Opioid addiction has been described as the worst drug epidemic in US history — its victims snared, in many cases, after a visit to a dentist or doctor. Medical professionals have often been happy to hand out prescriptions for painkillers like OxyContin and Vicodin, a practice that reflects the success of aggressive marketing efforts by pharmaceutical companies.
Now the federal government is trying to intervene, asking physicians across the country to reconsider the way they've been treating pain for two decades. The Centers for Disease Control and Prevention (CDC) published the first federal guidelines on Tuesday for doctors prescribing opioids, laying out considerations that they should follow in order to curb the profligate use of such medication.
For years, powerful painkillers have been dispensed for common pain conditions. Purdue Pharma, the maker of OxyContin (oxycodone), pleaded guilty in 2007 to charges that it misrepresented the drug as "abuse resistant" as part of a multimillion-dollar marketing campaign, and paid $600 million in fines.
According to recent data, 28,647 people died in the US from opioid overdoses in 2014 — an all-time high.
"This is a difficult issue that doesn't have easy solutions," the American Medical Association's Task Force to Reduce Opioid Abuse said in a statement. "If these guidelines help reduce the deaths resulting from opioids, they will prove to be valuable."
The CDC wants physicians to stop defaulting to opioids and begin by considering other treatments for pain, such as over-the-counter medication. In cases that merit the use of opioids after other options have been considered, it recommends that doctors start with a low dosage and, if necessary, increase the amount incrementally. But the guidelines question the efficacy of long-term opioid treatment. Opioids should be prescribed in worst-case scenarios involving pain, such as cancer treatment and end-of-life care.
On a media call shortly after the regulations were announced, Dr. Thomas Friedman, director of the CDC, noted that the guidelines were "a tool for doctors and for patients to chart a safer course" — a benchmark, but not a mandate. They could have teeth in the way they influence what insurance companies will and won't cover, however, and could also be cited in civil suits brought against prescription-happy doctors.
But not everyone is thrilled. Some pain specialists argue that the guidelines will make it harder for people who suffer from chronic pain to get treatment, while some addiction experts believe that the CDC effort is too little too late — it won't change things for the two million people estimated to be hooked on pain meds across the country.
A 2012 study that was published in the journal Pain Physician found that 60 percent of opioid deaths occurred in patients who were "using opioids exactly as prescribed" and whose doctors were prescribing the pills according to existing medical board guidelines. The study found that the other 40 percent of opioid deaths occurred in people who obtained their drugs through pill mills — multiple prescriptions, doctor shopping, and drug diversion.
The researchers concluded that a key driver of the opioid epidemic was "inappropriate prescribing patterns, which are largely based on a lack of knowledge, perceived safety and inaccurate belief of undertreatment of pain."
The prescriptions in the majority of opioid deaths came from doctors who were operating by the general rulebook when it came to prescribing pills. The new CDC guidelines might conceivably lead them to adjust their prescribing habits.
"You have to rely on doctors to be ethical. Some doctors are not," said Sam Quinones, journalist and author of Dreamland: The True Tale of America's Opiate Epidemic. "We've spent 20-plus years convincing doctors that this is the proper way to treat pain. We talk about whether drug problems are caused by supply or demand. This was caused by excess supply."
Quinones said that the CDC's initiative marks a return to sanity.
"This problem began with a revolution in how we thought about pain in America. A way of thinking took over… that we were a country in pain and we had to aggressively treat that pain," he remarked. "All across the country we began prescribing pills for things that had never received a prescription before — and in massive quantities — while believing the whole time that these pills were non-addictive."
"That mentality has caused catastrophic collateral damage," Quinones added. "Nightmarish."
Some have argued that previous efforts to fight drug addiction with regulation have caused the problem to mutate rather than disappear. Some narcotics experts have linked the tightening of regulations on painkiller prescriptions to the rise in heroin overdoses.
In 2013, the FDA imposed tighter regulations on opioids, which in turn drove up their street value. Many Americans who were hooked but couldn't afford the black market prices turned to heroin, which is largely supplied by Mexican cartels. Black tar heroin, produced from poppies that grow in Mexico's Sierra Madre mountains, offers a cheap and potent alternative to prescription painkillers.
Deaths related to heroin hit 10,547 in 2014 — triple the rate recorded in 2010.
"Once someone is addicted to opioids, heroin is cheaper, it's more readily available," said Dr. Stephen Ross, director of addiction psychiatry at NYU Langone Medical Center. "But the pills shouldn't be prescribed in the first place. For everyone who is addicted now, we need to treat them."
Calling addiction the worst disorder to have in medicine, Ross said that the CDC guidelines should suggest that doctors receive training in screening for addiction when prescribing opioids. He is unconvinced by complaints from pain specialists that the guidelines will complicate pain treatment.
"They're well meaning, but they started this whole thing by saying pain was undertreated," he said. "There's no evidence that opiates treat chronic pain. In fact, they can make it worse."
Pharmaceutical companies are worried that medical authorities are starting to rethink pain treatment. Richard Samp from the Washington Legal Foundation, a conservative group that represents pharmaceutical companies in legal matters, believes the CDC guidelines were inherently biased, crafted by people who already had strong views about what opioid policy should look like.
"We think that what the CDC did was improper because they did not follow proper administrative guidelines," said Samp. "We've been asked, 'Are you planning to sue?' We have no comment."
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