The Opioid Crisis: A Historical Perspective | Wisconsin Public Television

The Opioid Crisis: A Historical Perspective

The Opioid Crisis: A Historical Perspective

Record date: Mar 28, 2018

June Dahl, Professor Emeritus of Neuroscience at UW School of Medicine and Public Health, discusses the history of opium and opioid analgesics and their use, the types of opioids that are currently in use and how to manage pain.

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Episode Transcript

So welcome to

Wednesday Nite at the Lab.

My name is Liz Jesse and I'm

a Science Outreach Specialist

at the UW-Madison

Biotechnology Center.

On behalf of the

Biotechnology Center,

UW-Extension and

Cooperative Extension,

Wisconsin Public Television,

the Wisconsin Alumni Association

and the UW-Madison

Science Alliance

I would like to thank you

for coming out tonight

to Wednesday Nite at the Lab.

We do this every Wednesday

night 50 times a year.

Tonight it is my extreme

pleasure to introduce June Dahl.

She is a professor

emerita of Neuroscience

at UW-Madison School of

Medicine and Public Health.

Dr. Dahl completed

her BA in chemistry

from Macalester College

in St. Paul Minnesota

and she earned her doctorate

in physical chemistry from

Iowa State University.

She arrived in Madison

with her husband

when he joined the UW-Madison

chemistry department.

In 1984 she was appointed to

the Controlled Substances Board,

Wisconsin's drug

Regulatory Authority.

It was service on that

board along with a bill

introduced into Congress in 1986

to make heroin available for

paying treatment for the dying

that led to her focus on

educational and policy issues

directed at improving

the management of pain.

Tonight Dr. Dahl

will provide a review

of opioids and their

use and she will address

the importance of

maintaining a balance

so that efforts to reduce

abuse of these drugs

do not interfere with the

appropriate medical use.

Ladies and gentlemen please

join me in welcoming June Dahl.

[audience applauds]

- So I selected

this as the title

of the comments I'm going

to make to you tonight.

"The Opioid Crisis: An

Historical Perspective"

and what I would like to do

is define some terms

starting with the word opioid

since we're going to talk

about the opioid crisis.

What are these drugs?

And I suspect all of

you know what they are.

They relieve pain,

they cause sedation,

they suppress cough,

they cause constipation

and they include the

illegal drug heroin

and also a lot of pain medicines

that are available

by prescription.

None of them is available

over-the-counter

at this point in time.

And they're drugs like

oxycodone and hydrocodone

and codeine and morphine

and there are a

whole bunch others.

One of the points I would

like to make is that

some of these drugs contain

other things besides opioids.

And one of them that's very

commonly prescribed is Vicodin,

which is hydrocodone

and acetaminophen.

And the acetaminophen is

a rather dangerous drug.

If you take a lot

of it you can have

severe damage to the liver.

Now that was a description

of some of the opioids.

I've just put this

slide in very quickly

to tell you that there

are a lot of others

and you can distinguish

them one from the other

by how long they last or

by how they are given.

So there are short-acting

drugs and long-acting drugs

and then they're ultra

short acting drugs.

And the only one that's

really used a lot today

in the ultra short-acting

category is fentanyl,

which can be given

intravenously or transmucosally.

Now when we talk about these

drugs perhaps you can tell me

how long do short-acting

opioids produce pain relief?

Do you know how--

- Two hours.

- Two hours!

Somebody else got

another number?

- Four.

- Four!

Well you could both be

right because how do we know

how long a drug

gives pain relief?

You ask the patient.

I always tell the students

that every patient

is an individual

pharmacologic experiment.

So you can't just

read a textbook

or a manuscript and figure

out how long it lasts.

You have to ask the person.

So some people get six hours

of pain relief from morphine.

But most get three to four

and some may even get two.

In the long acting category

there's a whole

range of durations

from eight hours to

perhaps even as much as 24.

And something like fentanyl

doesn't last long at all.

You have to keep giving it

in order to get an effect

There also are antagonists.

