These two articles examine the problem of pain from two very different viewpoints — one scientific, the other very personal.
First comes a report on the search for a safe, less addictive painkiller. Then a personal account by an American dealing with post-surgical pain in a healthcare system (Germany) that takes a remarkably different approach.
The first piece is definitely worth reading, but it’s clear the story remains a long way from its end:
In that respect, there are no clear winners on the near horizon. For the foreseeable future, we should probably expect drugs already in the pipeline, or well on their way through the process, rather than anticipate the advent of a spectacularly successful newcomer.
The big challenge is the “double whammy” of opioid use. On one hand, you must address the problem of tolerance and dependence. Some research suggests that symptoms of withdrawal can appear with a few weeks of continued use. In practice, that means almost everyone who uses them for certain medical conditions will experience at least some discomfort when they stop. Some people will experience a lot worse than that.
Then there’s the problem of craving, or drug hunger. Opioids create a feeling of euphoria that motivates continued use. In some users, we’ll see the symptoms we ordinarily associate with drug addiction: compulsion, loss of control, and continued use despite adverse consequences. Once these appear, relapse is common, as is profound disruption of one’s life.
Right now, the most common treatment for Opioid Use Disorder (OUD) involves the substitution of a different opioid for heroin. If things go as planned, the patient returns to normal function and simply remains on medication permanently. This is actually an imperfect process and a challenge to manage, but at the moment, appears to be the best we have.
Still, if science’s goal is to develop pain medications that are both effective and prevent new users from the problems described above, it’s necessary to address both aspects. And those may turn out to involve different parts of the brain, and different neurochemical processes.
Will be able to prevent addiction purely by adjusting the neurochemistry of the pain medications we use? I suspect the answer will be no. Addiction is too complex.
So we may be forced to continue relying on the so-called ‘soft stuff’ — therapy, support, lifestyle change, even spiritual growth– to treat people who have developed addictions. Such approaches are slow, outcomes are difficult to measure, and costs run higher than simple medications. But that may be the best option.
The second piece is a humorous, self-deprecating look at one pill-popping American’s struggles with the German healthcare system and the restrictions it places on opioid use.
You can emphathize. First they give her ibuprophen rather than Vicodin? Then they have the gall to warn her against overuse of ibuprofen?
Somehow she survives, to her astonishment. Even thrives. Learning that much of her anxiety, if not most of it, was based on fear of pain rather than pain itself — which, surprisingly enough, she discovered she could handle.
This is an anecdote, not a controlled study. As they say on TV, individual results will vary. Still, wouldn’t it be interesting to see a structured comparison of outcomes from pain control for post-surgical patients, in Germany, here in the US, and perhaps in other developed nations?
Would it come as a total surprise if we discovered that some of what we were doing to solve the problem of pain was actually making things worse?
Is the US Government restarting the War on Drugs? I can’t answer that, but the signs seem ominous.
We’ve all heard about Attorney General Sessions’ dislike for marijuana and contempt for those who use it. That’s no secret. Now we’re seeing changes at the Office of National Drug Control Policy.
I know Kellyanne Conway only from TV, but a quick check portrays her background as “pollster, political consultant, and pundit.” No evidence of training or expertise in dealing with drug epidemics. The article goes on to hint at major budget cuts for ONCDP, the sort that could mean the Office is on the way down– or perhaps, out.
Now we have Jim Carroll, a White House deputy chief of staff, to be nominated as the latest drug czar. Carroll formerly served as general counsel for the Office of Management and Budget.
Apparently both DOJ and HHS are preparing their own separate strategies for next year’s efforts to combat drug abuse. ONDCP was created to replace such separate campaigns with a more uniform strategy. In the past, drug intervention efforts had suffered from the usual bureaucratic snafus: Duplication, political influence, and of course, pork.
Personally, I thought the Christie-led expert panel came up with a reasonably good set of recommendations, and like most people in the field, I was puzzled by lack of follow thru. Now I see those panel members are being “replaced” by politicos. I’m wondering if that was simply because the White House had already decided to go in an entirely different direction– re-emphasizing enforcement and de-emphasizing treatment and recovery. That’s what we saw from the original Reagan-era approach, popularly called the “War on Drugs“.
