A story from the Associated Press recently reported on new statistics issued by the DEA, showing a six-fold increase in the use of opioids, primarily oxycontin and vicodin, over the last ten years. We discuss this trend which we have reported, and the relationship to pain management.
Howard: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. Of all the stories we’ve come across this week, the one that is perhaps most salient is an Associated Press story – a synopsis of the amount of pain killers being used in the U.S. and how it has increased substantially over the last 10 years. These numbers reported by the DEA show that between 2000 and 2010 there has been a 6-fold increase in the use of – primarily Oxycontin and Vicodin – opioids prescriptions. We’ve been talking about this for a long time, but do those numbers mean anything in particular? The other thing that I thought was interesting is the geographic centers highlighted – West Virginia and Kentucky, coal mining country, chronic back pain in Appalachia, in the Midwest and now we’re seeing a sharp surge in the Southwest and in affluent suburbia. What do these numbers say to you in those geographic locations, Darryl?
Darryl: Well I think first of all we have to look at those numbers from the raw data that is being presented – that there’s been a 600% a 6-fold a 600% increase in the sales – which means use obviously somebody’s got to be using them if they’re selling them, so use is increasing as well, but 600% in sales I don’t know of another business that will make you any better profit than that.
Howard: That’s pretty good.
Darryl: So, it’s always about the money – no wonder we recently saw pharmaceutical companies saying that people are being persecuted for using pain pills and are overly scrutinized when they have chronic pain. They also maintain that patients aren’t getting proper pain treatment because the practice is looked at as an over-extension of the use of pain medication, prescription opiate medications. If there is a call to stop prescribing these medications so frequently and for physicians to look more closely at the way it is being prescribed – well, that could mean a decrease in profits.
Howard: And there’s no disputing the increase in the number of overdose deaths and also pharmacy robberies.
Darryl: Exactly. The data is a bit old. The numbers are from about 2008 or 2000, 2010 some of the other reports show increased deaths in 2008, and it’s now 2012. We’re 2 to 4 years beyond those dates, but still I believe that there is an increase in prescription opioids being diverted at the same time that pharmaceutical firms are lobbying for the FDA and the DA to approve even greater strength prescription opiates. Well, there are many different pain drugs and what I see happening is that as the hot items – like “Vicodin is the big abuse item” then people who are medication shopping or drug seeking and prescribers who are too busy to pay attention somebody comes in and says, “I’ve got this horrendous chronic back pain, but you know, I don’t want that Vicodin stuff. Don’t give me that Vicodin – I know it’s addictive – so how about some Norco? Or why don’t you give me some Anexsia?” Well those are all the same chemical, the same drug, but under a different name. Or I just saw oh, I think it was in Wyoming or someplace in the Midwest one of the regions you mentioned… there is a dramatic increase in opana being prescribed.
Howard: Now what is opana? That’s not a very familiar name.
Darryl: Opana is a trade name for oxymorphone, which is a prescription opioid pain killer that has been around for a long, long time. It was once touted as being less addictive and less sedating than morphine or other pain killers, and it had street value and a good street name and people wanted it – but then Oxycontin came out and it has more milligrams per tablet. But opana the more common name is newmorphone or newmorphine, I believe might be schedule 3, meaning it’s more available than the schedule 2 drugs. If Oxycontin and Vicodin are under the scrutiny of our medical system and of the DEA and FDA, then many others will be subjected to the same scrutiny and hopefully sales of all prescription opioid pain killers will be examined. I also understand sales of Percocet and even Percodan, which is a schedule 2 has started to increase.
Howard: I saw an article from our drug czar I hate that term, drug czar – Gil what’s his name? Kolokoski
Darryl: Kerlikowske.
Howard: Yes, he addressed the White House and the administration’s point of view and that they were paying close attention to this issue . 40 states are now monitoring .at the pharmacy level .the use of schedule 2 and schedule 3 drugs . but still there’s no inner connection. So maybe this is where the federal government can play a role in helping to create some kind of inner connection between the states.
Darryl: Well, I think all of that is helpful in decreasing the diversion and abuse of prescription opioid drugs and .the state board pharmacies have taken a proactive role in computerizing their systems to get reports to monitor who’s prescribing these drugs and how much they’re prescribing. In the old days what we call schedule 3 drugs, which were the class 2 prescription drugs from the federal classification system of abusable drugs, were prescribed using triplicate forms and reported the attorney general so the information could be entered in a data base for review. But in today’s world, ever since Oxycontin’s main ingredient, oxycodone, was classified as a schedule 3 drug, which is a less restricted drug because of the fact that the manufacturer said it was reconfigured into a diversion proof, or a diversion resistant time release format where the 80 mg to 120 mg is compared to only 5 mg in Percodan. It was assumed that that massive a dose could not be absorbed all at once and so it was less likely to be abused. Well, that was as we all know a total mistake because folks on the street figured out how to go around that right away. So, now schedule 3 drugs are monitored as well and some states are considering monitoring all scheduled drugs… schedule 3’s, schedule 4’s and maybe even schedule 5 drugs to identify individuals who are overusing and prescribers who are over prescribing. Having said that, I want to tell you, drug addicts and alcoholics .hardcore drug addicts and alcoholics are extremely brilliant people. They have a much higher IQ than most of us and they figure ways around this – they always have and they always will, so there might be some glint of truth in the fact that the more restrictive we become and the more obstacles we put in the way of accessing these drugs, the real hardcore abusers are going to be successful and the people who legitimately need and use these medications are going to have a hard time getting them. It’s going to be harder and harder to get and harder and harder to treat their medical conditions. Overall, every time we put obstacles up, they prove effective in decreasing wider diversion, overdoses and abuse. So, I think some of that is good, but we also have to consider those people who have legitimate needs for these medications and ensure that they have ease of access to these medications.
