All-Time High: Following Doctor's Orders

By Kevin Tustin

(Part 3 in a series about the heroin/opioid epidemic and the lifesaving drug naloxone)

“As a result of the illicit traffic in these drugs (opium and its derivatives) the pharmaceutical profession in the country has lost much of its dignity, and this is fully justified by the facts.” -Dr. Hamilton Wright, March 1911.

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It has been documented that overdoses from opioids kill more people than heroin, and yet it takes nothing more than a doctor’s signature to get them.

Heroin and opioids are both powerful drugs, the latter claiming 44 lives every day due to overdose according to the Centers for Disease Control and Prevention.

The CDC reported in March 2015 that of approximately 44,000 drug-poisoning deaths in 2013, 16,235 involved opioid analgesics, and another 8,257 involved heroin. Over 1,000 deaths involved opioids and heroin.

While heroin may be illegal, opioids are not, yet it’s just as easy to get a dime bag of heroin on the street as it is to rummage through a parent or grandparent’s medicine cabinet to find a prescribed painkiller.

Are doctors merchants of death who with a single stroke of a pen prescribe a legal drug that is killing twice as many people as illegal heroin?

But why is the one that kills more people and administered by medical professionals legal, and the other not?

That is all according to schedules as outlined by the Controlled Substance Act signed into law in 1970.

Heroin is a Schedule I drug, meaning it has a high potential for abuse, has no accepted medical use of treatment in the US, and has “a lack of accepted safety for use of the drug or other substance under medical supervision.”

In short, no doctor has the authority to prescribe these types of drugs. A recent exception to the rules in recent years is marijuana where changes in some state laws regarding recreational/medicinal use of it has relaxed, and/or even decriminalized its usage.

Acid and other hallucinogenics are also listed as Schedule I drugs.

Like Schedule I, Schedule II drugs also have a high potential for abuse, but are deemed to have “currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions”.  Abuse of these drugs may lead to “severe psychological or physical dependence,” according to the CSA.

Schedule II drugs include opium extracts, oxycodone (Percocet), hydrocodone (Vicodin), fentanyl, morphine and methadone, all pain medications.

Doctors have the authority to prescribe these Schedule II drugs, but are they getting too high on the power of prescribing them?

IMS Health’s National Prescription Audit shows that the number of prescriptions for opioids has increased from 76 million in 1991 to a record high of 219 million in 2011. It dropped a bit to 207 million in 2013.

Reports from the International Narcotics Control Board in 2008 say the US accounted for over 99 percent of global consumption of hydrocodone and 83 percent of the world’s consumption of oxycodone.

“Doctors are the reason it’s getting out of hand,” said Dr. Charles O’Brien, founding director of the University of Pennsylvania’s Center for Studies of Addiction, about the heroin and opioid epidemic. “They write prescriptions badly.”

Dr. Patrice Harris, chair-elect of the board for the American Medical Association, did not seem to hold the same view when asked if doctors were the driving force of the epidemic.

“As I’ve gone around, folks are not focused so much on one particular aspect, but really focusing on the complexity of the issue, and the complexity of the solution,” she said during a recent phone interview. “The fact is that it’s not really a ‘one-size-fits-all’ approach that’s going to get us out of this crisis.”

When asked if she knew why the prescription of opioids has increased in the last five years, she said that the numbers differ from state to state and that it is an effective way to treat pain.

Chester County District Attorney Tom Hogan believes this is a problem fueled by doctors and pharmaceutical companies.

“There have been great advances in the treatment of chronic pain, and this class of drug can be used legitimately, and you see these pill mills out there and it is very clear that they are misusing and abusing their authority to prescribe this class of drug,” Hogan said during a June phone interview.

According to a March 2014 article in the Journal of the American Medical Association Internal Medicine tracking frequent sources of opioid pain relievers for non-medicinal year-round use, doctors would eventually become the most direct source of obtaining opioids.

For up to 29 days of use, prescriptions from one or more physicians accounted for 18 percent of a person’s source. By up to 200-365 days of use, the percent went up to 27.3

In other fields, 62 percent of users got it for free from friends or a relative up to the first 29 days of use, while 7.6 percent bought from a friend and 2 percent bought from a dealer or stranger.

Beyond 30 days and up to one year of usage, getting pills for free from friends and relatives dropped to 26.4 percent, while buying from a friend or relative increased to 23.2 percent, and buying from a dealer or stranger more than tripled to 15.2 percent.

 “(Doctors) are fueling this, both heroin and prescription drug abuse epidemic. The only way to stop that is to hit the pharmaceutical companies where it hurts: in their pockets,” Hogan added.

Hogan said the problem in Chester County is the prescription pills, not so much the heroin, saying half-way through the year there were 24 deaths attributed to prescription drug overdoses and four heroin-related deaths.

It was an overdose death in Chester County that pushed Hogan to get some sort of grip on this issue. He would team up with state Sen. Dominic Pileggi, R-9, of Chester, in advocating for Senate Bill 1164, a Pileggi-sponsored bill that allows for police officers to administer naloxone to save the lives of overdose victims.

Pileggi, like Hogan, credits prescription pills with the surge in overdoses in the area in the past five years.

“It’s complicated, but the major causes are the increase use of prescription opioids and people becoming addicted to those alongside the fact that heroin is on the street, readily available and cheap,” said Pileggi during an August phone interview. “That combination has, I think, been the foundation for the increase.”

When the pills get too expensive (up to $1 per milligram), a bag of $5 heroin will give the same high for cheaper.

In a May 2014 senate caucus testimony, Dr. Nora D. Volkow displayed that while hydrocodone and other opioids were the top drug used to get high in participants of a poll from the end of 2009 to the start of 2012, the use of OxyContin decreased while heroin increased.

“The emergence of chemical tolerance toward prescribed opioids, perhaps combined in a smaller number of cases with an increasing difficulty in obtaining these medications illegally, may in some instances explain the transition to abuse of heroin, which is cheaper and in some communities easier to obtain that prescription opioids,” Volkow attested to.

O’Brien admits that some doctors dishonestly sell OxyContin prescriptions, but on the other hand, pain treatment is something doctors don’t know how to do, or they don’t like to.

“A lot of doctors don’t understand how addicting these pain medications are, so someone goes to a dentist to get a wisdom tooth pulled, which, in most cases, you have pain for a couple of days,” said O’Brien. “They give them a month’s supply of OxyContin, which then finds its way on the street and develops a street value.”

Alternatives to opioid pain relievers include aspirin, but even that may not be the best solution either, according to O’Brien.

“If you refuse to give them opioids and you treat them wrongly with non-steroidals, then they run the risk of bleeding,” said O’Brien. “We do have good pain medications, but some of those medications are addicting, and we have doctors worried about using aspirin because that causes about 30,000 deaths a year because of bleeding, but the morphine- type drugs cause addiction. You get in trouble no matter which way you go.”

According to O’Brien, when hospitals are inspected every four years they get a bad mark, but are not documented when prescribing too many opioids, a move O’Brien things should change.

Prescriptions are not the “end-all, be-all” treatment in Harris’ eyes, saying doctors are making decisions on treatments based on the patient and that are evidence-based. She said there is no minimum or maximum number of opioids a doctor can prescribe, and that these types of prescriptions can be denied to a patient if the doctor sees fit.

O’Brien said emphasis on pain treatment has resulted in more opioid medications to be prescribed.

“If you’re a doctor and you have to treat pain and don’t know the signs of addictions, it can be pretty hard.