Dopesick - The opioid crisis in the USA

[ME/CFS Skeptic]

Just watched the fictional TV-show 'Dopesick' and the HBO-documentary 'The Crime of the Century'. Both are about the opioid crisis in the US.

They tell the story of how in the 1990s a pharmaceutical company 'Purdue Pharma' started marketing their opoid painkiller OxyContin to regular pain patients instead of the cancer patients with extreme pain it was originally intended for. They lobbied the FDA (one of the regulators later started working for Purdue) to include statements on the label suggesting the drug was less addictive than other opoids because it was coated. There were no studies to back this up but Purdue used an aggressive marketing campaign with misleading charts to convince doctors that OxyContin was not addictive and that it could be prescribed long-term for all sorts of pain.

When patients did become addicted they invented theories and hired experts that always had 'increase the dose' as the solution. If patients kept complaining about pain, they were said to have 'breakthrough pain' so they would need a higher dose. When patients (and doctors) became addicted it was said to be 'pseudo-addiction': they longed for the the meds because they were still in pain, not because they were addicted. They had an unrecognised pain and doctors had to prescribe more.

Unsurprisingly, blame was shifted to patients: the drug was safe, the abusers were the problem. If you became addicted, then this was not because of the drug but because of you, your addictive personality etc. You would probably have become addicted to something else if it was not OxyContin etc.

In another documentary I watched about this topic, there was a mother who explained during a protest: "They caused me, believing what the doctors said, to be an accomplice to my son's death. When my son talked about his pain, I said: 'did you take your pills?'"

I might not have a completed overview on the problem, but the story touched me. It shows how the medical system can be corrupted and although very different, I saw some similarities to how poorly ME/CFS patients have been treated.

 

[Shadrach Loom]

I just finished, and would highly recommend, Demon Copperhead, Barbara Kingsolver’s retelling of David Copperfield, which is set in the opiate-blighted former mining communities of West Virginia. A Purdue rep has a small villainous role.

It’s astonishing what US pharma companies can get away with.

 

[JemPD]

I just finished, and would highly recommend, Demon Copperhead, Barbara Kingsolver’s retelling of David Copperfield, which is set in the opiate-blighted former mining communities of West Virginia. A Purdue rep has a small villainous role.

It’s astonishing what US pharma companies can get away with.

ooo i LOVE Barbara Kingsolver! I'd like to try that book but i struggle with certain types of violence and because i have to have audiobook instead of reading its harder to control what you hear.
Do you recall if it has any interpersonal violence in it Shadrach? Particularly sexual violence, stalking, stabbings etc.

With regards the movie... thanks for that review @ME/CFS Skeptic i will check it out sounds interesting.

My only awareness of the opioid crisis is from tv/film etc - eg New Amsterdam, Greys Anatomy, Four Good Days

And... of the reaction to it seeming to drive/influence/involve itself in the revision of guidelines for chronic pain, with fear of it happening here leading to people having the meds they rely on removed in favour of mindfulness etc.

 

[Shadrach Loom]

ooo i LOVE Barbara Kingsolver! I'd like to try that book but i struggle with certain types of violence and because i have to have audiobook instead of reading its harder to control what you hear.
Do you recall if it has any interpersonal violence in it Shadrach? Particularly sexual violence, stalking, stabbings etc.

With regards the movie... thanks for that review @ME/CFS Skeptic i will check it out sounds interesting.

My only awareness of the opioid crisis is from tv/film etc - eg New Amsterdam, Greys Anatomy, Four Good Days

And... of the reaction to it seeming to drive/influence/involve itself in the revision of guidelines for chronic pain, with fear of it happening here leading to people having the meds they rely on removed in favour of mindfulness etc.

There are a couple of lurid deaths and some casual brutality, sexual violence does feature, but is implied rather than being described in detail. The narration is male first person throughout, and Copperhead is as decent a chap as Copperfield, which hopefully reduces the chances of any scenes being too triggering.

 

[Dolphin]

My only awareness of the opioid crisis is from tv/film etc - eg New Amsterdam, Greys Anatomy, Four Good Days

And... of the reaction to it seeming to drive/influence/involve itself in the revision of guidelines for chronic pain, with fear of it happening here leading to people having the meds they rely on removed in favour of mindfulness etc.

