Diane speaks with Dr. Roger Kligler who is living with advanced stage cancer on why he's suing the state of Massachusetts for the 'Right to Die' and with Dr Jessica Vitter, and intensive care and palliative care specialist on why better communication is so needed between doctors and patients facing end-of-life issues.
Public health experts say the abuse of prescription medication is the fasting-growing drug problem in the United States. A new Obama administration initiative aims to reduce addiction levels by 15 percent over the next five years. Among others elements, it would require doctors to receive special training for prescribing painkillers. Many in law enforcement laud the proposals. But people who need powerful drugs to manage chronic pain are concerned. They fear tougher rules for physicians will make it harder for them to get relief. An update on what’s being called a public health epidemic.
- Dr. Robert Dupont president of the Institute for Behavior and Health; former director of the National Institute on Drug Abuse.
- Charles Horner chief of police, Portsmouth (Ohio) Police Department.
- Dr. Paul Christo director of the Multidisciplinary Pain Fellowship Program at The Johns Hopkins Hospital; former director of the Blaustein Pain Treatment Center; host of "Aches and Gains," a weekly radio show in Baltimore.
- Dr. Nora Volkow director of the National Institute on Drug Abuse of NIH.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The number of Americans who abuse prescription drugs rose by 20 percent between 2002 and 2009. The problem leads to an estimated 1 million emergency room visits a year, and it's the leading cause of injury death in 17 states. Joining me in the studio to talk about the use and abuse of prescription pain medication, Dr. Paul Christo of Johns Hopkins University Hospital and Dr. Nora Volkow of the National Institute on Drug Abuse.
MS. DIANE REHMWe are going to open the phones, take your calls, 800-433-8850. Send us your email to email@example.com. Feel free to join us on Facebook or send us a tweet. Joining us by phone from Rockville, Md., Dr. Robert DuPont. He's president of the Institute for Behavior and Health. Good morning, Dr. DuPont. You and I haven't seen each other for a while.
DR. ROBERT DUPONTIt's -- but I've been listening to you practically every day since that time. And I'm thrilled to be on the program, Diane.
REHMI'm so glad to have you with us. Give us your sense of the scope of the problem as it exists now.
DUPONTWell, I consider it the defining drug problem of the 21st century. And the idea that prescription drugs would -- causes many emergency room visits, as all illegal drugs put together, is just staggering. Another statistic that I find remarkable is in my lifetime, I thought I'd never see any drug was used more commonly, or initiation was used more commonly, than marijuana. But in 2009, we had 2.4 million people who first used marijuana and 2.6 million who first used a prescription drug illegally.
REHMI gather you regard it as even worse than the crack epidemic back in the 1980s.
DUPONTYes. The crack epidemic was sudden and so dramatic. This is building more slowly, but it's much larger. And the potentials for death, in particular, are way beyond anything we saw then. You know, prescription pain -- for pain medicine, a one-day dose can be sold on the black market for $100. And a single dose can -- is lethal to a non-patient. There is no other medicine that has those characteristics. And if you think about that combination and the millions of people who are using these medicines, you get some idea of the exposure of the society to the prescription drug problem.
REHMAnd talk about the Obama administration's new proposal to curb prescription pain killer addiction.
DUPONTI think it is historic. What Gil Kerlikowske did on Tuesday when he announced this plan was lay out a path forward. He took the various government agencies that were all confronting the problem and brought them together and showed them a path and got our country on a path to deal with the problems. So I think that was a historic development with the four-part plan that he put forward. So I'm very optimistic, very impressed with that.
DUPONTWhat I think is missing, however, is their realization that this is just a toe in the water. This is a first -- a down payment on a national effort that's going to be prolonged and is going to cause the whole country, including doctors and patients, to rethink and make changes in how we handle prescription medicines, especially the opiates.
REHMAnd that is the voice of Dr. Robert DuPont. He's president of the Institute for Behavior and Health. Turning to you, Dr. Christo, how do you see it, as a drop in the bucket or truly beginning to address this problem?
DR. PAUL CHRISTOYou know, I think many of us who treat patients who have acute pain and especially chronic pain applaud the efforts of the Obama administration in terms of, essentially, decreasing the supply of opioids that are on the market. However, I mean, I just don't want us to miss sight of the huge problem that exists right now in terms of persistent pain. I mean, there are some estimates that the prevalence of pain reaches 100 million people, almost a third of the population. So while I applaud the efforts -- and I'm concerned, too, of the -- basically, the rates of non-medical use of prescription opioids and the deaths associated with that. My concern is that it's going to lead to further undertreatment of pain.
