It's well known that pharmaceutical companies must shoulder a large part of the blame. I'd say, most of the blame. Holton mentioned a New Yorker story, "The Family That Built an Empire on Pain," that I'd read which described in excruciatingly painful detail how the Sackler family became hugely rich by selling OxyContin through Purdue Pharmaceuticals.
"Selling" doesn't do justice to the crap that happened. Purdue knew that OxyContin was being overprescribed, with jillions (more or less) of pills finding their way onto the black market. Purdue paid six hundred million dollars in fines, but the New Yorker story says:
Given the billions of dollars that the Sacklers and Purdue had reaped from OxyContin, some observers felt that the company had got off easy. Arlen Specter, the Republican senator from Pennsylvania, remarked that such fines amounted to “expensive licenses for criminal misconduct.”
Coelho said that doctors were encouraged to prescribe OxyContin by attractive young female pharmaceutical reps. Helping to sway them was an absurdly over-cited 1980 letter to the editor in the New England Journal of Medicine (NEJM). Yes, a mere letter to the editor. Here it is.
This study only dealt with hospitalized patients, not people prescribed opioids on an outpatient basis. Nonetheless, the letter was used frequently in advertising for OxyContin and, I assume, other opioids. The NEJM only issued a retraction in 2017, long after it should have.
Holton said that pharmaceutical companies marketed opioids as being low risk and high benefit, but they were very wrong on both counts.
After 30 days of using opioids, there's a 47% chance a person still will be using them in three years. And if I can read my scribbled writing correctly, after using opioids for 90 days, there's a 66% chance a person still will be using them in five years. Whatever the percentage actually is, the longer the use, the greater the chance of addiction. Also, the higher the dose, the greater the chance is.
Four out of five heroin users had used opioids previously. So if there's a gateway drug to heroin, it is opioids, not marijuana. Regarding marijuana, neither of the speakers mentioned this, but research shows that after states legalize marijuana, the number of opioid prescriptions and the daily dose of opioids goes way down.
Since no one has ever died from an overdose of marijuana, this argues for legalizing pot as a way to reduce opioid addiction and the harms that come with overuse of opioids.
Astoundingly, Holton said that 216 million opioid pills are prescribed each year in Oregon. That's about fifty pills per person. So it's hard to believe that all of these prescriptions are medically necessary. The good news is, as shown in the slide above, that Oregon is making progress on reducing opioid use.
Nationally and in general, though, the trend is disturbing. This slide showed how opioid deaths are just the tip of the opioid problem iceberg.
And this slide shows how mortality rates in the 45-54 age group, which I gather is a prime age for using opioids, has been rising in the United States (red line; not sure why it says "USW"), while the rates have been falling in other industrialized countries.
Another slide fell prey to bad focusing on my iPhone. It showed that opioid prescription rates are much higher in this country, perhaps because we have such evil pharmaceutical companies like Purdue, and lack a national health system. Coelho said that meth use is spiking in Oregon. Stimulant prescriptions are increasing.
On the positive side, this slide showed that Baltimore had a 40% drop in overdose deaths over seven years following an expansion of opioid agonist (counter-acting) medication. Many police officers now carry agonists such as Naloxone, which is great.
Lastly, this slide shows what needs to be done to combat the opioid epidemic. It's a bit hard to read, so here's what it says;
(1) Safe pain management. Better access to safe and effective pain care.
(2) Fewer pills. Protect the community through safer prescribing and better medication disposal.
(3) Support harm reduction, treatment & recovery. Better access/availability of naloxone, MAT, & other addiction treatment & recovery supports.
(4) Data/education. Better data to inform action.
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