I’ve witnessed the entire cycle of the opioid epidemic

As I write this (in Novem­ber 2017), the opi­oid epi­dem­ic is dom­i­nat­ing the news reports.

The recent num­bers are stag­ger­ing — 90 Amer­i­cans die every day from drug over­dos­es.  That even dwarfs the (shame­ful­ly high) num­ber — 35 or so — who die each day from gun vio­lence. And it comes close to the equal­ly shame­ful­ly high num­ber of deaths from car crash­es — about 100 per day.

Over the course of my career I’ve been a first hand wit­ness to the entire arc of the opi­oid cri­sis.

It wasn’t always like this.

When I was first in prac­tice, in the ear­ly 1980’s, AIDS was the biggest health news — abuse of pre­scrip­tion drugs was far down the list of impor­tant pub­lic health issues.

But that was soon going to change.  It began with an innocu­ous sound­ing let­ter to the edi­tor of the pres­ti­gious New Eng­land Jour­nal of Med­i­cine in 1980:

To the Editor:

Recent­ly, we exam­ined our cur­rent files to deter­mine the inci­dence of nar­cot­ic addic­tion in 39,946 hos­pi­tal­ized med­ical patients who were mon­i­tored con­sec­u­tive­ly. Although there were 11,882 patients who received at least one nar­cot­ic prepa­ra­tion, there were only four cas­es of rea­son­ably well doc­u­ment­ed addic­tion in patients who had no his­to­ry of addic­tion. The addic­tion was con­sid­ered major in only one instance. The drugs impli­cat­ed were meperi­dine in two patients, Per­co­dan in one, and hydro­mor­phone in one. We con­clude that despite wide­spread use of nar­cot­ic drugs in hos­pi­tals, the devel­op­ment of addic­tion is rare in med­ical patients with no his­to­ry of addic­tion.

Jane Porter
Her­shel Jick, M.D.
Boston Col­lab­o­ra­tive Drug Sur­veil­lance Pro­gram Boston Uni­ver­si­ty Med­ical Cen­ter, Waltham, MA 02154

The authors didn’t describe their method­ol­o­gy; oth­er researchers nev­er fol­lowed up to cor­rob­o­rate their results. By today’s stan­dards, the let­ter might not even qual­i­fy as hav­ing any sci­en­tif­ic val­ue at all.

But appar­ent­ly the over­ly rosy view of pre­scrip­tion nar­cotics was the mes­sage many doc­tors were ready to hear. Opi­oids pro­vid­ed a sim­ple solu­tion to treat­ing patients’ pain.

The pub­li­ca­tion of this let­ter was the begin­ning of a long down­hill slide, result­ing in the chaos our health sys­tem is deal­ing with now.

In the ear­ly 1990’s, I was a mem­ber of the New York Acad­e­my of Trau­mat­ic Brain Injury. This was a mul­ti­dis­ci­pli­nary group that held month­ly edu­ca­tion­al meet­ings to fos­ter cross-dis­ci­pli­nary think­ing in the field of head trau­ma.

The fea­tured speak­er at one of the month­ly gath­er­ings was Dr. Rus­sell Portenoy, head of the Amer­i­can Pain Soci­ety.  His pre­sen­ta­tion was on how to block acute pain from becom­ing chron­ic pain with the aggres­sive use of phar­ma­ceu­ti­cals.

Here’s a sum­ma­ry of Dr. Portenoy’s main points:

  1. It’s impor­tant to inter­rupt pain before it becomes chron­ic.  Once pain set­tles into the brain, it cre­ates rever­ber­at­ing, self-per­pet­u­at­ing cir­cuits. Then pain is hard to get rid of.
  2. Opi­oids are actu­al­ly safer drugs than one of the main alter­na­tives, non-steroidal anti-inflam­ma­to­ries (NSAID’s.)  NSAID’s are impli­cat­ed in 15,000 to 20,000 deaths a year, pri­mar­i­ly due to uncon­trolled bleed­ing from a torn up stom­ach lin­ing.
  3. You can safe­ly pre­scribe opi­oids with lit­tle risk of addic­tion.

I was impressed by Dr. Portenoy’s pre­sen­ta­tion.  I cer­tain­ly found myself in agree­ment with his first two points. My own prac­tice was focused on treat­ing acute pain so that it wouldn’t devel­op into chron­ic pain.  And I was well aware of the dan­gers of pain killer drugs.

What was exces­sive­ly opti­mistic was Dr. Portenoy’s third major point.  In fact, the opi­oids then being pre­scribed, and even new­er ver­sions (like Oxy­con­tin), which in the­o­ry should have been hard­er to abuse, were too eas­i­ly trans­formed into weapons of human destruc­tion.

And, unknown to any of the meet­ing atten­dees, Dr. Portenoy’s lec­ture sched­ule was being finan­cial­ly sup­port­ed by Pur­due Phar­ma­ceu­ti­cals, the com­pa­ny that devel­oped and made bil­lions of dol­lars from Oxy­con­tin.

What’s more shock­ing is that Dr. Portenoy was only one small play­er in the mas­sive invest­ment phar­ma­ceu­ti­cal com­pa­nies were mak­ing to push unsafe prod­ucts on the Amer­i­can pub­lic.

Now the pen­du­lum has begun to swing away from the indis­crim­i­nate use of opi­oids.  Unfor­tu­nate­ly, our med­ical sys­tem is so drug-ori­ent­ed that many prac­ti­tion­ers don’t have the imag­i­na­tion to under­stand the full poten­tial of non-phar­ma­ceu­ti­cal pain approach­es.

Pain is a com­plex phe­nom­e­non, with sen­so­ry, neu­ro­log­i­cal, hor­mon­al, psy­cho­log­i­cal, and social com­po­nents. Ear­li­er in 2017 I had the oppor­tu­ni­ty to address a meet­ing at Robert Wood John­son Med­ical Cen­ter on the top­ic of “Com­ple­men­tary Ther­a­pies in Pain Man­age­ment.” I tried to illu­mi­nate the val­ue of the hands-on treat­ment I offer pain patients with­in this mul­ti-fac­to­r­i­al mod­el.

Although our knowl­edge base about pain and the poten­tial of non-drug treat­ment keeps grow­ing, it may be many years before we can reverse some of the ingrained habits devel­oped under the hyp­not­ic spell of large phar­ma­ceu­ti­cal com­pa­nies.

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About Ronald Lavine, D.C.

Dr. Lavine has more than thirty years' experience helping patients alleviate pain and restore health using diverse, scientifically-based manual therapy and therapeutic exercise and alignment methods.

His website, askdrlavine.com, provides more information about his approach.

Please contact him at drlavine@yourbodyofknowledge.com or at 212-400-9663.

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