REHMHere is my concern -- and turning to you, Dr. Volkow, to ask you about this. People do become, as Dr. Christo has pointed out, sort of torn up by pain. What can they do besides getting involved with these kinds of drugs that deal with pain? If they haven't got anything else out there, what can they do?
DR. NORA VOLKOWYou're putting the -- your finger in the difficulty and challenge of this epidemic, which is -- which we have not had for other drugs. These drugs, when used properly, can be lifesaving for patients that suffer from pain, whereas, when diverted, they can actually be lethal. And so we are challenged by this epidemic. On the one hand, we do not want to curtail a proper treatment of those that need them. At the same time, we cannot close our eyes of the devastating consequences the increased availability of these medications has made with respect to diversion and abuse. So where is it where we are?
DR. NORA VOLKOWI think that in looking at it critically, objectively, I can say that we really know very little about chronic pain. And, also, if you look at how we are dealing with it, we're actually addressing chronic pain almost as if it were acute pain times many days. So we treat it as -- with similar medications, except for long periods of time. So while opioid analgesics have been very useful, we have to recognize that we've been using them the same way, basically, almost like we used them 50 years ago. And we really do not have medications that have -- that divert from those that could be transforming on the way that we deal with chronic pain.
DR. NORA VOLKOWMoreover, we have very few stories that have actually evaluated the efficacy of opioid analgesics, which are the ones that are abused, in chronic situations. There are very few randomized trials. So we don't even really even know how effective they are for the management of chronic pain. So in your question, what should we be doing? Well, to start with, we should be doing more research that addresses the need for better treatments of patients suffering from chronic pain.
REHMDr. Nora Volkow, she is director of the NIH's National Institute on Drug Abuse. Here in the studio as well, Dr. Paul Christo. He is director of the Multidisciplinary Pain Fellowship Program at The Johns Hopkins University Hospital and director of the pain treatment center there. He is host of "Aches and Gains," a weekly radio show in Baltimore. On the line with us is Robert DuPont. He's president of the Institute for Behavior and Health, former director of the National Institute on Drug Abuse. I can see that many of you have already phoned in. It's clear, chronic pain is a problem for so many people, so the problem becomes, Dr. DuPont, how one manages pain without becoming addicted to the drug which is used to treat that pain.
DUPONTYou know, Diane, I think that the use of the medicines by patients who are using the medicines as directed by their physicians who are not also using other drugs that their physicians don't know about is very safe. And I think Dr. Christo was mentioning that. I don't think anything we're talking about should discourage anyone from using these medicines to treat pain.
REHMWhat medicines are we talking about, Dr. DuPont?
DUPONTWe're talking about opioid analgesics that are modeled on the experience with morphine but have now become primarily synthetic analogs that have the same basic effect on pain. Medicine like Vicodin, for example, and OxyContin would be examples, but there are literally hundreds. And this class of medicines has become the most widely prescribed class of medicines in the United States, surpassing all the other areas for high blood pressure and high cholesterol and anxiety. It's remarkable that we have now more pain medicines prescribed than any of these other categories of prescriptions drugs. But I want to go back to the point.
DUPONTThe key is we need to have these medicines kept within the medical system. And what has to happen is people have to be aware of the fact that there are people who appear to be pain patients but who are using these medicines in an entirely different, abusive, addictive way and who are selling these medicines. And we've got people who are casually passing the medicines on to other people and leaving the medicines around so they are stolen, taken by teenagers. So it becomes an initiating drug for teenagers. What has to happen is to close the system more effectively, so the medicines are used by the patients for whom they're prescribed, and they are not diverted into situations where they are really dangerous. For those patients, it's good. For others, it's lethal.
CHRISTOThose are great points, and I agree with you, Dr. DuPont. Further, I would say, you know, there's such a great variability in pain education among physicians, and that's one of the problems that we struggle with. So I think that there are estimates that only 5 percent of those who suffer from pain actually see a pain specialist. Therefore, most patients are seeing primary care physicians who are on the front lines and who lack the education necessary to do what you're talking about, essentially to ensure the safety of the use of prescription opioids for patients who have pain.
