Prescription Narcotic Analgesics...

Prescription drug Addiction????

The New York Times, today, published an article entitled: Ohio County Losing Its Young to Painkillers’ Grip about prescription drug abuse.

This is one of the latest salvos in a war on prescription narcotic analgesics.

Narcotic analgesics are the modern incarnations of a very old substance – opium, which is produced from the sap of the opium poppy, Papaver somniferum. Less complex opiate based substances have been with humanity for thousands of years – beginning during the neolithic age about 9,500 years B.C. Opium cultivation began around 3,400 B.C. in Mesopotamia.  The history of opium smoking goes back to 4,200 B.C. The addictive nature of the drug was first noticed in the 1600’s.

Use of opium was widespread in Islamic cultures in the middle east beginning about 500 B.C. Opium use spread from the middle east to China beginning in 400 B.C.

Paracelsus’ Laudanum, or tincture of opium, was introduced to the west in the sixteenth century. Laudanum has been widely used for a variety of therapeutic purposes all over the world and is still produced today.

Recreational use of opium began in Muslim societies in the 1500’s. 

Use of opium in the United States expanded during the 19^th century. In the 1800’s, there were thought to be between 150,000 and 200,000 addicts in America. At the time, opium was widely prescribed to women to treat a variety of symptoms and women were believed to make up the majority of those addicted.

All use of opium was banned in China in 1799 after it had been introduced by the British around 1690. Protestant missionaries began to document the ‘pernicious nature’ of opium around 1890 when they formed  the Permanent Committee for the Promotion of Anti-Opium Societies in China. [Some of these missionaries were medical doctors, what they had to say about the therapeutic use of opium is not disclosed.]

Opium use in the US was restricted by the adoption of the Harrison Narcotics Act of 1914.

The Harrison Narcotics Act[1] banned all use of opium based medications, even when given by a physician. The stated purpose: To curb a dangerous and immoral addiction. The chosen method of enforcement: Felony prosecution of doctors prescribing opiates to their patients who were addicted. In the 1920’s 35,000 doctors were prosecuted under the Harrsion Act. Thousands of other doctors had their careers ruined by enforcement activity. 

Vigorous prosecution of ‘addicts’ was carried out at the same time. By 1928, 19% of all federal prisoners were serving time for narcotics related crimes.

Enforcement under the Harrison Act continued until 1932, when an administrative decision was made to reduce the number of prosecutions. It was decided that it was inappropriate for field agents to build their careers on the backs of legitimate prescribers of opiate based compounds.

The Harrison Act was superceded by the Drug Abuse Prevention and Control Act of 1970. The DAPCA and a 1975 SCOTUS holding - U.S. v. Moore - continued, and legitimized, the prohibition against prescription of narcotics to addicts. [Conservapedia has a somewhat bizarre interpretation of Moore. About what I would expect from a source  who fails to cite any primary sources to support their conclusions and calls themselves the “Encyclopedia of Truth”. Maybe in the land of Sarah Palin.]

Following the formation of the Drug Enforcement Agency, the agency and the DOJ had problems quantifying the success of the DEA. Senator Charles "Chuck" Grassley complained that, in spite of a budget that has ballooned from $806 million to $1.5 billion in 1999, there was still no measurable proof that the DEA was having any effect whatsoever on the supply of illegal drugs in the US. Way to go Chuck. You just told the emperor that he has no clothes.

Instead of devising a way to quantify the success of their agency, the DEA created an entirely new problem – prescription drug abuse – against which to vent their ire. The problem was described as being as ‘bad as cocaine.’ 

This type of abuse - if it were a problem - was easy to quantify. Doctors kept records of prescriptions, pharmacists keep records of prescriptions filled and patients had to go to both to get their medication. In other words, physicians and legitimate users of narcotic analgesics were an easy target for the DEA. 

Modern ‘opiates’ are derivatives of opium that are much safer, convenient and effective. The most common forms in use today include hydrocodone; oxycodone; morphine; hydromorphone; and fentanyl. These are available in oral and parenteral forms. Preparations of sustained release oxycodone, such as OxyContin, were first introduced into the US in 1996. [While sustained release preparations of oxycodone are new, oxycodone itself was developed in 1916.]

Sustained release oxycodone preparations have gained widespread use in the US since their introductions. By 2001, OxyContin was the best selling non-generic narcotic analgesic in the US and sales topped $2.5 billion by 2008.

