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Guest Host: Tom Gjelten
The use of narcotic painkillers, or opioids, has boomed over the past decade. Doctors and drug makers have been promoting them for a new use: treating long-term pain from back injuries, arthritis and other health problems. Some patients are greatly helped by painkillers like Percocet, OxyContin and Vicodin. But an award-winning New York Times reporter argues that there is increasing evidence that these drugs, along with being widely abused, are often ineffective in treating long-term pain and can have serious side effects.
- Barry Meier Staff reporter, The New York Times; author of "Pain Killer: A 'Wonder' Drug's Trail of Addiction and Death."
Read An Excerpt
Excerpt from “Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death” by Barry Meier. Copyright 2013 by Barry Meier. Reprinted here by permission of Rodale Books. All rights reserved.
MR. TOM GJELTENThanks for joining us. I'm Tom Gjelten sitting in for Diane Rehm. On Tuesday, the FDA announced new labeling requirements for narcotic painkillers. The FDA wants to reduce abuse of the drugs and is now saying they should only be prescribed as a last resort for severe pain.
MR. TOM GJELTENNew York Times' reporter Barry Meier says this is a welcome change. Ten years ago he wrote a book drawing attention to the abuse of the painkiller OxyContin. A decade later, he says new research shows such painkillers, they're called opioids, are often ineffective in treating long-term pain and can have serious health consequences.
MR. TOM GJELTENHe has updated his book "Pain Killer: A 'Wonder' Drug's Trail of Addiction and Death," and Barry Meier joins me here in the studio. Thanks for coming by Barry.
MR. BARRY MEIERMy pleasure Tom, thanks for having me.
GJELTENAnd I'm guessing that all of you at one time or another has taken painkilling drugs or knows someone who has. I'm sure you want to know more about them. You can call us with your questions 800-433-8850. You can email us, firstname.lastname@example.org and of course you can always reach us via Facebook or Twitter. Remember our handle is @drshow
GJELTENSo Barry, you called attention to this in 2003 when your book first came out. You highlighted the problem back then. You were sort of, I mean it was a problem back then, but in a sense you were really ahead of the curve weren't you because a lot of the problem has really only emerged in these years since your book first spotlighted it?
MEIERWell, remarkably I was ahead of the curve in one sense. I was also behind the curve in another sense. At the time that the book initially came out the major focus was on the abuse of these drugs. There was this construct that the drug industry and pain management specialists said, had created which was as long as you used these drugs for patients they were safe.
MEIERAnd the big problem was when they got out on the street and they were abused by kids and others.
GJELTENYou talk about, somebody, I don't remember who it was who said, there was a bright line...
MEIERA (word?) line, a bright line, you see if you're on the patient's side of that bright line, you're good. You've got a white hat. You're on the other side of that bright line, you're a bad person. You're an addict. You're a drug abuser, what have you.
MEIERWhat we've realized, what the evidence is starting to show dramatically is that these drugs have real, serious consequences for patients. There is no evidence to show that they're effective in the treatment of long-term pain. They do work for some people. They don't work for many others.
MEIERAnd the long-term use of these drugs can carry serious side effects such as sleep apnea, listlessness, lethargy. They drive down the production of sexual hormones and as a result of that people lose their drive. There's a tremendous association between the use of these drugs and skyrocketing disability rates.
GJELTENMedically what is the problem? Medically what is the reason that these drugs are not as effective in treating pain as they were thought to be? What was the mistake that doctors made in thinking about what role these drugs could play in alleviating long-term pain?
MEIERWell, doctors, you know and bless them, they're always looking for a cure. They want their patients to be better. They want them to improve and they want them to have these problems solved. Pain, particularly long-term pain is a very complex problem. People who have chronic pain not only have physical pain but they either have psychological problems, emotional problems, social problems that maybe precede the pain or certainly come after having long-term pain.
MEIERAnd if you're only going to treat the pain, you're not treating many of these underlying factors that are associated with the pain.