REHMDr. Paul Christo, he is at The Johns Hopkins University Hospital and former director of the Blaustein Pain Treatment Center. Short break. We'll be right back.
REHMAnd welcome back. We are talking about a problem that is growing rapidly in this country, and that is addiction to pain medications. Here in the studio, Dr. Nora Volkow. She's director of the NIH's National Institute on Drug Abuse. Dr. Paul Christo of The Johns Hopkins University Hospital. And Dr. Robert Dupont is on the line with us. He's president of the Institute for Behavior and Health, former director of the National Institute on Drug Abuse. Dr. Volkow, you wanted to make a comment.
VOLKOWYes. I wanted to make a comment to -- from Dr. Christo's perspective in terms of education because it is very accurate in terms of the fact that medical students and health care professional that are going to be prescribing opioid medications do not appear to have the proper training. And there's been a survey to try to actually evaluate the amount of pain education that medical students get in the United States. And in average, most schools will provide that -- I mean, courses that mention pain in five to 10 weeks throughout the whole training.
VOLKOWAnd that is in contrast to what you will see in the veterinary schools, where you actually see seven full higher exposure to the treatment of pain in animals. So it's clear that we do not have sufficient education regarding screening our treatment of pain in general medical school teaching. And the same may be true for pharmacy, as well as nursing. And, in the meantime, there's been significant advances of our knowledge about pain, for once, about -- there's been a wide variety of different types of ways of prescribing opioid medications. And we've learned a lot about what substance abuse and addiction is. So there is a need to really increase the curriculum on the education of how to screen and manage pain.
REHMAll right. Here's an email from Phoenix, Md., that sort of puts the finger on the whole issue. Andrea says, "I've suffered with persistent pain for 35 years. Without prescription medications, my life would not be worth living. I applaud efforts by manufacturers, law enforcement and advocacy groups to make the public aware that we have to solve the diversion problem without trampling the rights of those who need it to live a somewhat normal life. The addiction rate among patients who are properly monitored is extremely low, and there is not a euphoric effect." Dr. Christo, is that your experience?
CHRISTOThat's a great email, and it summarizes, I think, my general experience with patients that I treat who have persistent pain and who are using what we're talking about, sort of long-acting or sustained-release opioids. I mean, you know, our goal is to ensure that they use these medications properly, safely. We monitor them. We ensure that they come up with therapeutic goals. And I have many patients who use opioids who are quite functional, who work part-time and full-time.
CHRISTOBut, I mean, it's our, as physicians, responsibility to produce the guidelines, to monitor patients and to develop a trustful therapeutic relationship with them so that if they're using these controlled substances and they develop problems associated with them, that they feel comfortable approaching me and telling me.
REHMWhat kind of problems are you talking about?
CHRISTOProblems that are associated with, say, misusing the medications, diverting the medications, having them stolen, using them more often than they should, for example.
REHMMore often than they should. Dr. Dupont.
DUPONTYes. I think that's very important, what Dr. Christo is saying. Patients who are taking these medicines as they're prescribed do not have any euphoria, are not sedated, are not in danger on the highway. They are perfectly functional. When people abuse these drugs, they take them in an entirely different fashion. They take much higher doses. They are very likely to use them by injection or by snorting them as opposed to taking them orally. And they often use it with other drugs of abuse, including alcohol, marijuana and many other drugs. So it's an entirely different issue.
DUPONTAnd I want to bring up something that hasn't been mentioned, and that is the potential for abuse-resistant formulations -- that is, the ability to dispense opiate medications in formulations that are not -- it's very difficult or impossible to inject or snort the medicines. And that discourages abuse of the medicines. And I think one of the things -- without inhibiting the proper medical use. And I think one of the areas that is very -- has a high potential for reducing non-medical use but not interfering with medical use is the encouragement of abuse-resistant formulations. And the FDA and others have been focused on when the medicines are used as indicated as their primary focus. And they need also to focus on when they're used in other ways and what can be done to discourage that.