And has anybody here not

heard of naloxone or Narcan?

Everyone has because

it's used a lot

to reverse the respiratory

depressant effects

of morphine and other opioids.

And another drug in this

family is naltrexone.

And you can see that

there are a whole bunch

of brand names there.

Again that's used for

different purposes.

And then they're the

new kids on the block

and these are the abuse

deterrent opioid formulations.

And they've been put together

to try to keep people

from abusing this

class of medicines.

How well do you think they work?

Well I would say that anybody

who is determined

to abuse a drug

can figure out a way to

circumvent the formulations.

And so they aren't abuse proof

but that's not a

surprise to you.

So that was the

overview of opioids.

But what about the word crisis?

I looked that up

in the dictionary.

You all probably know because

you're more learned than I,

what's a crisis?

Any event that's going to

lead or is expected to lead

to an unstable and

dangerous situation.

And it can affect an individual

or it can affect a group

or a community or

a whole society.

And crises have damaging

effects at various levels.

Is there a crisis

involving opioids?

And what's the evidence

for that crisis?

Well actually there's

more than one crisis

relating to opioid analgesics.

One of them relates to

overdosage and deaths.

And I've put some

figures up here

but you can't really be

certain about the numbers.

How many people die

of overdose in a year?

It's not certain and

we get various numbers.

But I want to compare

the number of deaths

with the number of

deaths of soldiers

who died during the Vietnam War

and also the number of persons

who died of car crashes

back in 1972 when car crashes

peaked in this country

and then how many

people died in 1995

because of HIV/AIDS infections.

So you can see that

the numbers for opioids

are very large indeed.

So in fact there's another

crisis with opioids

that I want to talk about.

And that is the fact that

concerns about their diversion

and abuse is leading to

their underutilization

and that's leading to people

experiencing unrelieved pain.

So what's pain?

It all starts

with pain actually.

And we get different

feelings about what pain is

depending upon the era in

which we get information.

If we look at the giants

of ancient Greece,

Plato and his student Aristotle.

They considered pain

to be an emotional

not a sensory experience.

And pain was an independent

being that invaded our bodies,

took it over.

If you've had severe

pain doesn't that

sometimes feel that way to you?

Aristotle said that pain's

"like a spirit that enters through an injury".

This traditional view of

pain as an external force

has been a persistent one.

Pain is often seen as

an act of God or of gods

as a kind of punishment

or a test of faith.

And the word pain actually

comes from the Latin

that means penalty.

During the Renaissance,

Descartes took a different view

and in the 1600s

he refuted the idea

that pain came from the outside.

He proposed the pain was due to

an internal mechanical process,

that the body was a machine.

And pain was a disturbance

within the machine.

And then we go to

evolutionary theory

where pain is a way that

the body defends itself.

And it reminds us to avoid the

causes of pain in the future.

The intensity should

be proportional

to the risk that the

stimulus creates for us.

However natural selection

is rarely perfect

so some things are

disproportionately more painful

than the risk they pose.

And I ask you to think

about the lowly paper cut.

I find those

extraordinarily painful.

And think on the other hand

about the real agony of gout.

I found-- probably can't

see this too well--

but I found this online of

course where everything is.

And I can see this

incredible red swelling.

This is enormously painful.

And I like this

cartoon much better.

You see this ugly little being.

I like his tail and I don't

know why I think it's a male

rather than a female

but this is the gout

and you can see how he's

going after the joint.

And then we should

consider the pain

of what some have

called wounded warriors.

These are persons who

are injured in conflicts.

Seriously wounded

soldiers were questioned

after receiving their wounds

by Lieutenant Colonel

Henry Beecher.

And these individuals

had been injured

during the invasion

of Anzio in Italy.

If you ask young kids about

the Anzio beachhead invasion

they have no idea what

you're talking about.

But I suspect you folks do.

What he found was that if

he surveyed these soldiers

12 hours after their injuries that 25% of them said

they had slight pain,

32% had no pain and 3/4 of

them felt so little pain

that they didn't think

they needed medication.