If you recall, and I bet you do, the focus was on early childhood prevention programs and an aggressive arrest and incarceration policy for drug offenders. Much of this was conceived in the wake of that massive cocaine/ crack epidemic.
Circumstances were different then, of course. Cocaine wasn’t grown in the US so had to be smuggled in. Nowadays in addition to heroin from Mexico and Afghanistan, we also get plenty of prescription opioids via our own pharmaceutical industry. Then there’s the illicitly-made fentanyl that’s driving our current OD fatality crisis. and can be purchased over the Internet without much difficulty. It’s cheap and easy to make and generates a healthy profit margin, both on its own and as a hidden additive for other drugs.
It occurs to me that even if we could completely close the nation’s borders to drug traffic, the incentives are already in place for a quick ramp-up of domestic production. It’s not that difficult and the dealers will be clamoring for it. Money to be made.
About elementary school prevention programs: those are fine for awareness but not terribly effective in reducing later drug use. Whatever impact they have at age 7 or 8 appears to have largely disappeared by 13 or 14, the prime years for experimentation.
Point is, if this type of strategy didn’t succeed 30 years ago, what makes us think it’ll be a success this time around?
See, the thing about drug epidemics is that once you declare war on them, it’s only a matter of time until you begin to realize, reluctantly, that many of the people you’re battling are your children and those of your neighbors. That’s why ultimately, treatment and recovery work better than punishment and deterrence.
A bit more on the situation in Kentucky: I see the current administration is moving to add still more requirements for Medicaid recipients. First they wanted proof of employment or training. Now they aim to require applicants to complete a course in health or perhaps financial management.
I’m sure this all sounds perfectly reasonable to conservative voters, but in practice it usually translates into fewer people getting healthcare, including help for their drug dependence. That’s too bad because Kentucky is one of those states where the opioid epidemic began. The outcome research suggests the state benefited substantially from Medicaid access, and now it seems that the current administration intends to roll that back.
Might be that they fail to grasp exactly how easy it is to discourage people in need from seeking or accepting help. It’s not only stigma that’s the barrier. All that’s necessary to discourage most Americans, rich, poor, or in-between, from getting healthcare is to make it inconvenient or costly. Or both.
If you’re like most of us, you expect a reminder from your doctor or dentist a day before your appointment. It’s extra work for the office staff, but if they don’t make that simple call, chances are many or even most scheduled patients won’t show. Providers learned this the hard way.
It’s because people tend to forget appointments. Or have transportation problems. That’s especially true for poor people. They often miss the bus and arrive late. In a busy clinic, being late is about as bad as missing the appointment altogether. The office still has to pay the staff.
But the most obvious barrier is payment.
A big chunk of the opioid patient population is either indigent or uninsured. Most didn’t begin that way, but drug addiction tends to impoverish people. Many became eligible for healthcare only through the Medicaid expansion in their state. With the new requirements, a significant percentage will simply drop out and return to street drug use. When they contract other diseases related to substance use, like HIV/AIDs, STDs, hepatitis, etc., they’ll put off a visit to the doctor for early treatment. They’ll procrastinate until their illness is advanced, requiring more expensive and extensive care. Mostly likely, when they finally do access medical care, it’ll be through emergency services.
Many politicians who oppose Medicaid expansion worry that it will be abused by fellow citizens who they regard as ‘undeserving’ of healthcare, often because they can’t contribute financially to their care. Such as this from Kentucky’s governor: “Why should a working-age person not be expected to do something in exchange for what they are provided?” The assumption is that it’s somehow the result of laziness or an unwillingness to go to work.
But there’s another common reason for poverty: illness. That’s what opioid addiction is, you know– a chronic illness. Perhaps the Governor doesn’t believe that. Maybe he thinks that someone who’s been strung out on heroin or fentanyl for a number of years should be able to snap out of it based on willpower.
If they could do that, we wouldn’t have called them “addicted” in the first place.
Anyway, making employment or education a prerequisite for healthcare is just another way to reduce the number of folks in treatment for drug problems. Frankly, I can’t help wondering if that’s not been the real goal all along.
