The Truth About America's Oxy Epidemic
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Egged on by the nation's media, The Obama administration seems keen to start a full-fledged national panic over prescription painkillers. In April, the nation’s drug czar, flanked by the heads of the DEA and FDA, announced a major new law-enforcement initiative at a much-discussed press conference where he designated the widespread use of prescription painkillers like OxyContin an “epidemic” and a “crisis” comparable to crack in the ’80s and heroin in the ’70s.
But while it's true that prescription drug abuse has increased by 20 percent since 2002, with some 28,000 deaths by OD in 2007 alone, the roots of the painkiller problem are widely misunderstood. For the most part, opioid addicts are seen as victims of greedy doctors and profiteering pharmaceutical companies. In reality, however, most painkiller addictions don’t start in doctors’ offices, and it’s actually impossible to become addicted “by accident.”
So why does the media insist on blaming physicians and Big Pharma? For one thing, because greedy pharmaceutical companies and unscrupulous physicians have been responsible for a lot of bad things things. But the persistent myths that pervade the coverage of this epidemic pervade because real-world addiction doesn’t always fit into the neat narratives preferred by journalists and politicians.
1. Most Painkiller Addicts Were Never Pain Patients.
Reporters love to tell the story of the poor pain patient who got hooked on Oxys because he just couldn’t stop taking them after an accident or surgery. This tear-jerker is catnip to liberals who view the pharmaceutical industry as dedicated to exploiting innocent patients by bribing their doctors to overprescribe their expensive (but potentially addictive and dangerous) brand-name drugs. And since drug companies so often live down to their bad image, it’s easy to overlook cases that are not so black-and-white.
To make matters worse, this storyline is also beloved by addicts seeking to elude responsibility: “It’s not my fault! And it was an accident! My doctor and Big Pharma did it to me!”
But as one Florida newspaper found out to its embarrassment, the “accidental addict” narrative is rarely the full story. The man they’d featured under that headline as a doctor’s victim didn’t begin his life of crime because of pain treatment—he had a prior cocaine-dealing conviction.
However unwittingly, the Orlando Sentinel had indeed chosen a representative opioid addict: like their former coke dealer, the vast majority of people addicted to prescription painkillers were addicts before they ever “asked their doctor”—as pharma’s TV drug ads suggest—about OxyContin.
One study of some 28,000 found that 78% of people in treatment for Oxy addiction had never—not once—received a legitimate prescription for the drug!
And 80% of OxyContin addicts, according to research by the National Institute on Drug Abuse, have also taken cocaine. By contrast, in the general population over age 12, just 15% have even tried coke.
Unless you want to believe that pain patients are so delighted by their medical Oxy buzz that they went out and found themselves cocaine dealers, a more parsimonious explanation is that people with pre-existing addictions sought doctors to get opioids. It wasn’t the doctor or pharma that done it.
2. Most pain patients given opioids for chronic pain never become addicted.
I’ve written here before about the distinctions between physical dependence and addiction—put simply, people who are physically dependent on certain substance have a physical need for those substances to function normally, while addiction is compulsive use despite negative consequences.
People who take opioids daily for a month or more will inevitably develop physical dependence. But contrary to conventional wisdom, dependence has little to do with addiction, which is almost exclusively driven by a person’s psychological relationship with the drug. This is why, for example, although some blood pressure medications can cause potentially deadly withdrawal symptoms, no one robs their grandmother to get more of them.
People who are dependent on—rather than addicted to—painkillers can easily get relief by tapering off the drug. Indeed, many pain patients go through withdrawal without even realizing that that’s what’s causing their “flu.” If you aren’t psychologically attached to the drug, kicking opioids is not the gothic ordeal portrayed in so many movies.
In fact, the first time I quit heroin I was surprised at how mild the withdrawal was, given what I’d heard about its horrors. Actually, it was so easy that I picked up again a few weeks later—long after my not-especially-dire symptoms had disappeared! It was that kind of logic—and repeatedly making those kinds of choices—that made me not only physically dependent but an addict.
