In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive.

National Institute on Drug Abuse[1]

 [This is Fred and I’m here with more bad news about heroin and the other opioids now destroying us, plus some cheerful speculation. Note the paragraph quoted above. Apparently in the 1990s we didn’t understand that opium and its relatives are highly addictive, even though it was obvious 200 years earlier. See our recent blog[2] on Thomas de Quincey’s Confessions of an English Opium Eater.[3] So I guess our great planners didn’t expect patients to start abusing opioids once those drugs became plentiful by prescription. And once more people became addicted certainly no one expected the criminal class to fill the increased demand with their own, informal products. Who would ever dream such a thing?

Also, we still don’t know if opioids actually treat pain when they are used in the long term. According to one recent study: “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose dependent risk for serious harms.”[4] Translation?  The long term benefits are unclear, but the dangers are obvious.

Not to worry, the National Institutes of Health [NIH], and their parent, the Department of Health and Human Services [HHS] have swung into action. Today society has a problem with opioid addiction and they will solve it by:

  1. Improving access to treatment and recovery services;
  2. Promoting use of overdose-reversing drugs;
  3. Strengthening our understanding of the epidemic through better public health surveillance;
  4. Providing support for cutting-edge research on pain and addiction; [and]
  5. Advancing better practices for pain management.[5]

So what could go wrong? Well, think about it. If we’re going to improve access to “treatment and recovery” services [Point 1], what does that mean? Do we have some magic cure that will wipe away addiction? I don’t think so. It’s very difficult to ween an addict from his [or her] opioid of choice. It was that way for Thomas de Quincey, and the situation hasn’t changed.  And if the weening process takes a long time, that sounds expensive. Taxpayers beware!

OK, but surely it would be a good thing to promote “overdose-reversing drugs.” [Point 2] Yes it would, because those drugs prevent death by overdose and it’s always good to do that. But overdose drugs don’t cure addiction, so we still have the problem of treating the survivors.

All right, then what about Point 3? NIH wants to know more about the size of the problem, how many addicts there are, and so forth. Again, who can quarrel with that? “Knowledge is power,” we’re told;[6] and why rent a rowboat for addicts if we really need a passenger liner? So yes, by all means study the problem, but not at the expense of making progress elsewhere. And by the way, the early returns are in. See Crappy News, the next section.

How about “cutting edge research” [Point 4]; is that a good idea? Practically always, say I. If our scientists research pain, perhaps they’ll develop new ways to treat sufferers without dosing them with addictive substances. That’s got to be a “better practice” [Point 5] than what we’ve been doing.

Then what about “cutting edge research” on addiction itself? Should we work on that as well? Yes, and we’ll discuss that later, under Vaccines.]

The Crappy News, or Why One Should Avoid the Drudge Report Early in the Morning

So the other day I was minding my own business, checking the Drudge Report, when I happened on a piece from Reuters that said: “More than third of [all] U.S. adults [were] prescribed opioids in 2015.[7] [Drudge is my substitute for a morning tabloid; feel free to pick a different service if you want; but definitely we all need something to read at breakfast.]

Ugh? Looking further I found the original data, or at least an abstract of it.[8] Officially the study is called the 2015 National Survey on Drug Use and Health [NSDUH]. So let’s sketch the findings. What else can you do with an Abstract?

  • In 2015 72,600 eligible civilian, noninstitutionalized adults were selected to participate in the study, and 51,200 completed the survey interview.
  • Based on these inputs, NSDUH estimated that, in 2015, 91.8 million (37.8%) of U.S. civilian, noninstitutionalized adults used prescription opioids.
  • 11.5 million people (4.7% of all adults) misused opioids; and 1.9 million (0.8%) had an opioid use disorder.
  • Among adults with a prescription, 12.5% reported they misused it; and of these, 16.7% reported a “prescription opioid use disorder.”
  • Most commonly people who misused opioids did so to relieve physical pain (63.4%). Does that sound familiar? Check out Thomas de Quincy’s story, referenced above.
  • Misuse and use disorders were most common with adults who were uninsured, unemployed, had low income, or had behavioral health problems.
  • Among adults who misused opioids, 59.9% reported using them without a prescription, and 40.8% obtained prescription opioids – for their most recent episode – for free from friends or relatives.[9]

So there you have it. Lots of doctors prescribe opioids; more than one-thired of U.S. adults had prescriptions in 2015; and some of those also used opioids without a prescription. Thank you, NSDUH, for that insight.

And some patients get violent if their doctors refuse to write prescriptions.[10] The states are upset; they argue over-prescription and the resulting addictions are impacting state resources;[11] and they’re beginning to sue the drug companies [and others] they think are responsible. Congress is alert, and will hold hearings on the matter.[12] Mexico is producing more and more opium to satisfy the demand growing in the U.S.[13] [Frankly, I didn’t know Mexico produced any opium; I thought most of the world’s supply came from our dependency, Afghanistan.] And, of course, our medical establishment is studying the problem that, one could argue[14], it created.

