Unintended Consequences: Are We Inadvertently Increasing Heroin Overdose Deaths?
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Two years ago, The Fixspearheaded an effort to highlight the public health epidemic caused by the overprescribing of opioid pain medications which resulted in the tens of thousands of overdose deaths that were making front page news. The epidemic was iatrogenic- “caused by physicians”- in nature. Until quite recently, the vast majority of physicians understood that opioid pain medications—invaluable for short-term pain, for treating cancer and for easing suffering at the end of life—had no place for longer-term, chronic use. It was accepted that the opioids’ side effects and the potential for tolerance, the risk of addiction and the eventual pain of opioid withdrawal made for a very poor risk-benefit analysis for their patients. Unfortunately, over a decade ago, a variety of forces changed all that, including a general movement in medicine to treat pain more adequately, a tendency for consumers to believe that every discomfort should have a medical cure and a devastatingly successful campaign by pharmaceutical companies to convince physicians that opioid pain medications, prescribed to patients with genuine pain, would not lead to addiction. These factors were the primary agents behind a sea change in physician behavior, where routinely and repeatedly, opioid pain medications were prescribed to patients suffering from chronic, non-terminal pain.
Obviously, as a nation we are still devastated by this paradigm shift. Into the calculus of addiction, which was already impacting around 15% of our population, prescribed opioid addiction was introduced. Vicodin and OxyContin led the charge, and opioid addiction quickly became the fastest-growing drug problem in the nation. Accidental drug overdose outstepped car accidents as the most common cause of accidental death, with most deaths resulting from prescribed opioids.
In a series of articles designed to bring a better understanding of these complex issues to primary care physicians, The Fix has endeavored to illuminate the problem of the opioid epidemic as well as to inspire change. And there have been important actions taken since these efforts began two years ago. Have they had the desired impact, orhave efforts to decrease the overprescribing of prescription pain medicationsinadvertently created a boom in the misuse of heroin?
Federal and State Action
In the past two years, both federal and state governments have enacted changes designed to impact the epidemic of addiction and overdose from prescribed pain medications. The federal government has pushed for pain medications to become more difficult to misuse by requiring that they are more difficult to crush, break or dissolve. Additionally, it has reclassified Vicodin and other products containing hydrocodone from Schedule III to the more restrictive Schedule II, which imposes more restrictions on prescribers. At the same time, most state governments have created Prescription Monitoring Programs or Prescription Drug Monitoring Programs (PMPs or PDMPs).
These are electronic databases that collect information on prescribed substances, allowing physicians and other prescribers to see what medications their patients have been prescribed, and by whom. These programs are designed to avoid “doctor shopping” by making a patient’s medication history transparent to all providers. Among other things, PMPs are designed to “facilitate and encourage the identification, intervention with and treatment of persons addicted to prescription drugs”. But, in addition to these goals, are PMPs and the other efforts that have been implemented in the last two years to address the prescription opioid epidemic also driving people to heroin?
The answer is cloudy, and for a number of reasons.
The Heroin Epidemic
There is no question that there has been an enormous increase in the number of heroin-related overdoses over the last decade, and that there has been a very dramatic increase in the last couple of years. The real question is whether well-intended efforts to combat the prescribed opioid problem are responsible.
A recent article in the Economist that made a splash in the treatment community asserts that “the face of heroin use in America has changed utterly”, that the old stereotype of heroin users as young, poor, black and male has been replaced by a new reality in which users are overwhelmingly white, increasingly older, middle-classed and female. The shift is connected to prescribed opiates. In profiling a woman who was given OxyContin following an injury, the article connected the patient’s heroin habit to the prescribed opiates, in a scenario that has become all too familiar: “On the black market OxyContin pills cost $80 each, more than she could afford to cover her six-a-day habit; so she began selling her pills and using the proceeds to buy cheaper heroin. As if from nowhere [she] had become a heroin addict.”
Figures from the Centers for Disease Control support the idea that the prescription opioid crisis continues in full force. Over 100 people a day die in this country because of drug overdose, a figure that has been rising steadily for over two decades. In 2012, of the 41,502 drug overdose deaths in the US, 16,007 or about 38%, involved prescription painkillers.
There is also ongoing evidence that many of the millions who were initially introduced to opioids by their doctors have turned to heroin, and in fact that most of the people that use heroin now started out with a prescription opioid. While most hospital ED admissions for opioid overdose are still caused by prescribed painkillers, bothgovernment authorities and local media around the country continue to report anongoing dramatic rise in heroin overdose deaths.