The soldiers wounds

released them

from this horrendous

situation which might

ultimately threaten

their whole being.

This wasn't the case with

veterans of the Iraq War

and it's not the

case with persons

who are injured in accidents,

industrial accidents

that produce similar

kinds of lesions.

Those persons are very

vigorous in their demand,

I should say, I

wrote pursuit here,

but it's really demand

for pain relief.

And the International

Association for

the Study of Pain

put these concepts

together very nicely

when they created a

definition of pain in 1975.

They recognized the

dual nature of pain

and said "it's an unpleasant

"sensory and

emotional experience

"associated with actual

or potential tissue damage

"or described in

terms of such damage.

That certainly captures very

well the kinds of reports

that we see from

individuals who were injured

in various situations.

Now we need to talk because

I was asked to do so,

a little bit about the history

of opioid analgesics themselves.

The history of embracing

and rejecting their use.

How many times has

this pendulum swung?

One, two, three, four, 10, 12?

What do you think?

Actually the swing

has really been

fairly large and numerous.

And so we need to look a

bit about opium history.

The earliest reference

to opium growth and use

was in about 3400 BC.

That was even before I was born.

By 1300 BC the Egyptians

were cultivating opium

and they named it on the

basis of the capital of Egypt

at the present that

time which was Thebes.

Hippocrates who is considered

to be the father of medicine,

noted way back when

the pain-killing

properties of opium.

And around 330 BC

Alexander the Great

introduced opium

to Persia and India.

and then comes Paracelsus.

Any chemists in the audience

know about this individual.

He is putatively the

father of toxicology

and he's the person who

actually compounded laudanum.

Laudanum is 10% opium

and alcohol.

And that led me to

ask the question is

when did alcohol

come into human use?

Anybody got a guess?

10,000 years ago.

Because of course you

don't have to take

the alcohol from some plant

or anything like that.

It's produced when

plants ferment

so it's pretty accessible

if you look out for it.

Thomas Sydenham who's considered

the father of English medicine

or the British Hippocrates

recognized the power

of opium around 1680.

He wrote a couple of

things that I think

are one statements that

we ought to think about

that I really adhere

to at the present time.

He said opium and I would

substitute opioid analgesics

is "one of the most valued

medicines in the world

"which does more

honor to medicine

"than any remedy whatsoever."

He also wrote that

"among the remedies

"which it has pleased God

Almighty to give to man

"to relieve his sufferings

none is so universal

"and efficacious as opium."

Those words are

still true today.

And so in many ways these

are God's gift to humanity.

What's this?

That's a poppy!

Isn't that gorgeous?

That's the source of opium.

Now how do we get

opium from this poppy?

Well not from grinding up

the poppy leaves, not at all.

But from waiting for the plant

to dry and form these pods.

And notice that

wonderful drip there?

Opium comes from that

juice of the poppy pods.

And people can score

these pods, open them up

and the juice will run out.

Now the poppy juice

contains morphine

and also contains

codeine and thebaine.

And thebaine is important

because it serves as

a raw material for the

synthesis of other opioids.

One of the opioids that's

got great attention

all of the time is heroin.

And heroin is actually

diacetyl morphine

and why is it so abused?

Well because it's less

bulky than morphine

and it's easier to smuggle.

What's the source

of morphine today?

Where does it come from?

- [Man] The juice.

- The juice, that's right!

There is drugs that

cannot be synthesized

de novo in the laboratory

and opioids are one category

and cardiac glycosides

constitute another category.

I'm sure it won't be long

before there are

synthetic processes

to produce morphine

in the laboratory.

But right now

that's not the case.

So here are some

structures for chemists

who love to look at structures.

And there's morphine, notice

those two hydroxyl groups.

And they get acetylated

and the acetylation transforms

that molecule to heroin.

Down below morphine

is methadone.

You ever heard of that?

It's a long-acting

orally effective drug

it could also be

given parenterally.