Vaccines

None of this is good, but is there sunlight behind the clouds? A month or so ago a friend[15] sent us an article about medicines that fight opioids and other addictive substances.[16] Apparently this has been researched since the 1970s, although without much recent success. Right now therapists have only three medications – methadone, buprenorphine, and naltrexone – to use to help the opioid addicted “get clean” and stay drug free. They work, but “not perfectly.”[17]

Current research is directed toward finding vaccines to directly counter opioid addiction. Most foreign substances are blocked from entering the brain by something called the blood-brain barrier. Opioids are an exception to that. They are very tiny molecules; can penetrate the barrier and enter the brain; and then do their damage unopposed. Opioids may lose their advantage – of small size – if they are attacked by antibodies “that bind to the drug molecules, creating complexes that are too large to cross into the brain.”[18] If the brain isn’t accessed, “there’s no high.”[19] And, one might add, there’s no corresponding brain damage to reinforce later addictive behaviors.

So the research is directed at triggering the human immune system to directly attack opioids. To (i) convert opioids to larger things that will not pass into the brain, or (ii) flush them out of the body before they reach the brain, or (iii) to do both. The Scripps Research Institute in La Jolla, CA, and the Walter Reed Army Institute of Research in Silver Spring, MD, have promising lines of study, and may have vaccines ready to begin human trials in the not too distant future. There are other candidates out there as well.

Conclusion

The situation with opioids is grim and looks worse every day, but perhaps there really is sunlight behind the clouds. The important thing for Congress to remember is that, when they’re throwing oodles of money at law enforcement to chase bad guys with drugs, they shouldn’t forget the scientists who, with funding and a bit of luck, may solve this problem for everybody.

Until the next one comes along, of course. Humans are weak, and our criminals are very ingenious. Didn’t you know?

 

[1] This is from the website of the National Institute on Drug Abuse, an organization within NIH. You can find it at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis . It was last updated in June of this year.

[2] That’s the blog of 07/16/2017, Opium Portrayed, at  https://opsrus.wordpress.com/2017/07/16/opium-portrayed/

[3] That’s Confessions of an English Opium Eater, Being an Extract from the Life of a Scholar. It’s currently in print from the Oxford University Press.  It was first published in 1821 in London Magazine, and was picked up in 1886 by George Routledge and Son. You can find the hard copy on Amazon. However, in keeping with blog policy, we found an alternate, free source for the text, this time in an eBook from Project Gutenberg.  Go to http://www.gutenberg.org/files/2040/2040-h/2040-h.htm .

[4] See Annals of Internal Medicine, The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop (February 17, 2015) at Abstract, available at http://annals.org/aim/article/2089370/effectiveness-risks-long-term-opioid-therapy-chronic-pain-systematic-review .

[5] See n. 1.

[6] See Knowles, Oxford Dictionary of Quotations (6th Ed., 2004) at Proverbs, p. 624, n. 45.

[7] It’s at Reuters Health News, Seaman, More than a third of U.S. adults prescribed opioids in 2015 (July 31, 2017), available at http://www.reuters.com/article/us-health-opioids-prescriptions-idUSKBN1AG2K6 .

[8] The Abstract appears as Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health (August 1, 2017). You have to pay for a copy if you want to read the underlying article. I don’t know why that’s the case, since the study apparently was funded by our government. Anyway, the abstract is available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782928/pdf/nihms753305.pdf .

[9] These findings are paraphrased or directly quoted from the Abstract.

[10] See, e.g., Fox 5, Hundreds mourn doctor slain after denying opioids to patient (August 2, 2017)), available at http://www.fox5ny.com/news/271464646-story .

[11] See Reuters, Raymond, State attorneys general probe opioid drug companies (June 15, 2017) available at http://www.reuters.com/article/us-usa-opioids-idUSKBN1962JJ

[12] See Clair McCaskill speaking to the DNC on July 28, 2016, available at https://www.bing.com/search?q=hthtps%3A%2F%2Fwww.yahoo.com%2Fnews%2Fu-senator-launches-probe-five-top-opioid-drugmakers-165514279 finance.html&form=EDGEAR&qs=PF&cvid=59500fa1e8204d0a8a8906e8292f9679&cc=US&setlang=en-US&elv=AXXfrEiqqD9r3GuelwApuloTP6wVwkOjONBqpuAMtOReD2p9Vv8km70BwEANJJDGrbYQZQruLL%21jduPgTqpAT%212GMOjDF0L2w7LKJr4QVFIa

[13] See RT, US offers to help fund Mexico’s heroin eradication efforts – report (22 April 2017) available at https://www.rt.com/usa/385656-mexico-fund-heroin-reuters/

[14] In fact, there doesn’t really seem to be an argument about this. See n. 1 and the quote that accompanies it.

[15] That’s Dave Feagles. Many thanks, Dave!

[16] See Science News, Gaidos, Vaccines could counter addictive opioids, Vol. 190, No. 1, p. 22 et seq. (July 9, 2016), While we have this article in our library, we don’t have a web  address for it, so we’re citing to the hard copy magazine.

[17] Id. We’re citing to the print version of the article, but don’t have the printed pages before us. We estimate that this information appears around p. 23.

[18] Id. at around p. 24.

[19] Id.

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