VOLKOWYeah, and I want to make another point because I think this is something that also has led to a lot of questioning -- the sense that if you have pain and you're given an opioid medication, you're not going to become addicted, and that is not completely, correctly true. And so one of the issues that is very important for a physician prescribing opioid analgesics is to be aware of those that may be at higher risk of becoming addicted. And so this should not curtail the use of these medications, but it will mean that they would have to be followed more carefully. So who is at higher risk? Someone, for example, that had had a prior history of addiction, such as smoking or alcohol, in themselves or on their family. Another -- those that are also at higher risk are adolescents.
VOLKOWAnd, interestingly, adolescents are prescribed opioid medications. The number -- the prescription patterns have actually doubled over the past 15 years, and they are prescribed opioid medications predominantly for dental procedures. And they are prescribed them -- for them on a short period of time, but -- so it's -- when you are prescribed for short periods of time, you are unlikely to become addicted. And so that is not an issue. But when you are prescribing chronically opioid medications to adolescents, this is something that should be carefully thought about.
REHMDr. Christo, how does a drug like OxyContin or Vicodin work?
CHRISTOWell, these are, you know, termed opioid medications. They are -- what they do is, when you take a medication -- say, via mouth -- that drug is absorbed. The active component, say, is, for example, oxycodone, then enters the bloodstream and binds then to what we call receptors, you know, in the nervous system. So, for example, in the spinal cord area, it's like a lock and key. So the OxyContin, for example, might be termed the lock, and the -- or, sorry, the key. And then the receptor would be termed the lock. So the oxycodone binds to the receptor. And then from there, there is sort of a complex range of mechanisms that occur to help reduce pain at the spinal cord level and even at the brain level.
REHMYeah, I would think the brain would have to be involved somehow. But then if one takes such a medication for chronic pain, what are the side effects?
CHRISTOWell, there are side effects that we discuss with every patient who are going to be using these long-term. And so the typical side effects can be constipation, nausea, vomiting, fatigue, drowsiness and then others. Obviously, sort of addiction is one that a lot of my patients are concerned about, and it's fairly rare. I mean, the range, though, can be huge. Somewhere between 3 percent to sometimes 40 percent has been documented in terms of the risks of addiction. Yet in -- I think, overall, in my practice and those of others that I'm in communication with, you're looking at maybe 10 percent, 15 percent risk of addiction.
CHRISTOBut, you know, that is -- I don't think we should focus necessarily on the risk of addiction. It's there, but it shouldn't be a reason to withhold these medications, as that previous emailer discussed.
REHMDr. Dupont, would you agree?
DUPONTYes. I think that that's right. But I think the issue has to do with whether the person takes it as directed and the physician is informed. I saw a patient just two days ago, Diane, who was given Vicodin for a dental procedure, and that precipitated a relapse to alcoholism for the patient. Now, she didn't tell the doctor that she was an alcoholic. And that dentist who prescribed that would have no knowledge, even now, that she's relapsed to her alcoholism. But that is a serious risk. I think from the patient's concern, Dr. Christo was talking about the patients worrying about addiction.
DUPONTOne thing that they can be very clear of is the antidote to addiction is honesty. If the patient is honest with the physician and honest about the use of the medicines and other medicines, the risk of addiction is vanishingly small. When it is -- what happens, though, is when the physician is not fully informed, oftentimes purposely by the patient to pursue an addiction -- and that's very dangerous. So honesty is the antidote to addiction. And when a patient has an honest relationship with the physician, and the physician is well-trained, as Dr. Volkow is saying, the risk of addiction is very, very low.
CHRISTOI wanted to add to Dr. Dupont's comments. In order to, let's say, ensure the honesty, especially with the use of these medications, many prescribers of opioids use opioid agreements, right, that sort of describe the risks associated with using the particular medication, the consequences of misusing them and that that honesty element that Dr. Dupont is referring to is critical. We also do urine testing, you know, urine monitoring to ensure that what we're prescribing shows up in the urine and that other substances like marijuana, for example, or benzodiazepines or heroin do not -- in other words, to ensure that those substances that they shouldn't be taking are not showing up in the urine.
VOLKOWYeah, I mean -- and that is very important. You can generate a contract with a patient and particularly these should be considering those that are at high risk. And among the other issues that need to be addressed, apart from those mentioned by Dr. Christo, is, for example, set up a series of expectations that the medication should do and evaluate it within a fixed period of time, and if that doesn't happen, then considering discontinuing medication. Another important aspect to regarding the prescriptions of these medications is the importance of educating physicians to provide with the adequate number of pills, as opposed to sending you home with a much greater number of those that you would need and creating an excess of available medication that is unnecessary.