My addiction was a result of my own decisions; it wasn’t something that mysteriously “happened” to me because I chanced to use heroin. I may have had impaired control over the later choices I made, but it was nonetheless I—not a dealer or a doctor—who made those decisions for me.
Studies regularly show that the odds that a person with no prior history of addiction will become hooked on prescription opiates are incredibly small, rarely reaching even 3%. In a recent study of some 5,000 pain patients who took prescription opioids for more than six months, a mere 0.27% showed any signs of addiction. Former addicts, of course, have greater odds, but most can be safely treated with opioids if there is no alternative to relieve their pain. The drugs by themselves do not inevitably trigger a relapse or wreak havoc with recovery.
And if they don’t make repeated choices to abuse the drugs by upping the dose or frequency, or popping them recreationally, people can’t “accidentally” slip, as if on a banana peel, into addiction.
To an opioid aficionado like me, it comes as a shock that most people actually don’t like the feeling they get from these drugs: research on normal volunteers who aren’t in pain finds that they typically don’t enjoy the experience. And about one third of subjects in clinical trials and other research on opioid use for chronic pain actually drop out due to side effects—a fact that doesn’t exactly square with the popular view that the drugs are irresistible or instantly addictive. There's no doubt that addiction to opiates is growing. But in the larger scheme of things, opioid addiction is relatively rare. Oxycontin is not an unconquerable demon that destroys in its path. People who are addicted to Oxy are generally pre-disposed to other addictive behaviors. But if we continue to try to fight the problem by ignoring this fact, we'll end up hurting pain patients who really need the drug, while doing little to help Oxy addicts.
3. Even physically dependent soldiers mostly don’t become lifelong addicts.
During the Vietnam War, Department of Defense officials were shocked when they learned how many U.S. soldiers had become physically hooked on heroin and opium while serving. But just as shockingly, they discovered that the vast majority did not become re-addicted when they returned home. To those raised on heart-rending images of homeless junkie vets panhandling on the streets of America, this fact may be hard to believe. What’s generally ignored but genuinely surprising is the very high proportion of combat vets who used heroin during their tour.
A study of nearly 900 returned vets conducted Dr. Lee Robins, a sociologist and psychiatrist at Washington University in St. Louis, found that a full 50% of U.S. soldiers tried opium or heroin in Vietnam—and 20% of those who tried these opioids under the highly stressful conditions of war±took them to the point of becoming physically dependent.
But stunningly, just 1% continued to use to the point of addiction after they returned home, even though a few did take heroin once or twice in America. Though they used opioids recreationally under high stress circumstances at a period in life when addiction risk is highest (late adolescence and young adulthood), an overwhelming majority of the soldiers did not become lifelong addicts.
The same will likely be true of our Afghanistan and Iraq war vets—though the repeated tours of duty they undergo could increase their long-term addiction risk.
So what does all this mean for the “painkiller epidemic”? The good news is that opioid addiction is relatively rare, even when large numbers of people are exposed to these drugs. The bad news is that we continue to try to fight the problem by ignoring this fact. Virtually all of the Obama administration’s major news initiatives are focused on “educating” doctors and tracking their patients and prescribing. But given that most addicts aren’t patients—and most patients aren’t addictd—this makes little practical sense.
If we want to develop drug policies that work, we need to base them on what addiction is really like, not on the stereotypes the media presents or on stories told by addicts who are spotlighted because they represent those stereotypes. The media also needs to stop exaggerating the size of the problem to make the story seem more important.
Next, we need to find out what makes people who get hooked different--what makes some people compulsively use certain drugs despite the damage they know they will inflict on their lives? Trying to prevent opioid addiction by eliminating access will never work because the very people who are most dedicated to obtaining drugs are the least deterred by making them harder to get. We need to make maintenance options available to those who need them and provide treatment referrals—not expulsion from care—when doctors discover misuse.
Otherwise, we’ll wind up following the same misguided policies used to “fight” crack—with the same harmful and ineffective results.
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