After the introduction of sustained release oxycodone products, the DEA created what was referred to as the “Oxycontin Special”.[2] [This link is to an article discussing the DOJ plan to target OxyContin.] Specifically to prosecute doctors and users of sustained release oxycodone preparations. The responsibility for this new scourge was laid squarely at the feet of doctors and pharmacists, who the DEA claimed, were responsible for the diversion of these drugs to addicts.

So, what makes these drugs ‘killers’?

Put quite plainly, the War on Drugs. Most particularly, the DEA’s war on physicians.

Utilizing standard DEA tactics, the primary action of the DEA against this imagined new threat was the demonization of all narcotic analgesics. With the release of sustained release oxycodone medications the DEA choose OxyContin to serve as the scapegoat for the ‘sins’ of all narcotic analgesics. And the DEA has been wildly successful in demonizing OxyContin. I would imagine even they are surprised at the way their propaganda has turned the public against OxyContin.

Which brings us back to the story in the NYTimes this morning.

Articles such as this are necessary for the crusade against prescription ‘painkillers’ to succeed. The DEA needs the crusade of prescription ‘painkillers’ to succeed. If it doesn’t, they would have to go back to arresting real drug dealers. Who don’t line up at their door with records of all the drugs they buy and sell.

I do not doubt that there are patients who abuse/traffic in prescription narcotic analgesics - just as there are others that abuse just about every kind of mood altering substance available to man. I have no doubt that reducing this abuse is an important job in our society. 

So, we see pieces like this that capitalize on the suffering of the few to serve the agenda of the DEA.

The problem is, with this article and others like it, it takes too simple an approach to the issue of abuse of prescription narcotic analgesics. They fail to consider that people with actual pain need to take actual narcotic analgesics to be able to live with their pain. They ignore the fact that incidents such as that described in the NYTimes are abberations - most patients using these medications use them appropriately and in an entirely legal manner. They offer no solutions, only punishment for a crime that is, mostly, of their own invention.


And they blatantly pander to our emotions, while dismissing reality.

No one seems to feel safe enough to stand up and say that the unnecessary demonization of the medications themselves is inappropriate. The problem is, if there is a problem, is with people who abuse these drugs. The DEA’s approach causes an even bigger problem in that it prevents people who need the drugs from getting the drugs. You don’t see this discussed much in the newspaper. People suffering from intractable acute and chronic pain live on the margins of society. It’s easy to marginalize them.

Again, the most telling part of the NYTimes article comes in the comments section.

Quite a few posters bring up the social conditions that accompany drug use. Particularly the economic downturn and the feeling of hopelessness it engenders. I agree. We need to do something about the current state of our economy. I don’t know what, but something. Maybe put some bankers in jail?

More than a few others cited the pharmaceutical companies’ profit motive for prescription narcotic analgesic abuse. That’s not realistic. The pharmaceutical companies and the doctors do not profit off of anyone’s addiction. Many of the people who abuse these drugs buy them in the ‘secondary’ market and not directly from the drug companies. Doctors make zero when they prescribe an drug. I don’t think profit motive is the demon here.

I want to applaud the posters who are concerned that the DEA’s unfounded beliefs about OxyContin and other narcotic analgesics will preclude people who need pain from getting pain relief. This is, perhaps, the most important part of this discussion.

John B from Birmingham, (Alabama? England?), says that people won’t stop selling drugs until selling drugs becomes a death penalty offense. Apparently, John has gorged himself on the DEA’s propaganda and is now intoxicated with their, and his own, ignorance.

John, those dealing or using drugs in many Islamic societies are sentenced to death. Yet, opium production is the major cash crop in Afghanistan. Guess it doesn’t work.

Meister, identifies himself as a ‘pastor’ and says he will not assist his church members in getting their prescriptions for oxycodone filled, because of the high street value of these substances. Even if it means leaving someone in severe pain.  Then he wants to know how many people actually have a need for oxycodone.