REHMAnd that takes us to the next email from Tom, who's listening on Interlochen Public Radio. "Please address the role of Florida pill mills in the distribution of prescription pain relievers and how the new Florida governor is standing in the way of attempts to reduce that role." Dr. Dupont.
DUPONTI can't comment on what's going on in Florida, particularly with the governor, but I can say that the pill mills are a very serious problem...
REHMWhat are they?
DUPONTThey're medical facilities -- I guess, you'd call them pseudo-medical facilities -- that are set up simply to write prescriptions for opioid medications. And the physicians there virtually do nothing else but that. The patients come in, plunk down their cash money for the evaluation and the pills and walk out with those pills. And they do this in tremendous quantities, many times taking the pills themselves because they're addicted, but also selling them and giving them away so that they become agents of spreading the addiction in the community. And the physicians play a central role on that. So stopping that is extremely important in terms of preventing addiction to these medicines.
CHRISTOLet's not forget, too -- Dr. Volkow mentioned this earlier on in the show -- that there are other medications that we use to help treat pain, aside from opioids, that can be quite effective. Certain antidepressant medications, for example, can be quite useful, anticonvulsive medications can be useful, and then a whole range of interventional procedures -- nerve blocks, for example, can help reduce pain.
REHMDr. Paul Christo. And you're listening to "The Diane Rehm Show." We're going to open the phones now, 800-433-8850. First to Jenny, who's in Charlottesville, Va. Good morning. You're on the air.
JENNYHi. I got two things I want to say. One, my mother, who was an alcoholic for most of my upbringing but have been sober for 25 years, got on the merry-go-round of antidepressants, anxieties and pain meds that were just thrown at her like M&M's. I mean, it was like anyone would write a script for her, including, like, physician's assistants, you know? By that time, she had many, many ER appointments -- I mean, ER, you know, visits. And she was always saying she had a stroke because she had to explain away her slurring and her staggering and her -- all that kind of stuff.
JENNYAnd she -- the last time she went to the ER, and it was like, oh, she's had another stroke, my brother went to her house, cleared out all the prescriptions that she had been given. In, like, a four-month period, there were 35 prescriptions. This woman weighs, like, maybe on a heavy day, 85 pounds. Thirty-five prescriptions -- all but two of them -- were for anxiety, antidepressants and pain meds. Only two were actually legitimate medicines that she needed. And it was finally then that she actually was involuntarily committed, thank God, because she was near-death for the past seven years.
REHMWow. Dr. Volkow.
VOLKOWWell, I'm very sorry to hear the story of your mother. And I think that, unfortunately, those highlight improper management of cases, like -- that are complex, like the one of your mother. And it also highlights a big problem that we're observing, which is when physicians are prescribing some of these medications, like opioid analgesics, they don't necessarily have information or they don't inquire about the information that that patient may be taking other medications. And these combinations of medications can actually be quite dangerous and can exacerbate the medical presentation of the patients, but also can result in overdoses.
VOLKOWSo -- and you're highlighting another aspect of it, which is the commonality of substance use disorders -- in this case, alcoholism -- with a wide variety of medical conditions, which actually makes the management of the patients harder, but, nonetheless, one that should be addressed properly.
CHRISTOWhat I do to help try to reduce this risk is, number one, to ensure that only one physician write the prescription opioids, so it's not going to me and the primary care physician. It's going to be one of us only. And, two, pill counts are helpful. So when patients come back to see me every month or two and I assess their use of opioids and functional state and quality of life, they're asked to please bring the bottle that contains the pills. And I count them physically to try to ensure, you know, whether they're using them properly.
CHRISTOIf I switch to a different opioid then -- for example, you started with OxyContin, and now I'm going to transition to a patch, a Fentanyl patch. Then I have the bottle of medications, and I then actually remove that bottle from them, give that bottle to the nurses. The nurses then have that bottle -- those medications destroyed. In other words, it reduces the volume of those prescription medications that that patient has.
DUPONTDiane, could I make a point about this?
REHMSure. Go ahead, Dr. Dupont.