We recently learned that the unexpected death of musician Tom Petty last October resulted from an accidental overdose with opioid medications used to treat severe pain related to a broken hip and other problems.
According to news reports, found in his system were:
fentanyl: Now the most widely used synthetic opioid in medicine.
oxycodone: Another opioid used for moderately severe pain. Sold under the trade name Oxycontin, among others.
temazepam: A benzodiazepine sedative, used for sleep, anxiety. Trade names Restoril, etc.
alprazolam: Another benzo; trade names include Xanax
citalopram: An antidepressant. Trade names include Celexa
acetylfentanyl: A “designer” opioid, not currently licensed for medical use. Sold illicitly.
despropionyl fentanyl: Yet another designer opioid.
So we have four opioids– two legal, two likely not– plus two benzos and a popular antidepressant, all present in Petty’s system at time of death. The family asserts that Petty had no history of drug abuse, and the medications were used solely for the treatment of severe orthopedic pain. Some questions that popped up in my mind:
Who wrote all these prescriptions? A single physician, or several?
If multiple prescribers were involved, were they aware of all the medications the patient was taking, and how much and how often?
If the last drugs on the list — the fentanyl analogs — weren’t prescribed, then where did the patient get them? And why? especially in view of the risks.
Why was he using two different benzos at the same time?
What was the purpose of the antidepressant? In view of all the depressant medications he was using, how effective could it have been? SSRIs carry their own risks, after all, especially in combination with the others.
This appears to be a classic case of polypharmacy, or simultaneous use of multiple drugs by a single patient, for one or more problems. The hazards of same are well known. Still, most physicians have been trained in managing cases where multiple meds are involved. So, what went awry in this case?
Hard to believe a celebrity like Tom Petty lacked the resources for top-quality medical care. Presumably, other factors were in play.
Also, did he have control over his own meds? For instance, were they in his medicine cabinet, or stuffed in a drawer next to his bed? Did Petty self-administer his own medications?
When someone’s taking a number of strong drugs on a regular basis, particularly depressants, it’s easy to lose track. Patients miscount, mix up dose times and amounts, or take extra doses or the wrong medication entirely. Any of those factors in play here?
By the way, I believe those two fentanyl analogs have already figured in unintended fatalities. Perhaps they did the job all by themselves. Which brings us back to the question of how they got into the mix. And why.
This incident, like the death of Prince last year, isn’t so much a result of the current opioid epidemic, as it is more evidence of a problem in medical care that began long before I ever entered the field in the ’70’s. The drugs have changed, but the outcome hasn’t. Another unnecessary death.
And in that respect, things remain the same at the top and the bottom of the socioeconomic scale.
This article takes another look at the factors that drive the opioid epidemic, based on the work of Christopher Ruhm, who examines the thesis set forth by economics researchers Deaton and Case, who concluded that the rapid escalation of opioid use and related fatalities was a sign of a community in “despair” from an eroding social structure. Think job loss, declining wages, parental neglect, broken homes, etc. Ruhm tests these assumptions and concludes that although such factors may influence a drug epidemic, they’re not its primary cause. For that, he suggests, we should look once again at the supply side.
It makes sense: Drug epidemics depend on access to drugs, and without sufficient access, not enough people can get hold of the desired substances to foster an epidemic. With cocaine, for instance, the watershed event occurred when traffickers realized you could fit a whole lot more cocaine than marijuana in the hold of a smuggler’s small plane — therefore reaping far greater profits per shipment. At the time, cocaine was primarily a drug of the moneyed classes. The researcher Mark Gold referred it to as a “drug of disposable income” Whatever money you had, cocaine would help you dispose of it. From an economist’s perspective, these privileged folks represent the opposite of unemployed miners in Appalachia. And yet it was the rich folk who drove the epidemic in its early stages.
I suspect the popularity of Deaton and Case’s model reflects a preference in the academic world for certain types of social theories. A friend and lifelong Democrat, who’d served in the substance abuse administrations of three different states, once remarked that addiction treatment often did better under Republican administrations. “We Democrats always get stuck trying to cure poverty,” he groused. His argument: Once addicts got into recovery, they were invariably more successful in their lives. So why not focus our attention on that goal first?
