‘Killing with kindness’ – where are prescription opioids coming from?

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Prescription opioids provide relief for millions in chronic pain. They're also the leading killer in the current epidemic.
Prescription opioids provide relief for millions in chronic pain. They’re also the leading killer in the current epidemic.

Author’s note: This series has explored questions about the opioid epidemic in Wilmington. It has focused on the basics: what are opioids, who are the people using them? Some questions remain: what is at the root of epidemic? Why is this epidemic hitting our area so hard – harder than nearly anywhere else in the nation? What can we do?

Those questions won’t have easy answers. But the picture will be clearer for those who understand the current efforts to address the epidemic. Again, a complicated picture emerges. Every group involved agrees our area is facing a crisis without parallel. Not everyone agrees on what to do about it.

This part of our series will show you the crisis through the eyes of the people fighting it. These are the many front lines against the opioid epidemic. By knowing where these groups stand now, we hope to provide a better sense of where the fight can go next.

Part VII – The opioid supply: from cartels and gangs to family and friends

The issues surrounding prescription drug abuse are related to the issues from illegal heroin. Dealing with heroin means expanding the reach of law enforcement across international boundaries, far beyond the Cape Fear region; it amounts to a worldwide operation against production in Afghanistan and South America, cartel syndicates in northern Mexico and organized crime along the eastern seaboard (more on this to come, in our conversations with law enforcement).

The supplying of prescription opioids is, by comparison, a much more local and intimate affair – which in some ways makes it more complicated.

The dilemma of chronic pain

Many of the 100 million Americans dealing with chronic pain are prescribed opioids. Doctors are legislators are struggling to balance relieving their pain with increasing rates of addiction.
Many of the 100 million Americans dealing with chronic pain are prescribed opioids. Doctors are legislators are struggling to balance relieving their pain with increasing rates of addiction.

There are over 100 million Americans, about one-third of the population, dealing with chronic pain, according to the National Academies Institute of Medicine. The percentages are even higher for the elderly.

Those in chronic pain face conditions like rheumatoid arthritis, post-stroke or post-surgical pain and cancer; their pain is debilitating and relentless.

Many suffering these conditions are prescribed opioid painkillers. A 2016 study in the New England Journal of Medicine notes everyone who uses them will become physically dependent. Not everyone who uses them will become addicted.

According to a the study, the “repeated administration of any opioid almost inevitably results in the development of tolerance and physical dependence … In contrast, addiction will occur in only a small percentage of patients exposed to opioids.”

Dr. Ann Quinlan-Colwell, Ph.D., a clinical nurse specialist in pain management at New Hanover Regional Medical Center, explains:

“Addiction takes place above the eyebrows,” Quinlan-Colwell said. “We’re talking about behavioral changes, craving for opioids even when they’re harmful. With dependence, we’re talking about biochemical changes. The body depends on the drug, and the withdrawal symptoms experiences when the drug is absent can be very unpleasant, but it’s not the same as addiction, which only happens in a small percentage of patients.”

Many people can potentially use opioids for weeks – or months, or years – without becoming addicted. About a third to half of the patients Quinlan-Colwell is consulted on are in chronic pain, but she said simply prescribing opioids, what she calls “mono-modal use” is not the answer.

“Opioids aren’t the only treatment for pain and they’re not necessarily the best,” Quinlan-Colwell said. “But they are the most common. What we need is multi-modal treatment. That means opioids, if necessary, are fine. But they’re part of a broader treatment including non-opioid analgesics, physical therapy and distraction methods like meditation or art therapy.”

Quinlan-Colwell said that “mono-modal” opioid prescriptions are common because they are inexpensive compared to more involved combinations of medication and therapy. “The challenge,” Quinlan-Colwell said, “is that some patients don’t have access to those services, or their insurance won’t cover it.”

Lack of pain-management education in medical and nursing school is also an issue, Quinlan-Colwell said. The field is a relatively new specialization.

“If you went to school ten years ago, you might have had an hour on it,” she said. “It’s getting better, but we still need more education.”

Quinlan-Colwell said that the “pendulum” of treating pain had swung too far towards prescribing opioids, but there have been efforts to correct this in the medical community. Based on the clinical evidence review, long-term opioid use for chronic pain is associated with serious risks including increased risk for opioid use disorder, overdose, myocardial infarction, and motor vehicle injury. That’s according to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

But even for those patients who do maintain long-term opioid treatment for pain, Quinlan-Colwell said it was “pain management,” not pain killing.

“I like to ask my patients to think in terms of real world goals,” Quinlan-Colwell said. “If a patient wants to be able to walk to the mailbox everyday, or make dinner every night, that’s an achievable goal. There are expectations, though, that are unrealistic. Patients come into hospitals, not just here but all over the world, and they expect to leave their pain in the operating room. We’re going to be able to manage their pain, but the idea that we’ll eliminate pain in not accurate.”