DUPONTTo go back to where we started with what ONDCP has put out, one of the things they are supporting is prescription drug monitoring programs. And if there was a prescription drug monitoring program, these multiple prescriptions would have been identified, and there would have been a chance to intervene. The way it is now in many states, there is no way to do that, so that none of these prescribing doctors had any way of knowing what the other doctors were prescribing. So I think the ONDCP program for prescription drug monitoring across the country being very effective with these medicines is an extremely important public health step.
REHMDr. Robert Dupont. He is president of the Institute for Behavior and Health. He is former director of the National Institute on Drug Abuse. When we come back, we'll hear from a police chief in Portsmouth, Ohio, who is dealing with this kind of abuse.
REHMAnd welcome back. We're talking about addiction to painkilling drugs. And joining us now is chief -- Police Chief Charles Horner. He is the chief of police in Portsmouth, Ohio. Good morning to you, Chief. Thanks for joining us.
MR. CHARLES HORNERGood morning, Diane. Thank you for the opportunity of being on your show and following such a distinguished panel.
REHMThank you. Can you talk about what's happening in your community?
HORNERYes. We have -- and I say, we -- I've been in law enforcement for about 28 years, which 10 I commanded a local drug taskforce and have seen firsthand the epidemic that has developed within our community and the region and throughout the United States, involving specifically opiate or opioids prescription medications. And we -- or I have occasionally described it as a tidal wave or tsunami with no end in sight basically for our local communities. We saw some ripples as OxyContin was released -- or actually prior to that, MS-Contin sulfate or morphine sulfate was released and used in the mid-'90s and late '90s. We saw an incredible increase in the use of it prior to OxyContin.
HORNERAround 2000, we saw a proliferation of OxyContin. And through early 2000s, we saw a gradual decline. And then with the settlement that Purdue Pharma had for the lawsuits against them and their improper promotion of their product in -- I believe it was -- 2007, we saw a tremendous spike. And I think there's a correlation, obviously, with the profits that occurred following that settlement, and we're paying the price. OxyContin and Purdue Pharma, I think, laid a foundation for the abuse of a lot of the other -- or the other drugs of abuse. You know, we are not seeing people die locally from heroine. We're not seeing people die from crack or hydrocodone. We're seeing -- like, deaths that occur are being primarily related to OxyContin.
REHMYou've, in fact, had fatal overdoses more than quadrupled in your community.
HORNERWe have and that we've described it as an epidemic. And our local commissioner of health has declared a state of emergency or health emergency for our county, and collectively our community has pulled together a multi-discipline team to try to address the epidemic.
REHMChief Horner, what do you think is going on? Is it unemployment? Is it the economy? What is happening?
HORNERWell, I think the -- and we sit -- Portsmouth, Ohio, sits approximately 100 miles south of Columbus, probably 100 miles east of Cincinnati. Those are our closest DEA offices, and we're at the foothills of the Appalachians Mountains. And I think history has shown that we -- and I say we -- Appalachia has been a specific area of emphasis for the distribution of OxyContin. And I think that the economy -- I think the -- I think everything contribute to a declining economic situation, health situation. You know, Scioto County itself is rated last in the healthiest counties in state of Ohio.
HORNERWe have the highest hepatitis C rate, and we attribute that to intravenous use of drugs, specifically opioids. It's a crisis that, you know, collectively, we have to deal with.
REHMAnd what about the relationship between prescription drug abuse and crime? What are you seeing there?
HORNERIn discussions with authorities throughout the state and local, we believe that 85 to 90 percent of crime, either indirectly or directly, is related to prescription medication abuse.
CHRISTOChief Horner, my understanding of the problem in that area is that the -- essentially, that people are getting opioids from these sort of drug mills, rather than using them for legitimate medical purposes and obtaining them from pain physicians or physicians in general. Is that what your understanding is?
HORNERClearly, the bulk of the prescription medications are coming from pill mills. We are now -- obviously, the Florida connection, that being that what we in the law enforcement describe as the OxyContin express. I think that 90 percent of opioids distributed throughout the United States are attributed to Florida...
HORNER...distribution. And, currently, we have crack dealers that are taking and distributing, moving from the sale and distribution of crack cocaine to sale and distribution of OxyContin, and specifically out in the Detroit, Mich. area.