Methadone was synthesized

by a German chemist

during the Second World War

because their supply of

natural opioids was cut off

and they needed a very effective

medicines to treat pain.

Notice hydromorphone in the

upper right-hand corner.

And that's very

similar to morphine.

It is in many ways

except it's more potent.

Does that mean it's

more effective?

No, it just means you

give less of the drug

to get the same

pharmacologic effect.

And notice down in the bottom

corner is the drug naloxone.

Many of you already

knew what that drug was

but I told you before this

is an opioid antagonist.

So you can see by

simple transformation

of the structure of

morphine to naloxone,

you get a compound that is an

antagonist of opioid actions.

Doesn't have actions of its own.

It's just a blocker.

- [Man] Can I ask

you why is that?

- Why is that?

- Yeah.

- I have no idea why that is.

It has something to do with

structure activity relationships

but I can't answer

your question easily.

It would take me

about 20 minutes.

But we can do that later.

How's that?

Is it a deal?

- [Man] Okay. [laughs]

- I don't think he really

wants to have 20 minutes

but he asked the question.

So a little bit

about opium history.

Before 1800 crude opium

was widely available

in the United States

and it was an ingredient

in multi drug preparations.

And of course as

I've already told you

in laudanum which was

10% opium in alcohol.

And it was very valued

for its calming and

soporific effects.

It was also a specific

treatment for GI illnesses.

Given that opioids

cause constipation

it's an interesting balance

to think about

treating GI illnesses.

It was a drug that

was prescribed,

well really supplied

very freely by physicians

in calm teething children

and it also calmed

hysterical housewives.

Now I don't know if it calmed

hysterical house husbands or not

[laughter]

but I will look into that.

- [Man] Yes, yes it does.

- I've gotta find that.

- [Man] In a pill form.

- In pill form!

A drug that calmed people

down was very appealing

because physicians had almost

nothing to work with

at that point in time.

There weren't effective agents,

there wasn't even aspirin.

So that was the good times

when there was opium.

And it was freely available.

So we're talking

about the history

of embracing and

rejecting the use.

What happened?

What happened was

that morphine use

became a booming business in

the 1800's in this country.

It had been isolated from opium

by a German pharmacist in 1803.

And he named it morphia

after Morpheus the

Greek god of dreams.

And manufacture of morphine

salts started in 1832

and the hypodermic

needle was perfected

in the middle of the century.

Wasn't this wonderful

for those persons

who were serving

in the Civil War?

During the 1800s there

was a dramatic increase

in the consumption of morphine

and the per capita

peaked in 1896.

just at the end of the century.

And then the

pendulum swung back.

Reaction to the freewheeling

use of the 1800s.

And in 1906 there was a

Pure Food and Drug Act.

In 1914 the Harrison Act

which regulated and taxed

the production, importation

and distribution

not only of opiates but

also of cocoa products.

And then in 1919

the Supreme Court outlawed

addiction maintenance.

And then in 1937 there

was what was called

the Marijuana Tax Act and

marijuana was linked to

other alarming drugs such

as cocaine and heroin.

So that was the era

when marijuana became

really bad stuff.

And in the 20 years

between 1930 and 1950

the severity of the

anti-drug laws increased

and it peaked in 1956 when

there was the death penalty

for the sale of

heroin to minors.

And I thought about

that when I heard that

Trump had recommended

the death penalty

for narcotic dealers

in this country.

I think that was the

word that was used.

So now we look at some of

the other perspectives.

And here's one about

the use of medications

for controlling pain in persons

who are dying of cancer.

This was published in 1941

in the Journal of American

Medical Association.

Dr. Lee wrote "The use of

narcotics in terminal cancer

"is to be condemned if it

can possibly be avoided.

"Morphine and terminal cancer

are in no way synonymous.

"Morphine usage is an

unpleasant experience

"to the majority

of human subjects

"because of undesirable

side effects."

Wow.

"Dominate in these lists

of unfortunate effects

"is addiction."

