Babies and Bathwater

Opium has a long history of use for medicinal purposes. As far back as the Neolithic age it was being used for anesthesia, general pain relief, and as a sleep aid. It was mentioned in the Ebers Papyrus, one of the oldest medical texts of Ancient Egypt, and the works of Galen and Dioscorides.

Its use for recreational purposes came along somewhat later. Some of the earliest reports mention it in the possession of soldiers returning from the Crusades. By the 14th Century recreational use was well established in the Near East. By the late 15th Century it was in China, and in Western Europe in the 18th.

Of course, along with opium’s burgeoning use as a recreational substance, addictions developed with all the accompanying negative effects. This alarmed the Chinese Daoguang Emperor and in 1834 he tried to end the smuggling of opium into China from Turkish sources through British and American ‘intermediaries’ (look up FDR’s grandpa Warren Delano, Jr., if you get a chance). This culminated in a standoff in 1839 in which the Chinese seized and destroyed 1,300 metric tons of opium and eventually led to the bombardment of Dinghai by the Royal Navy on behalf of their less-than-legal-minded private entrepreneurs. China lost the First Opium War and was forced to cede Hong Kong to Britain and pay a fine of twenty-one million dollars to replace the lost opium stocks. I don’t think even the Escobars of our time ever thought of demanding an entire city as payback.

In 1853 there was another attempt by China to stop the opium trade and again, they were walloped by the British (with French help this time) who actually occupied the famed Forbidden City. More reparations were paid and the opium trade was legalized, foreign traders (as they were now known) were granted travel rights in China and everyone in Merry Ol’ England breathed easier knowing they could get their laudanum.

The rise of opiates as a recreational drug in the United States in more modern times is pretty well known and I’m not going to belabor it here. Nor do I intend to minimize the horrendous human cost of opiate addictions and overdoses. I’ve known people that suffered from these as well as other addictions and I’ve seen the cost up close and firsthand. I’ve seen what it does to those left behind as well. But like any high-profile crisis, there’s a lot of posturing among our leadership to make a show of how the ‘good fight’ is being fought, while the fallout of tactics used is being swept under the rug.

Now don’t get me wrong. Opiates used to be handed out way too cavalierly. In the mid 2000’s I did my residency at MetroHealth Medical Center in Cleveland. We had a really impressive ER: 72 beds, Level 1 Trauma capable, the whole bit. But what I kept seeing were folks who would arrive in the ER with some acute injury, like a back strain, a rotator cuff injury, or the like, and would be given a couple weeks’ worth of Percocet and told to follow up in the FP clinic – pretty standard fare across the country, at the time. But we were busy, too, and it would take three or four weeks for them to get an appointment on the other side of the foyer. The patients would stretch their meds and by the time I got to see them they were developing dependency.

Not long afterwards the powers-that-be started putting restrictions on this freewheeling prescribing by the ERs. At least at this point they seemed to recognize this was a real part of the problem. Then In 2016 the CDC released new guidelines in managing chronic pain 1, and things took a turn.

Chronic pain is much different from what you get with a broken bone or a bad tooth. Just ask anyone with diabetic neuropathy, degenerative disc disease, ulcerative colitis, or any one of a number of cancers. It can be unrelenting. And it won’t get better. You’re not going to heal to the point the pain will go away. And that pain can put you in bed, unable to move, though sometimes even that doesn’t give you relief. It can make you sick, angry, and desperate. One large study in Sweden of over seventeen thousand patients found a 51% increase in suicidality in chronic pain sufferers 2.

What the CDC were trying to do was to put some kind of standardization and cohesiveness on approaches to managing chronic pain. Honestly their guidelines were pretty good. The general idea was that meds were being too easily dispensed and thus too available on the street, and the CDC recommended that every pain regimen have a clear reason for its existence (meaning a proven diagnosis), and a well-defined treatment goal. In the case of the chronic pain patient, often this goal could only be to control the pain so they could work, take care of their family, and otherwise be a content and contributing member of society. Sometimes it’s just not possible to expect that they could become pain-free and not need any treatment. The guidelines also advised reevaluating the regimen at certain points to make sure you as the provider were considering other options for pain control, and provided education on signs to watch for in your clinic visits for inappropriate use.

It was the implementation of these suggestions on the front lines, by state medical boards, pharmacy boards, insurers, and hospital systems, that caused the problems. The regulatory boards saw an opportunity to show the public they were actively involved in combating the opiate epidemic. Recommendations were made into hard-and-fast rules. Suggestions for treatment checkpoints became inviolate limits. Tapering off meds was the plan for everyone except, generously, the terminally ill. Sauron-like scrutiny was turned on anyone poking their head above the berm, no matter the reason and in spite of the claim that people would be ‘grandfathered’ in to the new treatment goals.

Ever fearful of losing government funding, or worse, hard-won licenses, hospital systems and pharmacies simply started to severely curtail opiate prescribing rather than really take a look at individual patients and make certain, as the CDC had suggested, that what they were getting was indicated and effective. Despite what could legitimately be described as patient abandonment, many organizations simply stopped prescribing controlled meds altogether. And the med boards went right along with this by targeting anyone that wasn’t jumping in the boat with them.

The rebound of this was immediate. People still had their pain. And, like it or not, many had become dependent and faced withdrawal. So where did they go? To the street. Where they were self-medicating, without a trained provider to monitor doses, frequencies, side effects and interactions. Where no pharmacist could guarantee a certified supply chain. Where no manufacturer was making sure the oxycodone wasn’t being supplanted with something more potent (read that: smaller doses required and thus cheaper) like fentanyl. And overdoses soared.

In Ohio the new rules went into effect at the very end of 2018. By this time opiate overdose deaths were peaking and looked like they were starting to drop. But at the same time the new rules were being put into effect they jumped up again and continued to rise a total of 46% through 2021 3, a trend mirrored in nationwide data 4. Here we’ve seen a slight reduction in 2022, and I’m anxious to see if 2023 proves this is a trend or just a statistical variation.

The CDC recognized what was happening and issued a paper in 2019 warning against the inappropriate application of their guidelines 5, but it remains to be seen if the regulatory boards are going to be as quick to get off the bandwagon as they were to get on it. Being able to stand in front of the  citizenry and claim you’re making things better is an addiction all it’s own, and can be just as tough to beat.

There's no doubt the opiate problem needs to be cleaned up. Opiates are dangerous medications if improperly used. But they can be lifesaving when they’re done right. And doing them right requires treating individual people, each of whom has their own story, on a one-on-one basis and not just trying to make ‘fits-most’ dictates from an ivory-colored concrete tower.

References

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

2. Chen, C., Pettersson, E., Summit, A.G. et al. Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study. BMC Med 21, 9 (2023). https://doi.org/10.1186/s12916-022-02703-8

3. Harm Reduction Ohio. 2022, October 17. First Projection of 2022: Overdose deaths on track to decline this year. https://www.harmreductionohio.org/overdose-death-on-track-to-decline-lightly-in-2022/

4. National Institute on Drug Abuse. 2023, June 30. Drug Overdose Death Rates. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=Opioid-involved%20overdose%20deaths%20rose%20from%2021%2C089%20in%202010,again%20in%202021%20with%2080%2C411%20reported%20overdose%20deaths.

5. CDC Media Relations. 2019, April 24. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain [Press Release]. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html