VOLKOWYeah, and this is very unfortunate situation that, in a way, mimics what's happening in the rest of the United States. And so we've been trying to identify what are the factors that are driving the epidemic of opioid analgesics. One of them is the increasing availability and the prescription of hydrocodone and oxycodone products has quadrupled over a 20-year period. And we are -- who are at greater risk? Those that are 18 to 25 years of age and followed by those that are 12 to 18 years old. How are they getting their medication -- that's one -- these drugs? And that's one -- or the question that's very relevant in order to do prevention. Most of them report that they are getting them from friends or relatives that either give them to them for free or sell them.
VOLKOWInterestingly, among adolescents, 30 percent of them are getting them from their own prescription. So the extent -- and this is very different from the way that you actually get other drugs and highlights, again, the crucial importance of educating physicians in the proper prescription practices for opioid analgesics to obviate the great availability of medications that we have, while at the same time protecting the right of patients suffering from pain to have access to these very valuable medications.
REHMAnd, Chief Horner, one other thing that was pointed out in a recent New York Times article that focused on your community is that one in 10 babies born last year tested positive for drugs. That means you've got second and even third generations born addicted.
HORNERYes. Unfortunately, that's true.
DUPONTDiane, a point that I think is important, this question of why this is happening. Why is that these medicines or these chemicals are very reinforcing, people like them? They are very attractive on a purely biological basis without any reference to any culture or any particular character...
REHMWhat does that mean, Dr. Dupont?
DUPONTThe -- you can show this with animals, that they like to get these chemicals because they produce brain reward. We're talking about prescription drugs, and that's confusing to many in the audience, I think, because it's really not prescription drugs as a whole. It's a very small segment of the prescription drugs, and those are substances that are called -- they're called controlled substances because they are specific chemicals that produce brain reward. Dr. Volkow is one of the leading scientists in the world in studying how this works. But it's clear that it happens, and it's really biological basis. But let me also -- the other thing is, think about the fact that when a patient walks out of the doctor's office, a single, daily dose can be sold on the street for $100. So if a person comes out...
DUPONT...with a prescription for 30 pills, that's $3,000 that they've got worth just to pass it on to somebody else. You think about how many people are attracted to that, to those economics, never mind the biology of it. And you get some idea of the potential for this as a major public health threat.
VOLKOWAnd there is also another point that is apparently contributing to the favoring of opioid analgesics as drugs of abuse and diversion, and that is the misguided belief by those abusing it that they are safer than traditional illicit substances because, after all, they are being prescribed by physicians. So the sense is if these medications are prescribed by physicians, they cannot be so dangerous, which is very inaccurate, because, when improperly taken, they are as dangerous as any of the illicit substances.
REHMAll right. To Mounds, Okla. Good morning, David.
DAVIDGood morning to you. And I just want to echo a point that was just made. And there are some similarities and some differences that I hear -- and I'm a former heroin addict. The difference are, to echo that point, is that people think that because they're prescribed by a doctor, that, for some reason, it's "cleaner." The similarities are -- is that people were talking earlier about the euphoric effects, and that's why people do that at first. But once the outset of addiction has occurred, then people do these drugs because they have to, because that's what they need to stay well. So that's why there's such a demand, and that's why there's such abuse. And that's why people are willing to go to almost any extent to get them, and that...
DAVID...very reminiscent of the heroin thing. And then the final point I will make is, not only are people use these in physical pain, but they are in emotional and spiritual pain as well. And those are the points I want to make.
CHRISTOThat element of emotional pain, I think, is often neglected. And I'm glad you brought that point up because having pain is not just a physical experience. It's very emotional. It can lead to demoralization and isolation and depression, and I think that often we miss that element in treating patients. And I think it's important for us to reach out to our colleagues in psychiatry and in psychology to help bring them onboard in terms of treating patients who have chronic pain.
REHMAnd let's go to Don, who's in Raleigh, N.C. Good morning to you.
DONGood morning, Diane. I'd just like to say that, for the most part, I pretty strongly disagree with a lot of what your panel is saying. And I'm really over the idea that those of us who need a medication, whether it be an opioid or pseudoephedrine or what have you should pay for the misuse and, basically, stupidity of others. I'm in chronic pain. I cannot get a doctor here in North Carolina where I live to write me the sort of prescription that I really need. And all I could say is thank God for the pill mills because I've been to them more than once, and I'm going to go back again.
VOLKOWYeah, and I'm very sorry that you've been denied access to proper management of your pain. The reality...
DAVIDThey're scared to death.
