Too Many Painkillers?

Written by Geoff Kane, MD, MPH. Posted on
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United States data for 2009 showed that more individuals died from unintentional drug overdoses (37,485) than from motor vehicle crashes (36,284). These casualties included individuals with histories of extensive drug use as well as drug-naïve experimenters, partly because overdoses are often “mixed,” and anyone consuming a combination of sedating substances, such as alcohol plus medications originally prescribed for pain, sleep, or anxiety, can’t predict their maximum effect or the timing of it. The rise in overdose deaths is linked to increases in availability and misuse of prescription opioid pain medications (such as oxycodone, hydrocodone, morphine, and methadone), which caused more overdose deaths than heroin and cocaine combined.

Prescription opioids became more available because societal expectations of physicians and other practitioners altered opioid prescribing patterns. In the past, medicines such as morphine were used sparingly, mostly for treatment of brief pain, like after major surgery. Opioids were also used to relieve pain at the end of life, especially pain from cancer. In the 1990s, however, society became aware of a vast number of people suffering physical, emotional, and occupational consequences from chronic pain—pain not due to cancer or terminal illness but caused by, for example, degenerative, neurologic, or inflammatory diseases. Opioid prescriptions increased, particularly after research showed that the risk of causing addiction was low when opioids were used to treat chronic non-malignant pain. But those research designs had to exclude any subjects with an existing addiction in order to see who might become addicted. Prescribers whose real-life practices exclude patients with addictive illnesses are rare to nonexistent! The message to opioid prescribers should have been: the risk of triggering addiction is low as long as you carefully establish your patient does not already have addiction or a strong risk for it.

Plus, in 1995, Purdue Fredrick (now Purdue Pharma) introduced OxyContin, a time-release formulation of oxycodone. The manufacturer promoted the new medicine to prescribers and consumers as a safe means for individuals with chronic pain to regain lost function. This increased the expectations on prescribers. OxyContin prescriptions became common, greatly adding to opioid availability.

Despite the increase in prescriptions for opioid pain medicines, a vast number of people still suffer with untreated chronic pain. Where, then, do all the pills go? Many are diverted to recreational or dependent drug users whose misuse of opioids is evidenced not only by the dramatic rise in overdose deaths but also by dramatic rises in emergency room visits related to opioid effects and in addiction treatment program admissions for opioid dependence. These costly problems emerged because the extensive availability of opioid pills coexists with a permissive attitude toward using them. Many citizens, especially youth, mistakenly believe it is cool and safe to consume these mood-changing controlled substances. No matter that they were prescribed for someone else.

Future installments of the NCADD Addiction Medicine Update will address a variety of topics including ways that individuals and communities can reduce the supply of prescription opioids and reduce the demand for their illicit use.

For more information, go to prescription drugs.  Detailed background on OxyContin can be found in the book by New York Timescorrespondent Barry Meier:  Pain KIller:  A “Wonder” Drug’s Trail of Addiction and Death, New York, Rodale, Inc. 2003.