Many addiction treatment providers say that this has become a familiar paradigmamong the patients that they treat. “A troubling comment pops up more and more during my discussions with people actively addicted to opioids,” writes Jeffrey T. Junig, MD, a physician and PhD neuroscientist who practices in Wisconsin. They say, “Now that O-C’s (OxyContins) are abuse-proof, we gotta’ use heroin.” Adds Dr. Junig who is open about being in recovery himself: “There are many addicts out there, each subject to severe withdrawal in the absence of their daily dose of oxycodone. What would a reasonable person expect them to do, knowing the intensity of their desire for opioids and their fear of withdrawal? Are they just going to stop?”
Arnold Washton, PhD, the Executive Director of Compass Health Group, a multi-specialty team of addiction providers in New York, reports that the same phenomenon Junig describes in Northern Wisconsin can be found among the C-suite executives that he sees in his high-end practice in Manhattan. He notes that “increasing numbers of clients are coming in reporting that they are physically dependent on heroin, having switched from OxyContin and other prescribed painkillers as they’ve become harder to get from their physicians. I’ve had two of these patients enter treatment just in the last week.” In Manhattan, adds Washton, “these guys don’t have to buy it on the street, there are heroin delivery services that will bring it to them in their doorman buildings.”
Percy Menzies, the President of the Assisted Recovery Centers of America in St. Louis, a treatment center based in St Louis, confirms that many of his patients come to use heroin as a result of changes in their ability to access prescribed opioids. He notes that:
“The restrictions that have been placed on prescription opioids have resulted in a decreased availability of these drugs on the street. Some of our patients initially were started on prescription opioids for chronic pain, but after a period of time the patients were ‘fired’ by their doctors for abusing the drugs. Some of these patients tried switching doctors and when nothing worked, came to us for treatment. Other patients obtained prescription opioids illegally from friends, stole them, etc., and then switched to the cheaper opioid – heroin- and got addicted to the heroin.” Adds Menzies, “We were caught unprepared for the ‘man-made’ addiction to prescription pain medications. Heroin quickly became the ‘generic’ version for the prescription opioids.”
But other addiction medicine providers are not seeing a lot of this pattern in their practices. Mark Willenbring, MD, the former Director of the Treatment and Recovery Research Division at NIAAA/NIH and the CEO of Alltyr: Addiction Treatment for the 21st Century, says “I am unsure of the prevalence of prescription opioid users switching to heroin but I suspect it is very small. Most people have no idea how to procure it and are too afraid of the consequences. I’ve seen this a few times, but only in people with a history of serious non-medical opioid or other drug use.” Adds Anna Lembke, MD, the Director of Stanford’s Addiction Medicine Program, “I find that the switching from prescription opioids to heroin is more common among the younger generation, who seem to be generally more open to experimentation with all types of drugs, and are not deterred by legal status. Whereas with middle-aged and older folks, heroin represents crossing a line for them, and they’d rather get help before going there.”
Andrew Kolodny, MD, the Chief Medical Officer of Phoenix House and the President of Physicians for Responsible Opioid Prescribing (PROP), is a long-time crusader against the “epidemic of opioid addiction caused by overexposure of our population to prescription opioids.” He argues for a balanced perspective on the challenges we’re confronted by. He points out that “there is strong evidence that heroin use was increasing before any significant federal or state interventions on prescription opioids were implemented. The idea that efforts to curb prescription drug misuse have led to a spike in heroin use or overdose has become a common media narrative, but the facts don’t support it. It is the overprescribing of opioids itself that has caused increases in opioid addiction of all kinds, not the efforts to control the prescribing. The transition from prescribed opioids to heroin has been happening since the beginning of the epidemic, and there is no evidence that the interventions brought forth to reduce the overprescribing have been fueling the increase in heroin use or overdoses. Because of the epidemic of opioid addiction, you now have markets for heroin that you didn’t have in the past. So there has been an increase in heroin overdose deaths, but that increase was prior to states’ implementation of Prescription Monitoring Programs or any of the changes from the FDA.”
Obviously, there are regional differences in both the severity of opioid addiction and the tendencies for users of prescribed opioids to switch to heroin. Other factors are also at play, such as the fact that most opioid overdose deaths actually involve a variety of substances, particularly, alcohol and benzodiazapines. Beyond that, since we know that the supply of heroin in the US is high and the cost low, it’s difficult to accurately assess the impact of any particular element or trend on the rate of heroin use and overdose. What is clear is that our problems with opioids, both prescribed pain medications and heroin, continue at full throttle, and more needs to be done. We’ll look at our options in Part II of this series.
Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [email@example.com] Find him on twitter—@richardjuman