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Published On May 21, 2015

POLICY

The Epidemic That Medicine Made

The misuse of opioid painkillers has become a major health crisis. How can the tide be turned?

As a high school senior in Arlington, Mass., Michael Duggan had a lot to look forward to. He was an athlete and a good student, near the top of his class. Then he broke his wrist during a hockey game and landed in surgery, which resulted in a prescription for the painkiller oxycodone. “I loved the high it produced immediately,” Duggan says. The young athlete continued popping the painkillers for fun with his friends on weekends. Within three years, he was also shooting heroin. While oxycodone remained his drug of choice, the street opiate offered a cheaper path to a similar high. Duggan’s descent into opiate addiction would eventually leave him destitute, homeless and near death on more than one occasion.

More than 15 million people report using prescription drugs for nonmedical reasons, according to the Substance Abuse and Mental Health Services Administration. Like Duggan, many were introduced to them at a physician’s office or in the hospital.

The 2013 National Survey on Drug Use and Health reports that more than 2 million Americans are now hooked on opioids—including oxycodone, hydrocodone, morphine and codeine—and related drugs. This is more than four times the population that is addicted to heroin.

Death rates from overdose of prescription opioids have quadrupled in the United States since 1999, contributing significantly to drug overdose becoming the leading cause of death by injury for several years running. More than 400,000 Americans end up in the emergency room every year as a result of misusing prescription opioids.

Hospitals exist to heal patients. A culture of widespread opioid abuse, with roots in drugs that physicians have prescribed, has flipped that notion on its head. Some are calling the abuse of prescription drugs “pharmageddon,” a drug epidemic that costs lives and drives up crime, undermining a paradigm of proper pain management and adding as much as $200 billion to health costs annually.

To begin to address this epidemic, the medical community first must acknowledge its own crucial role in it. In 2013, physicians wrote 230 million prescriptions for opioids. This would be enough to medicate every American adult continuously for one month, according to the U.S. Centers for Disease Control and Prevention.

And that’s 10 times as many painkillers as were prescribed in 1990, a time during which the medical profession was criticized for undertreating pain and opioids were generally reserved for terminally ill patients. Part of the change has arguably been a corrective trend toward compassionate treatment of painful conditions.

But the past two and a half decades have also seen the advent of blockbuster painkillers such as OxyContin, an extended-release formulation of oxycodone. “A big part of this upswing also was due to aggressive marketing by drugmakers and other advocates,” says Andrew Kolodny, M.D., a psychiatrist and medical director of Phoenix House, the nation’s leading nonprofit provider of substance abuse treatment and prevention services. The history of addiction involving laudanum and other opioid painkillers—America’s first epidemic of opioid addiction occurred in the second half of the nineteenth century—may have worried many physicians considering this new crop of drugs. But there was a feeling that they would be different.

Law enforcement and other government agencies are exploring new approaches to prevention and treatment as well as controlling the drug supply. Health care professionals, too, must play a role in each of these areas. And the solution may mean a revision of assumptions about drug dependency treatment and prevention. One reason the opioid epidemic has caught both the medical profession and the general public by surprise is the profile of its victims. “This is mostly a young, white, middle class and suburban problem,” says John Kelly, Ph.D., an associate professor of psychiatry at Harvard Medical School and the founder and director of the Recovery Research Institute at Massachusetts General Hospital. Many users, including Duggan, started with a legitimate pain prescription.

And once users become addicted, treatment is notoriously difficult. A growing body of research is demonstrating just how addictive prescription opioids are, in part because they affect the same pain receptors in the brain as heroin. Using opioids results in euphoric highs initially. The brain soon adapts, however, and a shift occurs from using the drug to feel good to needing to use the drug to avoid feeling bad. Once dependence has occurred, withdrawal is extremely painful. “People still don’t understand that opioid addiction is a chronic, recurrent disease that often progresses if it’s not treated,” says Sarah Wakeman, M.D., the medical director of substance use disorders at MGH’s Center for Community Health Improvement.

Duggan is one of the lucky ones. He sought treatment, and despite several relapses, he beat his addiction. He is now married and a father, and the founder of an addiction recovery service called Wicked Sober. But many others aren’t getting the help they need. “We have an addiction treatment system that hasn’t caught up to the problem, and the federal government isn’t investing enough funding into finding solutions,” says Kolodny of Phoenix House, which has waiting lists for beds in the hardest-hit regions of the country. “There’s so much more that needs to be done.”