Problems With Long-Term Opioid Use: How We Got Here

In the first of a two-part series, Join Together speaks with Barry Meier, New York Times reporter and author of the new e-book, “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake,” about the problems with long-term opioid use for treating pain and how it became so widespread.

What was the approach to pain treatment before opioids became common?

Barry Meier: Narcotic painkillers, or opioids, are a large class of drugs derived naturally or synthetically from the opium poppy. Some commonly used opioids include morphine, hydrocodone, oxycodone, fentanyl and methadone. Opioids have been around for thousands of years and have long been used to treat pain. But in the mid-1990’s, there was a huge change in how doctors used these drugs. Before then, drugs like morphine were used principally to treat pain from cancer, after surgery or at the end of life. Narcotic painkillers were also used to treat more common kinds of pain caused by back injuries, headaches, arthritis and other conditions. But traditionally, the painkillers used in these cases were so-called “combination” drugs in which an opioid was mixed with an over-the-counter pain reliever like acetaminophen. Examples of such drugs are Percocet, which contains oxycodone, and Vicodin, which contains hydrocodone. There were other ways to treat long-lasting, or chronic pain, though they were used less often. One method was known as the “multidisciplinary” approach and it was based on the idea that chronic pain involved not only physical issues but also social and psychological ones. Patients were admitted into hospitals and weaned off of narcotic painkillers and other drugs. Then, they were put through programs, typically lasting about three weeks, which involved physical therapy, behavior modification and psychological counseling.

How did opioid prescribing become so widespread?

Barry Meier: In retrospect, it is hard to understand how drugs that have caused so much chaos became so widely prescribed. But the opioid boom that unfolded over the past decade was brought about by a mixture of forces that ranged from good intentions to medical wishful thinking to corporate profiteering.

In the past, doctors had limited prescribing opioids even to cancer patients and the dying because of addiction concerns. But in the 1980’s, researchers showed that cancer patients could be put on narcotics for months without getting addicted. That led to the idea that a much bigger group of patients – those with chronic pain from common causes – could also be safely treated with opioids. And to make this happen, pharmaceutical companies and pain specialists launched a movement in the mid-1990’s known as the “War on Pain” to change how doctors viewed opioids.

A pain specialist in New York, Dr. Russell Portenoy, provided the movement with its scientific underpinnings. He argued that the addiction risks of opioids were overblown and that they were also safe to use at high doses. This idea was critical to their expanded use because a patient often quickly adjusts to an initial dose of an opioid requiring a doctor to up the amount to provide the same painkilling effect. This reaction, known as tolerance, can then repeat itself, leading to higher and higher dosages.

Portenoy published some small studies to support his theories. But his research might have amounted to little without the other development that helped launched the opioid era – the introduction of the drug OxyContin.

OxyContin’s active ingredient, oxycodone, had long been used in Perocet and other drugs. But the drug was critically different in several ways. For one, it was pure oxycodone, making it far more powerful than Percocet. Secondly, its narcotic was packed at high doses into a time-released tablet. And thirdly, and perhaps, most importantly, OxyContin was marketed in a way unlike any narcotic painkiller before it.

Unlike strong opioids such as morphine that were principally used inside hospitals, OxyContin’s maker, Purdue Pharma, aggressively promoted it to general practitioners and family doctors. In doing so, the company claimed that that OxyContin time-release formulation would pose an addiction risk to patients of “less than one percent.” And the Food and Drug Administration, in a monumental mistake, allowed the company to say that its slow-release design was “believed” to be less prone to abuse than fast-acting drugs such as Percocet. (The idea was that drug abusers preferred a drug that gave them a quick hit).

As part of the “War on Pain,” patient advocacy groups funded by the drug industry also successfully lobbied state lawmakers to make it easier for doctors to prescribe narcotics. And insurers also played a critical role in driving the widespread use of opioids by cutting back on funding for alternative treatments such as “multidisciplinary” programs.

In the short-term, such programs, which cost from $15,000 to $25,000, are more costly than pain pills, which run about $6,000 a year. So insurers started insisted that doctors prescribe pills.

Barry Meier, a reporter for The New York Times, writes about the intersection of business, medicine and the public’s health. Mr. Meier is the author of an e-book, “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake” (The New York Times, 2013), and Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale, 2003). Visit his website at www.barrymeier.com.

Read Part 2 of his interview Friday, September 13.