Meister, perhaps you could ask a doctor. I am sure you are a great preacher. However, your moral judgments about the appropriate use of narcotic analgesics do not qualify you to decide whether a patient ‘deserves’ or ‘needs’ a particular medication. The doctor does that. By refusing to help your followers obtain prescribed medications, you are substituting your own judgment for the doctor’s judgment. And you do so without really knowing who actually has diverted these medications. You deny your followers help because of your perception of the ‘street value’ of these medications. This is your perception, not reality. [Unless, of course, you have conducted a survey of drug dealers to determine the actual value of these medications. Which I doubt. Your information probably comes from the DEA and its press lackeys.]

Several respondents bring up the fact that medical marijuana could treat the conditions people take these medications for. And that marijuana is neither addictive nor does it provoke its users to violence. Thanks for bringing this up, but you are making way too much sense. I mean, you think the American people and the DEA actually want to make things better? They don’t. They want to impose their moral beliefs on others and if they have to leave some in severe, intractable pain, that’s okay with them.

Grenpa from Minnesota muses as to whether these drug deaths aren’t actually suicides. I wonder, too. 

Herb K rings in another vote for the death penalty for drug dealers. In 2007, state prisons held over 250,000 people imprisoned for drug related offenses. As a WAG, let us say that 50% of those incarcerated have been convicted of dealing drugs. That means that we would have to execute 125,000 people. And that would only take care of the people in prison, now. We would have to execute more each time someone was convicted of selling drugs.

Assuming we were to give the full right to due process to all these offenders, the cost of prosecuting these cases as capitol crimes would be staggering. One study in Maryland cited the cost of prosecuting a single death penalty case to completion at $37 million.  Of course, if we are willing to shortcut a person’s constitutional right to due process, then we can save a little. But, it seems hardly appropriate to quibble over finances when it comes to committing state sanctioned murder.

Matt Connolly from Boston thinks there must be collusion between the DEA and the makers of OxyContin. [Wait, while I stop laughing] He, also, believes that doctors and Purdue, (the makers of OxyContin), are making “enormous profits” off the abuse of OxyContin.

Matt, the DEA probably loves people like you. You want them to get even more involved in prosecuting the consumers of an entirely legal substance. Used while under the care of a licensed physician. Right.

Kevin Griggs of Tampa, FL  says, “That is why they are called pain “killers”. Actually, Kevin they are called narcotic analgesics. And they don’t ‘kill’ pain, they reduce your perception of it.

Ingrid from Maine thinks that we have this “stubborn insistence that all pain is pathological and must be immediately relieved.” She, apparently, believes that ibuprofen is the appropriate medication for all pain.

Ingrid, I have to ask, where did you go to medical school? Pain is pathological. Your body doesn’t perceive pain, unless there is something wrong. You can ignore your pain, at risk of your health. I guess. Next time I treat a patient with a compound fracture of the femur or a patient with chest pain from an acute myocardial infarction, I will tell them that their pain is not pathological and just hand them a couple of Advils.

When you are in a car accident and you look up and see me arrive in my LSU, please remember to remind me you don't think all pain is pathological or that it needs medicine other than ibuprofen for treatment. I won't believe you. That's because nearly 30 years in advanced pre-hospital care and in trauma center emergency departments clearly shows adequate pain relief is an important part of patient care.

Dave Clemens says it right when he describes America as a “pitiless society.” I couldn’t agree more. Since the Bush administration, pain seems to be looked upon as a moral failing.

Another New Jerseyan, rings in with the statement that one can become addicted to narcotic analgesics in a matter of days. No, you cannot become addicted in a matter of days. This is wishful thinking or an urban myth. Appropriate use of narcotic analgesics seldom leads to addiction. Attitudes like this are formed when the public believes everything the DEA says.

Paul from Narraganset, one the drugs you are talking about is secobarbital.[3] It has not been banned. It is no longer widely used as sleep agent because there are other, much more effective drugs - like diphenhydramine, aka Benadryl.

MD from PA thinks there are a lot of “bad cops and informants out there reselling confiscated drugs.” Interesting thought. However unsupported. Not that I don’t want to agree with you. BTW, MD, if there were mandatory drug testing for people using narcotic analgesics, they would all test positive.

And so the debate rages...

[1] The Harrison Act also banned use of cocaine, although it clearly is not a narcotic.

[2] Note: this is a cached website, the original is no longer available.

[3] I like to watch re-runs of cop shows from the '60's and the '70's. Secobarbital/Seconal/'reds' are featured in most episodes. After watching these programs, one gets the impression there were secobarbital vending machines on every corner.