I don’t have much in-depth knowledge but my understanding is opioids are much more widely used in the US health system than in the UK or many other western countries. I think I saw a figure of the usage in the UK being something like 2% of the US (adjusted to population sizes)? And the wide use in the US causes a lot of problems. So I don’t think the people who want less use of opioids in the US are necessarily the “bad guys” or some sort of extremists.

 

[Dolphin]

An example I vaguely recall: after a dental procedure, someone in the UK or similar country would get prescribed one or two opioid tablets. While someone in the US might be prescribed one or two weeks of tablets, by which time they could have a level of addiction.

 

[perchance dreamer]

I was offered hydrocodone over and over for pain when I started developing fibromyalgia. It and other opioids just made me feel terrible in the head and didn't help much with pain. Constipation was really difficult to deal with, too. I'm glad they didn't work because I knew people who had maintenance prescriptions for them and had real problems getting off the drugs.

In the U.S., the pharmaceutical lobby has a huge effect on politicians and the judicial system, making it really hard to get reforms.

 

[JemPD]

So I don’t think the people who want less use of opioids in the US are necessarily the “bad guys” or some sort of extremists.

No no i'm sure they're not, i realise its a genuine problem. A massive, tragic and horrifying problem.
I just meant that the recently revised NICE guideline for chronic pain, may have been a pendulum swing too far in the direction away from prescribing opioids (in the UK), and as i understand it, has caused a lot of chronic pain sufferers problems.

 

[Dolphin]

No no i'm sure they're not, i realise its a genuine problem. A massive, tragic and horrifying problem.
I just meant that the recently revised NICE guideline for chronic pain, may have been a pendulum swing too far in the direction away from prescribing opioids (in the UK), and as i understand it, has caused a lot of chronic pain sufferers problems.

OK. I see US patients posting quite a bit about opioids on social media and I could imagine some people might be inclined to agree with them based on the information given without realising prescribing patterns are very different in the US to many other countries.

 

[RedFox]

An example I vaguely recall: after a dental procedure, someone in the UK or similar country would get prescribed one or two opioid tablets. While someone in the US might be prescribed one or two weeks of tablets, by which time they could have a level of addiction.

When I got my wisdom teeth removed, they gave me a bunch of codeine/acetaminophen (aka paracetamol) pills. Maybe a week's worth? And I never needed any, ibuprofen was enough.

 

[MeSci]

I don’t have much in-depth knowledge but my understanding is opioids are much more widely used in the US health system than in the UK or many other western countries. I think I saw a figure of the usage in the UK being something like 2% of the US (adjusted to population sizes)? And the wide use in the US causes a lot of problems. So I don’t think the people who want less use of opioids in the US are necessarily the “bad guys” or some sort of extremists.

An unfortunate consequence of the control measures in the US seems to be that relatively-benign treatments like kaolin and morphine, which used to be available over the counter in UK chemist shops, are no longer available without prescription. I used to get a lot of diarrhoea, and found K & M to be indispensable. I have it again, and am occasionally using small amounts of the K & M I have left to deal with it.

My only real alternative, other than unnecessarily expensive treatments containing completely unnecessary substances, is paracetamol and codeine, and I don't like taking paracetamol unnecessarily!

 

[Michelle]

As an American, I wanted to add a little nuance to the discussion.

If we want to make, say, the Sacklers the scapegoat villains in all this, better them than the usual marginalized people imho. That said, I can understand why they might be a little confused about why they are being singled out for doing exactly what every other drug company in this country does. In addition to all the typical constraints on their time that health care providers the world over face, in this country they also have to deal with pharma marketing reps showing up at their offices pushing the latest drug du jour. To be sure, Oxycotin was especially dangerous but I've seen nothing to suggest their methods were any different than anybody else.

Of course, the other impingement on the time of health care providers is battling with insurance companies to pay for treatments because we have no f***ing universal medicine in this country. Which is one reason why opioid use is higher in the US. Opioids are cheap. They are easy to get covered by health insurance. They are quick for time-pressed providers to write a Rx for with some level of confidence that a patient can pay for it. Family members who do have health insurance will often share medicine with family members who don't have it.