What about all those people

who abuse these drugs

because they really liked them?

And then the

pendulum swings again

because an emphasis

came on end-of-life care

and that changed the perspective

on the use of opioids.

In 1948, Dame Cicely Saunders began her work in England

and she applied the

name hospice care

to specialized

care of the dying.

That term actually goes

back to medieval times.

It means a place to shelter

weary or ill persons

who have traveled

long distances.

The interesting thing was

that Dr. Saunders used heroin

to treat her patients

who were dying.

Remember heroin is

diacetyl morphine.

It's a controversial

way to give morphine.

For some reason Dame

Saunders thought

that there was something

special about heroin.

And it took a lot of convincing

to get her to change her mind.

In 1967 she founded St.

Christopher's Hospice in London.

And then in '74 Florence Wald,

who was Dean of the

School of Nursing at Yale

established the first

Hospice in the United States

in Branford Connecticut.

But this was a focus

really on cancer pain.

And in 1984 a bill was

introduced into the Congress

to make heroin

available to treat pain

in the terminally ill.

Now this bill did

not become law,

but this bill

stimulated my interest

in impediments to

effective pain control.

That was the summer, 1984,

when our family did

its Washington trip.

And the Washington Post

published an editorial

strongly supportive

of the heroin bill.

Well I tried to get into the

paper to talk to the editors

and I didn't succeed in that.

I was told I didn't know

what I was talking about.

And I tried to talk to

members of Congress,

equally unsuccessfully,

but I came back to Madison

and I decided we ought to

do something about pain

in a way that

heroin's availability

couldn't possibly do.

And with that kind of desire

we established

some programs here

to focus attention

on cancer pain.

And it worked very

well because in 1986

the World Health Organization

introduced the analgesic ladder,

gave a perspective on how

to treat the pain of cancer

as it increases in intensity.

But that was also a time

when there was a lot

of illegal drug use.

In the 60s there was

astonishing increase

in the use of illegal drugs.

In 1970 the Controlled

Substances Act was passed

and in 1973 the Drug

Enforcement Administration

was established and Richard

Nixon set up its purpose

which was to wage an all-out

global war on the drug menace.

What did Nixon's

efforts really do?

Well what they really did

was to reduce the production

of opium by Turkish farmers.

And in so doing we've had

a shortage of morphine

in this country,

a shortage of morphine

to treat persons in pain.

Unfortunately cancer

pain management,

which started so beautifully

with efforts in England

and subsequently in Connecticut,

it remains a significant

concern in ambulatory oncology

and I've given a

reference in this slide

to a paper from 2014 that

discusses the problem

and tells us that the

magnitude and scope

of pain treatment inadequacy

hasn't decreased substantially

in the past decades

in the United States

despite the fact

that there's been

a long-standing awareness

of this problem.

- [Man] It's just

gotten worse too.

- Just gotten worse in

many ways. Good for you.

In the early 1900's nearly 900

ECOG Eastern Cooperative

Oncology Group clinicians

were surveyed about

paint treatment barrier.

Half of them thought their

patients had good pain control

and a number of the

clinicians surveyed

cited many concerns

about pain assessment,

about the adverse

effect of opioids,

about the reluctance

that patients had

to report their pain and

take their medications.

And medical oncologists

today in 2018,

still identify those barriers

to effective pain control.

Also it was seen long

ago, 20 years ago or more,

that non-Hispanic white patients

and patients with the most

obvious burden of illness

are most likely to receive

adequate cancer pain management.

That shouldn't

surprise us at all.

And then there's

some seminal events

we need to be concerned about.

In 1986, Russ Portenoy

and Kathy Foley

of Memorial Wloan-Kettering

published a seminal paper

on the use of opioid analgesics

for the treatment of

chronic non-cancer pain.

Remember the discussions

previously had all been about

treating pain in

persons who had cancer.

And then in the 1990s extended-release opioid formulations

were introduced and the one of course we've heard most about

is Oxycontin, which

is extended release

or controlled release or

sustained release Oxycodone.