At the national level, 80% of heroin users reported their first opioid use was a prescription, according to the National Institute on Drug Addiction. (Photo Benjamin Schachtman)
At the national level, 80 percent of heroin users reported their first opioid use was a prescription, according to the National Institute on Drug Addiction. (Photo Benjamin Schachtman)

This is part of the risk-benefit management of opioids. Under the care of one specialist who can control dosages, and with a patient who can live with the bargain of pain-management – which also means living with some pain – opioids can treat chronic pain.

But that’s not always the case.

The CDC estimates more than 250 million opioid prescriptions were written last year. Even a “small percentage” of that has created a generation suffering with addiction. (A recent article in the Neuron journal of neurobiology cites rates between 2 percent and 6 percent of long-term opioid treatments result in addiction, which would be between 2 and 6 million people becoming addiction after being treated for chronic pain).

Some of them turn to street heroin, but some people continue to acquire legally prescribed drugs.

Killing with kindness

More than half of the people who are killed by prescription drugs acquire them illegally, but only a small percentage stole them or bought them on the black market – less than 5 percent for either, according to the CDC. The majority of prescription drugs abused, or “diverted” from proper use, were acquired free from family and friends.

“You cannot have people self-medicating, even out of kindness. You’re killing with kindness.” — District Attorney Ben David

According to the New England Journal of Medicine, “The most common form of diversion is the transfer of opioid analgesics by patients who have received legitimately prescribed opioids to family members or friends who are usually trying to self-medicate.”

Data from the Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/wp-content/uploads/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf
Data from the CDC and the Substance Abuse and Mental Health Services Administration. (https://www.samhsa.gov/data/sites/default/wp-content/uploads/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf)

It seems difficult to believe that an epidemic of such tragic scope could have anything to do with what must seem, at the individual level, to be a harmless act of kindness – giving a painkiller to a loved one in pain. But that is exactly what the data indicates.

District Attorney Ben David said, “these are powerful, dangerous medications. You cannot have people self-medicating, even out of kindness. You’re killing with kindness. That’s the reason we’ve worked on our pill take-back efforts. We set up fixed take-back sites at the correctional facility and the courthouse. And, across the river, Brunswick county leads the state in recovery of unused prescriptions.”

By cross-referencing toxicology data from overdose deaths with state prescription records, the North Carolina Public Health Department was able to determine that the fatalities from prescription drug use was split nearly in two: half of the fatalities came from patients with no prescriptions, but half came from those with recent, legal prescriptions.

For those that acquired their prescriptions legally, the issue becomes cloudier. There are on the one hand the so-called “pill mills,” like the one the North Carolina State Bureau of Investigation (SBI) alleged was being run in Greenville, North Carolina, after arresting a doctor in a raid last week. On the other hand, there are also doctors who haven’t had the proper education on the power and risks of opioids, according to Jean Fisher Brinkley, spokeswoman for the North Carolina Medical Board.

According to Brinkley, new measures allow the board to work with the SBI to investigate all of these issues. The Safe Opioid Prescribing Initiative, launched in April of 206, marks a sea-change for the NCMB (read more info about the initiative here).

“Until now, we’ve been a complaint driven agency,” Brinkley said. “We could only react when something went wrong, if there was an overdose, or if someone contacted us to say, ‘hey, this doctor is handing out pills like candy.’ ”

The board’s new initiative allows active investigations of treating the largest number of patients and prescribing the highest doses or strongest types of opioids. Brinkley said that some of the cases, like those in Greenville, were “egregious,” where “very little medical practice was actually going on,” but that in general, overprescribing had come from “practitioners that didn’t have the information or the training to handle pain management or to look for the signs of abuse or addiction.”

Brinkley said nearly half the cases investigated by the new initiative were pain management practitioners.

“These are doctors dealing with people in serious pain. They had the best intentions.”

Next: conversations with local and state government leaders about addressing the opioid epidemic from both the supply and demand sides.

[cp_messagebox align=”left” color=”#ffffff” shade=”noshade” border=”#000000″ font_color=”#000000″]Heroin or Hydrocodone? Opiates or opioids? The conversation about this epidemic is often peppered with technical terms and names. Check out our appendix of terms.[/cp_messagebox]

Part I – The epidemic, by the numbers

Part II – Opioids: from heroin to prescription pills to and ‘psycho synthetics’

Part III – The many changing faces of opioid addiction

Part IV – Mental health and opioid abuse

Part V – The power and potential risk of harm reduction

Part VI – Opioid demand, the fear of detox and the path to treatment

Opioids: An appendix for readers

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