“Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”
— Jane Porter and Dr. Hershel Jick, Boston University Medical Center, in a 1980 letter to the New England Journal of Medicine.
This seemingly innocuous, 101-word letter written by doctor and his assistant at the Boston Collaborative Drug Surveillance Program in 1980 has been cited for decades by pharmaceutical companies and other researchers as evidence that opioids don't cause addiction, thus transforming the letter into a much more extensive study than it ever was intended to be.
“It was just a letter saying one experience in Boston in a hospital setting had patients with chronic pain who didn't appear to be addicted to opiates, even with long-term use. There was no evidence. It was just someone's opinion,” explained Chris Solaro, an emergency medicine physician and chief of medicine at Blessing Hospital. “But this little letter was misinterpreted as evidence that long-term opiate use wouldn't cause addiction.”
Citations of the letter didn't slow down in the following decade.
Mitchell Max, a doctor and president of the American Pain Society, wrote a 1990 editorial in the journal Annals of Internal Medicine in which he urged improvement in pain assessment and treatment. He emphasized in his piece the findings of Porter and Jick, recommended medical professionals encourage therapeutic opiate use and lauded a Wisconsin cancer pain management initiative that led to a tenfold increase in morphine prescriptions in 12 years.
The next year, the American Pain Society released quality assurance standards for pain relief. Those standards followed Max's recommendations and called for medical professionals to chart pain and its relief; measure pain intensity; and have each clinical unit identify values for a pain intensity rating and pain relief rating system that would lead to a review of the current pain therapy. Doctors shortly thereafter responded to the new standards by increasing opioid prescriptions to treat chronic pain.
“We were being told that pain should be the fifth vital sign and that we were undertreating pain,” said Michael Connolly, a family medicine doctor and professor at Southern Illinois University Medicine in Quincy. “The expectation became that we should have patients be pain free, which is never a reality. So we prescribed more and more. Medicare got on board and said it would be a quality measure, so we would be paid by whether we were treating patients' pain and what their satisfaction level was. To avoid not getting paid, we prescribed more.”
In 1996, Purdue Pharma introduced OxyContin, and, referring to Porter and Jick's observations, said in all of its marketing the risk of addiction to OxyContin was less than 1 percent.
“The manufacturers would say it's time released, it's long acting, people won't get addicted to it, they won't abuse it. But they were wrong,” Solaro said.
The company was brought under federal charges in 2007 and paid more than $600 million in fines for false advertising.
“Meanwhile, physicians started prescribing this because it was well-marketed, and then a lot of people with chronic pain started taking this medicine and became addicted,” Solaro said. “You can see why all of these factors came together to increase prescribing habits. But now we're left over with a number of patients who are addicted to these medications for all of those reasons. It's just an unfortunate time that all of this happened.”
Opioid addiction is a substance abuse disorder.
“A small fraction of patients who take opiates will develop addiction. Addiction is different than tolerance or withdrawal or physical dependency,” Solaro said. “Addiction is a whole separate mechanism within the body that takes months to develop.”
When an opioid is taken, it treats pain but also affects reward centers in the brain to give a sense of well-being or euphoria. Tolerance develops over time. To get the same effect of pain management and sense of well-being, higher doses are required. If a person stops taking the drug, withdrawal sets in.
“Your body is so used to it that once you stop, your body has a physical reaction to it. This can cause nausea, vomiting, diarrhea, anxiety. You get shaky, clammy. You feel awful,” Solaro said. “That will go away in a few days, sometimes a week or two.”
But for somebody who suffers from addiction, getting off of the medication and withdrawing doesn't cure the addiction. And they are the people most at risk for overdosing.
“The problem is they develop tolerance, and if they were to stop, the addiction would say they are still craving that substance,” Solaro explained. “They may go out and try to find it themselves. They don't know how to dose it properly, and their tolerance is gone. They might take a big enough dose where they overdose on it.
For many people, feeding their addiction often leads them to buying illegal prescription narcotics. Often addicts move from buying prescription drugs illegally to heroin, which can be cheaper.
Medical professionals all agree that addiction does not discriminate.
“Addiction does not see any race, color or economic status,” Preferred Family Healthcare residential coordinator Rosemary Trinkle said. Her colleague, clinical manager Jeanna Parkhill, agreed.
“It's across the board,” she explained. “It's in predominately wealthy families as well as lower socio-economic levels.”
Today, doctors and hospitals are taking efforts to curb prescribing habits.
In Illinois, doctors utilize a prescription drug monitoring program. With the program, medical professionals log on, can look up a patient's name and see where in the state the patient has gotten prescriptions for opiate drugs and from which providers.
Both Solaro and Connolly agree that the program is helpful in eliminating prescribing to patients who may be doctor shopping to feed a drug habit. However, Missouri is the only state in the U.S. that does not have such a program. Efforts to implement such a program have been repeatedly turned back in the state Legislature.
State Rep. Holly Rehder, R-Sikeston, is among those who have worked to establish a statewide monitoring program.
“(The program) is a repository for your Schedule II and Schedule IV narcotics, and those are the ones that are most commonly misused and abused,” Rehder told The Herald-Whig in March 2017.
Opioid addiction and subsequent overdoses are on the rise, with the Centers for Disease Control and Prevention reporting that more than 30,000 Americans died in 2015 in what it calls an epidemic. The CDC says that almost half of those deaths involved prescription medication.
Rehder believes a PDMP would help doctors stay ahead of troubles before they become tragedy.
“Not having a PDMP prevents physicians from being able to see their patients' narcotic information if they go to see another physician,” Rehder said.
Blessing recently has begun an analysis of its doctors' prescribing habits.
“There are a few studies that show a pretty wide variation with the frequency of which opiates are prescribed by physicians, so one physician may prescribe way more opiates than another, and there's really no rhyme or reason for that,” Solaro explained. “(The Blessing audit) is to make sure there's no outliers (in prescriptions). The idea is to define a standard so if we are prescribing opiates, then we're prescribing them in a safe and effective manner.”