In 1997 the pain standards

from the Joint Commission

were promulgated.

Which meant that

healthcare facilities

could no longer ignore pain.

And I was extraordinarily

pleased to get a grant

from the Robert Wood

Johnson Foundation

to work with the

Joint Commission

to develop these standards.

And it's been really

frustrating to read

that those standards

are responsible for

our current problems with

diversion and abuse of opioids.

Apparently if you don't

ask anybody about pain

you won't ever have a problem because you don't have to treat.

In the early 2000s there

was a rapid increase

in the prescribing

of opioid analgesics

and then also an increase

in the diversion

and abuse of drugs

and increased deaths

from these drugs.

And sadly a lack of evidence

for the efficacy of opioids

for the management

of persistent,

I'm using that word

instead of chronic,

persistent non-cancer pain.

What's the future?

What are the crises

in pain management

that we need to be

concerned about?

Well one of them I've

already suggested is the case

and that is the lack of

evidence for outcomes

and inadequate education

of primary care providers.

And it's upon this

group of providers

that the major burden

of care has fallen.

There's a lack of access

to multidisciplinary care.

Well, why is that

so darn important?

Because we have to use

the diversity of methods

and drugs in order to

manage pain effectively.

There is an inadequate

reimbursement

for behavioral and

physical therapies.

And then as I said already

there's an uncertainty

about the value of

opioid treatment

for chronic non-cancer pain.

And a big problem with

managing chronic pain,

persistent pain in

persons who have

a history of substance

use disorders

as you probably know

we no longer talk about

drug abuse and drug abusers,

we talk about

substance use disorder

and persons with

substance use disorders.

The vocabulary has changed

in the last three years.

And again repetitive,

repetitive uncertainty

about the risk and indeed

the meaning of addiction.

So what are the benefits

and what are the risks

associated with

opioid treatment?

If you're interested

in reading anything

I'd be happy to email you papers

that provide some insights

into the answers

to these questions.

The effectiveness of

opioids for chronic pain

has not been adequately studied,

but a very astute

clinician wrote in a paper

in the New England Journal

of Medicine in 2016,

that "The absence of evidence

is not evidence of absence."

So when he wrote about

the use of opioids

for the treatment

of chronic pain,

he really was

emphasizing the necessity

of achieving the right balance.

How do you balance

effective treatment of pain

against any potential

for diversion and abuse?

And he rightly wrote

about the right balance

being achieved

through education.

There's some very

interesting quotes

that I will share with you

as quickly as possible.

One of the things was

shared by Chris Pasero,

who was a nurse

practitioner and advocate,

a medical director of surgery

said to a director of nursing

at a prestigious

hospital in California,

"Please inform all bedside nursing personnel

"to refrain from asking

patients if they have pain.

"The prevailing

understanding is that

"patients are more likely

to complain about pain

"if nurses ask if they have it.

"If necessary doctors

will determine

"if the patient has pain."

[crowd murmurs] - [Man] That's

how it is at the VA.

- [June] Why? - [Man] That's how it is at the VA.

- Oh no that wasn't the VA.

- [Man] I'm saying

they do that today.

- Oh a similar perspective.

A reaction to the Joint

Commission standards

which I take personally

from Jane Ballantyne

and Mark Sullivan who are at

the University of Washington.

"We believe that opioids

will still be over prescribed

"unless changes are made

to the blanket requirement

"to treat on the basis

of the report of pain."

They actually believe that

you shouldn't ask people

if they have pain

because if you do

they might give you a report

and that you might make a

decision about treatment

based upon that patient report.

Well that's not the

way to do things.

So the problem with

chronic pain and opioids

is that it's chronic

pain is very prevalent

and it's among the most

debilitating medical conditions

but also among the

most controversial

and complex to manage.

How many people in this

country have persistent pain?

He knows. How many?

- Oh I don't.

- Oh, you don't know.

- [Man] I thought you were

asking all the people--

- All the people in the room.