That was his view. Of course, the current White House hasn’t focused on the drug problem, either. Things change, I guess.
With some caveats, I’d agree that when the supply is abundant, tjhe demand for drugs responds favorably. Drugs reinforce their own use. Addiction will be the outcome for a solid minority of those who at least experiment with the drug (well, except for tobacco). Not everyone who tries an addictive substance will develop an addictive disease. And a good thing it is, too.
The second factor in the genesis of addiction is vulnerability. That’s partly genetic, part environmental. One person may progress into addiction quickly, another may get away with regular use for years before losing control. Some will become dependent on the drug but quit voluntarily — motivated by the fear of consequences. Unfortunately, we can’t predict in advance which user will fall into which category. And frankly, neither can they.
That’s why it’s so difficult to intervene early. By the time someone recognizes their own addiction, it’s deeply rooted in every aspect of life.
You might think of addiction in terms of hardware and software. Addictive drugs alter the brain– the hardware, so to speak– but the environment influences the expression of addiction in the individual — the “software”. And when someone goes to ‘unpeel’ this longstanding behavior, they wind up addressing both sides of the equation.
It occurs to me that despite all the debate about nature vs nurture, it’s always both. They vary in importance from person to person. But they’re always present in tandem.
I see the Federal government has allowed states to place work requirements on Medicaid recipients. Kentucky’s the first state to take advantage of the new rules, with others soon to follow. The Governor justified it as follows: “Why should a working-age person not be expected to do something in exchange for what they are provided?”
I can’t help seeing that as a moral and political argument rather than a medical one. And not very practical, either. I wish he’d save it for some future time when we’re no longer in the midst of an opioid epidemic (let’s hope that time comes).
The problem: Requiring proof of employment for indigent people to qualify for healthcare is likely to drive opioid addicts away from help — when the goal should be to attract them to it.
Why? Let’s say you live in a community that’s threatened by escalating opioid use. Actually, there’s a good chance you do. Naturally, you want government to do whatever’s best to minimize the adverse effects of opioid addiction on your community. These are serious and fall into three broad categories:
Overdose— the most attention-getting. I’m referring to both fatal and non-fatal OD. The first is a tragic waste of life, leaving grieving families in its wake. The second is a major drain on limited resources, especially for law enforcement and healthcare.
Drug-related crime— property crime, burglary, theft, home invasion, etc, but also sales and trafficking, gang activity, and violence. It’s the stuff you read about in the headlines.
Community health— HIV/AIDS transmission, sexually transmitted disease, hepatitis, blood borne illnesses. All this represents major new stress on limited healthcare resources. Who pays the bill? We do.
In other words, government must act not just for the benefit of the opioid user, but for the benefit of the larger community. Who among us wants to live and work and raise a family in the midst of a drug epidemic?
Fortunately we know, based on years of experience, that simply enrolling addicts in affordable treatment options is the “low-hanging fruit” of successful intervention. We make it easy for opioid users to get medications that help break the cycle of drug use and minimize relapse. This can be done on an outpatient basis, and it’s waayyy cheaper than a hospital bed or a jail cell. It’s just a far better return on investment for the taxpayer.
In short, we strive to make sure that affordable treatment services are:
Available — we have enough treatment slots to meet the need
Convenient to transportation, and
Financially accessible. We don’t want to turn people away because they can’t pay.
We’re the beneficiaries. Our communities are better places to live, because of what we do to manage the scourge of addiction in an effective, and cost-effective, manner.
Now: If our goal is to get more users into treatment without delay, we shouldn’t place unneeded barriers in their way — such as insisting they maintain employment as a condition of health benefits that allow them to access treatment. We should focus on engaging them in treatment first, knowing that once they are, they might actually be able to get and keep a job.
Frankly, it makes perfect sense to me. But then, I’m not a politician.
Thanks to Senator Mike Lee’s Social Capital Project for the map.