To be sure, they often had spare opioids among their personal pharmacies of unused medications because in the early 2000s there was emerging research suggesting that chronic, undertreated pain led to all sorts of bad long term health outcomes (and yes, Purdue and other companies took that preliminary research and ran with it--as drug companies do). So, at least in this country, there was an effort to treat pain aggressively (Pain as the Fifth Vital Sign). At the county health department where I received my primary health care throughout the 2000s (note: this is where poor people who have no insurance get health care in this country--if they're lucky!), Vicodin and Percocet were practically handed out like candy, even though there was none of the wine-ing and dine-ing of clinicians that one would see in the sort of practices that Purdue and other drug companies were targeting. These were your more heroic doctors working with poor people trying to alleviate suffering the best they could in a terrible system.

And among the terrible constraints of this system was coverage policies. Many state Medicaid programs (the insurance for the very poor and disabled) required providers who were initiating long-acting opioid therapy in a patient (as opposed to short-acting drugs like hydrocodone or oxycodone) to start with methadone because it's the cheapest of all opioids. But methadone has a much longer half-life than other opioids--up to 59 hours compared to 5 hours for morphine. Which extends the time for potential respiratory depression. So it should have been no surprise when overdose deaths from prescription opioids spiked in the 2000s before finally dropping after Medicaid programs dropped the methadone requirement. Alas, overdose deaths over all continued rising from NON-prescribed opioids such as heroin and fentanyl.

And one of the big reasons for the spike in street drug use is that, as pendulums do, it swung wildly in the opposite direction when health care providers--often quite abruptly--stopped prescribing opioids. So people started buying them from dealers, not knowing exactly what they were buying. Lobby groups like PROP (Physicians for Responsible Opioid Prescribing) began cultivating media contacts and pushing the idea that opioids are always evil, will usually make you addicted (in fact, while studies differ based on methodology, the median percent of those who develop Opioid Use Disorder seems to fall around 10%), and that CBT and mindfulness meditation can replace morphine. The CDC got involved in 2015 with "guidelines" for opioid use that had the effect we all warned them that it would: namely, the "guidelines" became rigid policy. Providers were (are!) being carefully monitored by the Drug Enforcement Agency about their opioid prescribing. Fearful of being disciplined, losing their license, or going to jail, many simply abandoned their pain patients. And so suicides of chronic pain patients then spiked, as did overdose deaths from the use of street opioids.

In short, it's one big systemic mess that goes well beyond the Sacklers, even if they surely aided and abetted the mess. And I worry that blaming a few drug companies may be emotionally satisfying but is not addressing any of this.

With all that said, I'm glad I happened to be at the clinic I was when I was getting very sick with ME/CFS because, after years of trying all sorts of other treatments for pain, my doctor did initiate me on a long-acting opioid, MS Contin, that has been very helpful for me (at least after the obligatory trial of methadone, which caused terrible dry mouth and somnolence at a tiny dose that wasn't enough to treat my pain). Any constipation I experienced was short-lived. But otherwise, it makes moving a bit easier, makes sleeping possible. As part of a multi-modal pain management plan, it's made having ME/CFS slightly less horrific. When I was reading this tread about the pain other members here are experiencing without access to opioids, I shuddered to think what so many of you are going through. I also felt enormous relief that I ended up with the primary care practice I did in 2011, which not only provided me with home visits but specialized in palliative care. They were still under a lot of pressure to reduce my opioid use--particularly in the dark days following the CDC guidelines--requiring tapering down the dose to be in compliance (rather than because it was medically indicated). But they have been better insulated to weather the pendulum swing.

And thankfully my state Medicaid system did not, in the end, adopt a chronic pain guideline similar to NICE's as their assembled task force in 2018 recommended. Our Health Evidence Research Committee actually evaluated the evidence and decided that, um, no, a hodge-podge of unblinded studies with subjective outcomes of tai chi or acupuncture or CBT to treat chronic pain were not strong enough evidence to support the use of tax dollars to pay for them.

But it still doesn't leave us with much that is evidenced-based with which to treat chronic pain.

 

[Trish]

That's really interesting, thank you @Michelle.