100 million, how's that?

A trivial problem right?

The limited therapeutic

alternatives

for this horrendous problem

have combined to produce

an over reliance on opioid meds.

And this, associated with

this alarming

increase in diversion

and overdose and addiction,

that physicians

understandably have questions

about whether and when how to

prescribe opioid analgesics

for chronic pain.

Josh Bloom wrote an article

that he published

online very recently

and he said, "In 2016

it's reported that--"

I don't know

how many people died

of a drug overdose,

maybe 43,000,

maybe the number is 33,000

that involved opioids,

as 18,000 deaths from natural

and synthetic

opioids and methadone

but the important

comment he made,

which I emphasized

before and want to again

is that in 2005 at least

half of the people who died

from prescription

opioid overdoses

had also taken a benzodiazepine.

44% of the time they

had taken alcohol.

These sedative drugs

are very lethal

when combined with

opioid analgesics.

The other important point

is that now we've seen

a change in the

source of the drugs

that are abused or are

involved in opioid overdoses,

90% of opioid overdose

deaths in the recent years

were a result of

illicit fentanyl

and its analogs, or heroin,

or a combination of opioid

drugs with other drugs of abuse.

And alcohol is certainly

a drug of abuse.

The other point he made

which is very important

is that pain patients

who use opioids

correctly and responsibly

are not the persons who

are dying of overdose.

They're not.

Now how about controlling the

swing of the opioid pendulum?

Again another article

published recently

in the New England

Journal of Medicine.

Some clinics have

established policies

of not prescribing

opioids at all.

And yet we know that opioids

are an important part

of the therapeutic

armamentarium.

And as the pendulum swings

from liberal opioid prescribing

to a more rational measured

and safer approach,

we can strive to ensure that

it doesn't swing too far,

leaving patients

suffering as a result

of injudicious policies.

What about the effect of

opioids and non-opioids

on pain related function

in patients with

chronic pain problems?

There was a paper published

relatively recently

in the Journal of the

American Medical Association.

The authors concluded that

treatment with opioids

was not superior to

treatment with non-opioids

for improving pain related

function over 12 months.

They said that the

results do not support

the initiation of opioid therapy

for moderate to severe

chronic back pain

or hip pain or knee pain if

it's due to osteoarthritis.

But they don't support

discontinuation of therapy.

so this JAMA paper has attracted

an awful lot of attention.

And the results have

been used to justify

aggressive tapering or

immediate discontinuation.

What happens if you cut somebody

who's been on an

opioid for a long time

and you stop their drug?

- [Man] We're going

through withdrawals.

- Yeah you go through

terrible withdrawal.

And Medicare misread

the recommendations.

The CDC gave a

90-milligram red flag

for patients in acute pain

who are just starting

opioid therapy.

It's not for patients

with chronic pain

who have been taking opioids

for a long period of time.

And yet the results were used

to justify aggressive tapering

or immediate discontinuation.

To repeat what's on line one:

actions "that could harm people"

And so the authors

of that publication

which recommended that

you not start opioids

with persons who have

certain osteoarthritic pains

said we can't walk

away from patients

who've been treated for

years even for decades,

we've created double

tragedy for those patients.

So how many times does

the opium pendulum swung?

Well, here's another report.

It was an Internet post.

I tried to get the source.

This describes John, a

former cable company salesman

who's used Oxycontin,

that horrible drug,

to treat the severe back

pain caused by injury

sustained during

a mugging in 2011.

Before he found a medication

that worked for him

he said "My wife was

about to leave me

"because I was a

miserable bastard.

"When you're in that much pain

you just want to go to sleep

"and not wake up."

Last fall John was told that

by a physician assistant

that his dose was

going to be reduced.

It had been 60 milligrams

three times a day.

The PA said this was too high

and would have to be

dramatically reduced

under a new rule.

I guess that rule

is the CDC guideline

that didn't set

any mandatory limit

but it recommended people

not start on high doses

of 90 milligrams per day.