GJELTENYou know, I think that's a fascinating thought, Barry, because when I've gone to the doctor and I've been in pain, I'm often asked, how would you rate it on a scale of 1 to 10. And it seems to me that's one of the most absurd questions you can ask a patient because, you know, that suggests there's some kind of objective idea out there of what pain is.
GJELTENSome people can tolerate a lot of pain and experiencing the same level of pain as somebody else, they might say that's a 2. Another person with the same pain might say that's a 9.
GJELTENI mean, so how can a doctor even know how much pain a person is in?
MEIERIt's a very difficult question. Pain for doctors is one of the most frustrating and difficult questions, you know, issues to treat, problems to treat particularly chronic pain. And so, you know they want to do something that's going to intervene and have you know, immediate results.
MEIERIt could be drugs like OxyContin or other narcotic painkillers. It could be these nerve blocks that people get shot into their back. So they want a quick, simple, easy solution so when the patient comes back, you know, I'm feeling better.
MEIERThe big problem is that particularly with the opioids is that the effectiveness of these drugs even as a painkiller quickly wears off because people have this natural, their reaction to them, they develop what's known as tolerance. So they need higher and higher dosages to get the same painkilling effect and as you're raising that dose you're also raising the likelihood that this patient might have serious side effects from the drugs.
GJELTENOkay. Let's lay out some facts here on the table to begin with. First of all, what are the drugs you're talking about? We've mentioned OxyContin, the generic class is opioids. What are opioids first of all? Where does, I assume that opioids come from opium in some fashion?
MEIERThese are all natural or synthetic derivatives of opium, so basically the class of drugs would include drugs like Oxycodone which is either used in OxyContin, drugs like Percocet, methadone, morphine, Hydrocodone. There's about 10 or 12 very widely used drugs that fall into this class of drugs.
MEIERIn fact, they're the most widely-prescribed drugs in this country and their use has boomed when this war on pain began, this effort to sort of pharmaceutically annihilate pain began about ten years ago and the use of these drugs has tripled I believe. And along with that you've had a tripling of overdose deaths and other serious consequences.
GJELTENSo the prescription of these drugs has tripled since when, since the late '90s?
MEIERA decade, yes, since the late '90s, correct.
GJELTENAnd the deaths from these drugs, now these are deaths from overdoses you just said?
GJELTENSo that would assume that people who have died had not been taking them properly, not following their doctor's instructions?
MEIERThere has been basically -- I think it's fair to say that most of the overdose deaths come from the misuse of these drugs, people who are abusing these drugs. That's one class of problems that has evolved from these drugs but there's been another class of problems that's gotten much less publicity.
MEIERI tried to highlight that in the new book, which is the consequences for patients who are taking these drugs as directed. They may not be experiencing overdoses. Some of them certainly are but they're experiencing serious consequences in terms of essentially having their lives change, not for the better but for the worse.
GJELTENNow you mentioned that there was, in the late 1990s, something called the war on pain. Tell us a little bit about that. What were the origins of that? What were the reasons for that?
MEIERIt grew out of some very noble, good instincts. Basically, in the late 1970s and into the '80s, there was significant under-treatment of cancer. People believed that if you used opioids to treat cancer you would be addicting people. And it was sort of insane. I mean here people are dying. They need to have their pain relieved during these serious, fatal illnesses.
MEIERAnd so there was a movement growing out of the hospice movement in England that opioids should be used more aggressively in the treatment of cancer. That happened. That was an extremely good thing. And one of the folks who was involved in that movement, a doctor by the name of Russell Portenoy, said, you know, we're using them successfully in treating cancer patients, maybe we can use them just as successfully in treating more common forms of chronic pain, be it back pain, fibromyalgia, chronic headaches.
MEIERSo this whole movement started gearing up and that movement, you know, sort of started to gain speed along with the development and the launch of this drug OxyContin, which kind of became the flagship drug for the war on pain.
GJELTENI have to ask you, Barry, if these drugs, the production of these drugs is a profitable enterprise and whether there's some sort of pharmaceutical, industrial sort of force behind this?