Howard: And I think that is what the story in Huffington Post was responding in part to to a series in that did bring up this barrier, or this dichotomy between what’s considered effective pain treatment and the continued effort to control the abuse of these kinds of drugs. We no longer call it the war on drugs, by the way.
Darryl: Good.
Howard: According to Mr. Kerlikowske.
Darryl: What is he calling it?
Howard: I don’t know, but he says he has discarded the war on drugs approach in favor of a less simplistic one, one that truly addresses the complicated public health and public safety issues that arise. So, I guess we’ll have to wait to see what the next national drug control strategy is.
Darryl: You know, one of the things that’s worth mentioning here is that we really don’t do well in treating chronic pain. For some reason, since the beginning of medicine, chronic pain was viewed as a purely simplistic symptom of a specific trauma to the body which affects parts of brain and if we just throw an opioid or different medication at it – that’s going to solve the issue. Well, as we begin to understand the neurophysiology of pain and especially of chronic pain, we’ve come to realize that there are multiple issues involved with pain. There are nociceptive and non- nociceptive pain – one is due to injury of tissue causing a stimulus of your pain neurons, but the other is due to actual nerves nerve cells that are over anxious or over-reactive. As we deal with chronic pain in the addiction field, we realize that a lot of the pain has to do with stress levels and the more effective we are at helping people address their underlying stress conditions or their acute stress conditions, the less pain they experience and the less medication they need and the less relapses occur. We have also started to understand the pain gates and how neurons compete with each other from periphery through the spinal cord to deliver information to your brain and if the pain gates are pre-occupied then you’re not going to experience pain. So things like doing intense crossword puzzles or Sudoku will stave off pain because the person is deeply involved in trying to solve the puzzle. Regarding the psychological component and sociological component of pain, we found that people who continually whine, is that a word I should use here?
Howard: That’s a word, whine is a legitimate word. We’re not talking about fermented grapes.
Darryl: No, no, no
Howard: The other whine!
Darryl: The nagging, complaining. When people continue to whine or complain about being in pain and not feeling well all the time
Howard: I think we’ve all had some aunts or relatives like that.
Darryl: When they focus on pain – they actually experience more pain more intensely, whereas if they take it off their priority radar and talk about other things in life, they suffer less pain. So from a clinical basis, we’re becoming much more effective in treating pain through clinical approaches, but we’re not doing it in medicine yet. Medicine still relies on the fact that a person has a hurt foot, or a a hurt tooth .that a person definitely has some chronic myalgia and must be given more and stronger opiates to take care of the problem even though the problem seems to be getting worse and worse. So, I think we need a new approach but medicine doesn’t have the time or the clinical ability to provide what treatment professionals provide in addiction treatment through chronic pain groups where we deal clinically with the pain issues. I think it speaks to a stronger issue that I continue to harp about… as addiction treatment becomes more and more medical, as we recognize that addiction is a true biological medical issue and as medications are developed to treat addictions, say like the recent or within the last 10 years, the explosion of bupinorpherine and suboxone in treatment of heroin addiction. The key issue I’ve got to keep reminding doctors of is you don’t patients in a silo. You don’t treat them as a silo, rather you deal with their brain cell addictions, with the whole process of addiction and doctors need to get them involved in clinical therapy. Patients need counseling and to participate in the groups and do all these things in conjunction with the discoveries and the recent innovations in the medical field – these treatments have the best results, the best outcomes of ensuring people get well. But if you go the pure silo route of just giving them a medication, I think the outcomes are not going to be very good. We’ve got to break that strong mindset that medicine has of “oh, surgery give them surgery or just give them ..”
Howard: a magic pill, whatever it is.
Darryl: Magic bullet or something .
Howard: Magic bullet, magic pill, magic knife, whatever. I think that’s an excellent point. Systems theory has been one of my pet projects for several decades – trying to understand it because it applies to this context. It is very much the alteration of consciousness, pain, addiction. They’re all symbiotic system at work. On that note, we’ll say adios for now. Darryl, thank you very much.
Darryl: Thank you, Howard.
Howard: That wraps our pod for today. Please check back soon for the next in the series and keep in touch – your questions and comments are always welcome.