VOLKOWThere are two things, and they are not exclusive -- the notion that there are patients that are suffering from pain that are all medicated, that does not negate nor is it exclusive at the same time with the other reality that pain medications with opioids are also overprescribed. And, again, the improper education leads physicians to be afraid of prescribing opioid analgesics to patients that need them, while at the same time it may lead other physicians to overprescribe opioid analgesic without realizing that they are unnecessary for that particular type of thing.
CHRISTOI'd like the caller to also remember that there are non-opioids that can be helpful, and maybe you've tried them. But things like certain antidepressants can help.
DAVIDMany of those medications are as dangerous, or more dangerous, than the opioids. Look at what -- look at the liver damage that can result from using acetaminophen, for instance. It's just -- it's crazy. I don't get it. Long-term therapy on a lot of non-opioids or non-steroidal anti-inflammatory drugs is not good for you.
VOLKOWYeah, and I think that that's why I started my first comment, is we really need more research for the development of more effective medications for chronic pain.
REHMDr. Nora Volkow. She is director of the NIH's National Institute on Drug Abuse. And you're listening to "The Diane Rehm Show." Let's go to a caller in Marianna, Fla. Good morning, Joe.
JOEGood morning. I'd just like to make a comment that I really don't have any control over. But has our current administration exhibited any optimistic desire of addressing and eliminating the overkill of illegal drug pushers and misuse of the media and holding them accountable some way, just like we are currently holding BP accountable for an accident?
REHMDr. DuPont, what about drug ads?
DUPONTWell, I think we can go back to what Dr. Christo and Dr. Volkow were saying, that there's a problem here because there really is a need for better treatment of pain. And I think there is a point to the widespread use of these medicines. On the other hand, I think what has been missing for much of the discussion is the recognition of the high rate of non-medical use of these, estimated at something like 20 percent of all of these pills that are prescribed are used non-medically. That is a huge problem. And I think that that has not been adequately addressed, and I think it needs to be addressed also by the manufacturers.
DUPONTBut I think what happened with ONDCP on Tuesday was a major step in that direction to -- as I said at the beginning, to change our national thinking about these drugs and to recognize the very serious problem with non-medical use that is measured in deaths, is measured in emergency room visits and measured in addiction. And that needs to be factored into this equation, and it's not going to be simple.
REHMAll right. To -- finally, to Southwest Virginia. Good morning, Steve.
STEVEYes. My question -- I'm just going to comment. I'm a trucker. Now, I'm down here in the streets. And what's going on where I live is my sister sells half her pills, her daughter does. But what I'm trying to tell people, if OxyContin is worth $100 a pill -- you got 60 -- that's $6,000. You wouldn't leave $6,000 in a cabinet somewhere. You'd have to lock this dope up. Your mother, your sister, your next-door neighbor will come sneak over and get 10 pills at a time.
HORNERI agree. Medicine cabinets are a tremendous source of prescriptions -- or drugs of abuse getting onto the street and impacting the drug abuse situation in our county. You know, the cost -- I think it's important to point out that the cost -- the previous caller indicated, that, you know, we shouldn't be funding this -- you know, we should be funding this. And the reason being is in Ohio alone, I think it was estimated that the cost to the state of Ohio was something like $3 billion. The ramifications of dealing with this drug problem, this drug epidemic, you know, in a time when the state of Ohio has a deficit and local communities have a deficit, you know, $3 billion goes a long way.
CHRISTOI do ask my patients to purchase lock boxes if I'm prescribing opioids or other controlled substances to them. I think it's important that I educate them on the need to keep them controlled and in a safe place so that diversion is reduced. I mean, I've had some patients who've told me that, for example, they've had construction workers come to their house and steal their medications that were out on the cabinet, for example, or in the bathroom.
REHMBut it's also kids.
VOLKOWYes. And just to get an idea to your public at what the numbers are, 12th graders have reported 8 to 10 percent in the past year abuse of hydrocodone and 5 percent abuse of Vicodin.
REHMDr. Nora Volkow, she is director at the National Institute on Drug Abuse. Also, Dr. Paul Christo of Johns Hopkins University, and Robert DuPont, he's former director of the National Institute on Drug Abuse, and Charles Horner, chief of police at the Portsmouth Police Department in Ohio. Thank you, all. Thanks for listening. I'm Diane Rehm.
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