There was a recent opinion piece in the NY Times by David Kessler, a former Director of the Food and Drug Administration. The piece was entitled “How To Fight The Opioid Epidemic“. To summarize, the author’s recommendation is as follows:
“The administration needs to put under one authority all of the programs and funding sources focused on drug abuse now spread among more than a dozen agencies…With current workplace technology, the programs need not relocate. The H.H.S. secretary and the attorney general, along with other cabinet officials, can have input. But they need to be part of a centralized effort commanded by a new cabinet member who will have explicit, unambiguous authority over these programs…”
I was immediately reminded of the origins of our current Department of Homeland Security, in the aftermath of the 9/11 catastrophe. Remember the debate around that? The end result was a massive agency whose core missions are (I’ve included the links for each):
I’ll leave it up to you: How we doin’ so far? Guess the answer depends on who you ask.
So what could we expect from a newly created Cabinet position for, um, Drug Crisis Management? Would a Cabinet Secretary be able to corral the necessary funds from Congress and cooperation from the other Departments and Executive Branch, given the competing interests?
Yeah, I’m not sure either. When it comes to the US Government, there’s a lot I’m not sure of these days. I thought that blue ribbon commission did a pretty good job with its 60 recommendations, but I haven’t seen much subsequent action. Please let me know if I missed something important.
In fact, to be perfectly honest, I haven’t sensed much commitment from government, period. It’s all under the control of one party, so how much attention does the opioid crisis get on Breitbart or Fox News? That’s probably the best indicator of “political will” when it comes to taking on the opioid epidemic– which by this point is really three interrelated problems, involving prescription painkillers, street heroin, and now, fentanyl. Each requires its own strategies.
That’s a heck of a challenge. One that I fear may require more commitment than our government is yet willing to make. In the interim, we’ll just keep doing the best we can with the (very limited) resources at hand.
From time to time someone asks my opinion on which of the commonly abused substances is 1) most addictive, and 2) most harmful. I usually go with the humble cigarette. Tobacco can be ingested in multiple ways, and harm can result from any of them. But the cigarette is truly a marvel of drug delivery– it’s been called a “crack pipe for nicotine.”
When you talk to adolescents about why they first picked up any drug, it’s in the firm belief that “just one time” can’t possibly hurt. The study seems to contradict that. If 7 in 10 go on to some level of daily smoking, that helps explain the extraordinary health consequences that plague us as a society.
There’s really nothing to compare. CDC gives cigarettes credit for more than 480,000 deaths a year, in the US alone. That’s equivalent to the population of Kansas City, Missouri. At 1,300 deaths a day, it’s one-fifth of the national total. Smokers die on average 10 years earlier than nonsmokers.
There’s a big part of our health costs right there.
Much of this is attributed to the advent of the commercially manufactured cigarette. It was the engine behind the lung cancer epidemic. Prior to its introduction, doctors rarely saw a lung cancer case.
As the popularity of smoking grew, the marketplace was flooded with cheap products in lurid packaging. By the 1930’s, many ads touted cigarettes as an aid to good health and sports performance. Golfers like Ben Hogan, baseball players such as Babe Ruth and Stan Musial, and footballers like Frank Gifford all served as cigarette pitchmen. Ultimately, though, it was doctors themselves who showed up to make claims on behalf of the coffin nails. It makes for an interesting read.
In the end, this is just raw capitalism at work. The more successful a product, the more competition it draws, and the greater the temptation for the seller to boost sales with unsubstantiated or even purely imaginary claims of health benefits. That forces real experts to devote valuable time and money to refuting them.
It’s ironic that the two drugs (alcohol and tobacco) that produce the most severe health consequences are the ones our society makes legal, and therefore widely available to the public. No, that doesn’t make a lot of sense. Still, it appears as if opioids, particularly in the form of fentanyl et al, are racing hard to catch up.
Of course, some of it is simple exploitation by unscrupulous executives, like Martin Shkreli. Then there are unjustifiable price increases for devices like the EpiPen.
As I’ve said before, we really can’t be shocked when a profit-driven organization, especially the investor-owned sort, aggressively takes advantage of an opportunity to boost the bottom line. They’re in business to make money. When the need for profits dovetails with the best interests of the consumer, everything’s great. But when they diverge– well, you get one guess whose needs are likely to take precedence.