He said "My whole life

turned upside down

"in a matter of 30 days,

I'm back in bed now.

"I can't really

get up very much.

"I'm right back where

I started in 2011."

So we have another

opioid crisis as well.

We have the crisis

where people are not

getting adequate treatment

but there is a

shortage of opioids

as a result of this call

back of opioid availability.

And it's left many hospitals

and surgical centers

scrambling to find enough

injectable morphine

or dilaudid or fentanyl.

These are drugs given to

patients who aren't abusers,

but are undergoing surgery

or they've had cancer

or they have traumatic injuries.

This shortage which were

reported last summer

has worsened now.

And then another opioid crisis.

It isn't just opioids.

Overdose deaths linked to

legal and illegal drugs.

Remember benzodiazepines

and alcohol.

The author of this comment

said that he believes

there's an increase

in deaths of despair,

that something deeper has

gone wrong in American life,

because of poor

mental health care,

jobs leaving parts

of the country

and a growing sense

of social isolation.

When the public was recently

polled to ask their perspective

about the opioid abuse epidemic,

the results were very

interesting to me.

A majority didn't deem

addiction to pain medicine

was a natural

national emergency.

And few people see

it as an emergency

or a major problem in

their own community.

So public and private

sector leaders

are looking for a substantial

increase in funding

for opioid addiction

treatment programs.

Yet a large share of the

public is really uncertain

about the long-term

effectiveness of treatment.

So we have this lack

of understanding

of the problems that exist.

Many medical experts say

that the CDC guidelines

play up the hazards of opioids

while playing down

their benefits.

The overall message is that

clinicians should be stingy

with these medicines,

prescribing only

as a last resort

in maintaining the

lowest possible doses.

Despite the CDC is

protesting to the contrary,

the mission of preventing

abuse and diversion

seems to be interfering with

the average pain

practitioner's duty

to provide appropriate care.

And it leads in extreme

cases to suicides

by patients who can't seem to

get the relief that they need.

So concluding our challenge.

We need to maintain

our focus on pain.

It's under-treatment is a

major public health problem

in the United States.

Certainly the number of

persons who have chronic

or persistent pain is

just mind-boggling to me.

We need to maintain a balance.

We need to assure

that efforts to reduce

the diversion and

abuse of opioids

don't interfere with their

appropriate medical use.

I think that is not the

case at the present time.

I think there's a

lot of interference

with appropriate medical use.

And don't forget our other

prescription drug problem,

which I have alluded

to more than once.

The benzodiazepines.

Deaths involving benzodiazepines

increased from 1,135 in 1999

to 8,971 in 2015 and I

couldn't find the 2017 data

to present to you but I

doubt the number's gone down,

despite efforts to

reduce the prescribing.

And thus the availability

of benzodiazepines.

3/4 of guests involving

benzodiazepines,

at least a couple of years ago,

also involved an opioid

of lethal combination.

I think it's important also

to accept the challenge

presented by the National

Academy of Medicine.

We need a cultural

transformation to

better prevent,

assess, treat and understand

pain of all types.

The level of ignorance

is really profound.

It always astonishes me.

And the number of

hours spent on pain

in medical school

curricula is trivial

compared to the

magnitude of the problem.

I think it also is

important to embrace

the philosophy of

the Dalai Lama.

Pain is inevitable.

We're all gonna get it,

unless we have this

genetic predisposition

where we can't feel any pain.

We have this abnormal

sodium 1.7 channel,

that voltage-gated

channel and it's odd

because we don't feel pain.

But for all the rest of folks

except those 200 or so persons

with that genetic abnormality.

Pain is inevitable,

but suffering is optional.

And what we've got to

do is to make suffering

much less in this country.

It's not optional for

us to allow things

to continue as they

are and they're only

getting worse at

the present time.

So I thank you for your

very kind attention.

I'm sorry some of you

could not sit down.

I wanted to tell you

to come sit in here

there's seats in a row.

And I thank you

for your attention.

[audience applauds]

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