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Origins of the Opioid Epidemic – I Was There

Two physicians share their experiences learning the truth about opioids.

Every day, 130 Americans die from opioid overdose. Last year, 70,237 deaths were caused by drug overdoses, and opioids were the major culprit, according to the Centers for Disease Control. The White House Council of Economic Advisors (CEA) says that opioids have cost the country $2.5 trillion in the last four years. In 2018 alone, the CEA estimates that opioids cost $696 billion, 3.4 percent of the country’s GDP. The epidemic is a complex issue with multiple parties at fault, but two local doctors describe their experience as one that was fraught with conflicts of interest and insufficient information about the dangers of opioids.

When Dr. Mary Caire was doing her internal medicine and physical medicine and rehabilitation residency at LSU, she trained at the pain management clinic while working 100-hour weeks. Sleeping in the hospital every other day meant she had little time to do much of anything besides eat, sleep, and work. Pharmaceutical representatives took advantage of the doctors’ limited free time to provide educational lunches and dinners, often discussing the wonders of opioids.

“I remember very vividly them saying that you treat according to the subjective pain,” Caire says. “As long as you are treating real pain, there is zero percent chance of becoming addicted. They repeated that message over and over and over again. ‘As long as the patient is not lying to you, they can’t get addicted.’ ”

Caire saw the pain get worse and patients develop resistance to opioids, which then required more drugs. But the companies presented peer-reviewed studies that showed that if a patient has physiological pain, they cannot become addicted. Caire was suspicious of that claim and kept seeing evidence otherwise.

Caire continued her training and saw patients with real plain exhibiting drug-seeking behavior. She was told that it wasn’t drug-seeking, but pain-relieving behavior. “You do a gut check when they come in because they say they lost it or flushed it down toilet.” Caire says. “There was always a reason to get it a little earlier, always needed a little higher dose. We were taught to treat, treat, treat, and it didn’t matter how high we needed to go, as long as it treated the pain.”

That treatment plan and the patients’ behavior didn’t sit right with Caire, who attempted to wean her patients off the drugs, which appeared to her to be addictive. Although it was easier to write a prescription and move on to the next patient, she pushed patients into the inpatient withdrawal program, despite their protests.

Throughout her career, she saw more evidence of the addictive nature and impact of these drugs as the rest of the medical community woke up to the danger of opioids. One day during residency, she entered a hospital room to find the charge nurse passed out on the floor, with a low pulse and shallow breath. Caire got her onto a stretcher and raced down to the emergency room, performing CPR the whole way until she could get a dose of Narcan to reverse the effects of what they would learn was an opioid overdose. The nurse had been sucking the gel out of the opioid patch meant for patients and injecting it into her arm. “That is how desperate people are,” Caire says. “I didn’t think she was a bad nurse, I think she was just addicted.”

Caire was even forced to defend her license to the state medical board when a patient filed a complaint after Caire denied them opioids because of their drug seeking behavior. She tells a familiar story that the patient was requesting large doses of narcotics from an injury years ago when the patient came to her for a completely different reason. The case was eventually dropped. And Caire isn’t alone.

Dr. Kenneth Adams, who is now the Chief Medical Officer for Medicare & Retirement in Texas at United Healthcare, remembers a similar experience. He was physical medicine and rehabilitation resident in the 1990s at Parkland Hospital, and remembers receiving literature and information about the benefits of OxyContin, Duragesic, MS Contin and other narcotics. He want to dinners and conferences sponsored by drug companies and because of his specialty, he dealt with pain management following surgery, brain and spinal cord injury. Opioids were often part of the treatment plan. “I look back over 20 years ago and am appalled at how negligent the prescribing information I received was.  I was told about how safe and less addicting long-acting narcotics were and how they were better for second line treatment than continuing their first line treatment. It makes me ill to wonder how many addicts I may have created,” he writes.

While there are multiple checks on these types of prescriptions, Adams feels that the manufacturing companies have the first line of responsibility. Next is the distributors. “The distribution system has second line responsibility because even back in the 1990s they had the capacity to monitor and track where their narcotics were being prescribed and consumed and they chose to ignore the HUGE outliers (the “pill mills”) because of profits,” he writes.

Adams worries that the prominence of the opioid epidemic has made the medical world overcorrect, leaving patients in unnecessary pain and forced to go cold turkey off of pain medication when they get home. “Maybe that is for the best, but it was hard,” he writes.

Pharmaceutical companies and their distributors are not the only checks on these addictive medicines. Physicians are supposed to do no harm and only prescribe what is necessary. The Drug Enforcement Agency too, has the ability to check the number of pills being prescribed. If the DEA finds suspicious prescribing patterns it can intervene, and the organization determines the number of opioids that are produced. Between 1993 and 2015, the DEA approved 39 times the previous levels of oxycodone increase and 12 times the number of hydrocodone.

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