Then there’s the impact of the fast-rising pharmacy benefit management industry. This is a second set of for-profit businesses that take their own cut out of the price of a drug. And after the insurance company gets its discount, Big Pharma complains that some 30% of the final cost winds up in the hands of intermediaries such as these. Drug companies are then forced to raise their prices in order to meet their own financial expectations.
Don’t forget this is people’s health we’re talking about. I’m not always sure everyone remembers that. As a former insurance VP once said: we spend our day looking at spreadsheets, not people. You can lose sight of the impact of your decisions on your customers.
Anyway, every article I’ve seen on this subject has mentioned two changes to current practices that would yield quick positive results in terms of drug prices. They are:
Import drugs from other countries where they can be had at a substantially lower price. Given our extravagant pricing structure, that’s almost any other country. The savings could be passed on to the consumer, while maintaining a respectable profit margin.
Allow the US government to negotiate better prices for its purchases. This seems like a no-brainer. Right now, for example, Medicare is prohibited from such negotiation — meaning the price is effectively set by the seller, and not surprisingly, it’s often a lot higher than in other places. It’s like a homeowner who could force a buyer to pay whatever he happened to think his house was worth.
Almost every expert has expressed support for at least one of these changes. But there’s been enough opposition– all that lobbying by Big Pharma plays a role– to keep both in a state of suspended animation.
It’s certainly drawing attention now, from public health types. The liquor industry has long claimed that reduced taxes on their products will not lead to increased consumption. Public health experts, citing research, insist that it will.
Originally, the tax cut for alcohol was advertised as an aid to growth for small craft businesses. But it turns out that the cuts will also apply to the giant industry players. In real dollars, “Big Alcohol” will get by far the largest benefit, simply because they’re so darn big.
It’s the same criticism made of the recent bill as a whole– the greatest benefit will go to those who arguably need it least.
About that research: Scientific literature does seem to provide strong support for the notion that any significant reduction in price will likely lead to a corresponding increase in drinking. I wonder if that means expanded consumption among so-called “edge” groups: Lower income people, or younger drinkers, or seniors and others on a fixed income. People for whom the cost of alcohol is a major limit on consumption.
To allay this concern, the industry says the price of alcohol may not fall much, if at all. In their version, makers and sellers maintain the current price and simply invest the extra money they get in their business, particularly hiring more Americans. I suppose that will happen in some cases, but maybe not for the really large players.
Big Business operates on a different model. As the current CEO of Wells Fargo put it, to CNN: “… our expectation should be that we will continue to increase our dividend and our share buybacks next year and the year after that and the year after that.”
Sounds like more money for shareholders and salary and bonuses for execs. Can’t blame them, can we? These folks work for their investors. But it’s not a way to create new jobs in the good old US of A.
Something to consider: Average consumption is skewed towards either end of a continuum.
The 10% of Americans who qualify as heaviest drinkers consume an estimated 74 drinks a week, or 10-11 per day. On average. No doubt some weeks they consume less, and other weeks a whole lot more. The next 10% average 15 drinks a week, a big drop, but still an important segment to anyone who is marketing alcohol.
At the opposite end, however, are the 30% of Americans who don’t drink. Their motives include religious and cultural beliefs, medical problems, psychological issues, and of course, recovery from addiction. To a marketing exec at a big distiller, these folks are like people who pay off their credit cards every month– “deadbeats”, because they produce no revenue for the alcoholic beverage industry.
This brings me back to those “edge” consumers, less affluent and younger customers. Increasing their consumption is one way for the industry to expand its customer base. Of course, those users have fewer resources to pay for healthcare and legal problems that often result from more drinking. So who picks up the tab? The taxpayers, say the experts.
Think back to the appearance of crack in the mid-80’s. Its low price helped attract a whole new demographic to cocaine use.
Well, the bill’s already passed, so in that sense it’s too late. Still, some experts urge states to take their own steps to offset problems before they materialize. Raise the State tax, for example, or restrict sales to fewer locations. I imagine any such moves would bring quick negative response from the alcohol industry.
As far as they’re concerned, that’s their money now.
(Visited 16 times, 16 visits today)
Read Full Article
Read for later
Articles marked as Favorite are saved for later viewing.
Scroll to Top
Separate tags by commas
To access this feature, please upgrade your account.