MEIERIt's a massively profitable enterprise. To say it's a public-spirited enterprise would not be doing it justice. These companies, these drugs are extremely profitable. Purdue Pharma, which is a small, little drug company in Connecticut was kind of a speck on the wall till they developed OxyContin and within three years of its launch in the mid-1990s, it was a billion-dollar drug.
MEIERDoctors who were never prescribing this drug were now prescribing it and that kind of opened the barn door, if you will, to the widespread use of the most powerful pain drugs available, basically pain drugs that were once reserved for the most serious conditions available like cancer, treatment of terminal illnesses into the general mainstream of medicine where they were being used for dental pain, back pain, all kinds of pain.
GJELTENOkay. So doctors embarked on a war on pain. Pharmaceutical companies saw this as a way to make big profits. What about insurance companies, what has their role been in this trend?
MEIERThey loved it.
MEIERBecause it was cheap, it was close-ended. Prior to this there was the use of non-pharmaceutical treatments for pain, programs called multi-disciplinary pain treatment programs that were actually quite successful in treating chronic pain but they were open-ended. They were long-term.
MEIERSo much in the same way that antidepressants displaced talk therapy for psychological problems, pain pills displaced non-pharmaceutical therapies for chronic pain problems.
GJELTENBriefly, Barry, what have we learned about how best to treat chronic pain, if not by giving big, you know, OxyContin or Percocet?
MEIERYou know, depending on -- pain is very complex. There are many different types of pain. But if you're talking about long-term, chronic pain, I think, you know, the huge lesson here is that these are very complex conditions. They not only involve pain, they involve social, psychological issues and treating the pain is not resolving it and it's not actually helping this person.
MEIERWhat we need are treatments that allow people to re-engage with life, become active in life and to physically function as best as possible.
GJELTENBarry Meier is the author of "Pain Killer: A 'Wonder' Drug's Trail of Addiction and Death." It's just been updated in e-book form. Stay tuned, we're going to take a short break. We'll be right back.
GJELTENAnd welcome back. This is "The Diane Rehm Show," I'm Tom Gjelten. I'm your guest host today, and we're talking about the over-prescription, overuse, the abuse of narcotic pain killers. My guest is Barry Meier. He's a reporter who covers business and medicine for the New York Times. He's received two George Poke Awards for his reporting. And, Barry, we have really touched a nerve here this morning by talking about the abuse or the problems associated with narcotic pain killers.
GJELTENAlready I've got three emails from listeners who want to talk about their own experiences with these drugs. First of all, Kathleen wants to know if you know anything about the long-term use of tramadol. Is that right?
GJELTENIt's a synthetic opioid. After a car wreck 18 years ago and then destroying my stomach with ibuprofen, I was prescribed tramadol and assured it was safe over time. I hate the side effects of sleeping and constipation and wonder if I'm killing myself slowly with this medication. Gloria in Traverse City, MI: I always describe the potent pain killer to be used if needed after having a root canal. Over the weekend, after this operation, I developed a dry socket.
GJELTENAnd extremely painful condition which can sometimes occur. I was grateful to have the pills handy. I really didn't need a whole bottle, however. Later the leftovers -- and this has happened to me too, or I happened to have them -- the leftovers were stolen. But I've had a lot of leftovers. And then you wonder what you should do with them. Later the leftovers were stolen from my medicine cabinet by a young family member.
GJELTENThat was a real eye-opener to me, she says. From an anonymous listener in Baltimore: I was prescribed oxycontin for recovery for my knee replacement surgery. I took it religiously as prescribed until I had to give it up. Although I did not finish my course, it took me about two months to recover from the nausea and vertigo. My knee was in great shape. My stomach and hand were shot.
MEIERWell, I think this is kind of a gamut of problems that your readers, your listeners are responding to. These are very powerful drugs. There are many other drugs that can be used as alternatives to these drugs. There is a fascinating piece that was just written I just saw right before I came on today by the head of one of the major pain treatment groups, the American Academy of Pain Medicine.
MEIERBasically they're saying that, you know, this treatment method, this handing out of these powerful drugs as sort of the answer to chronic pain has been a failure. It's not the answer. And, you know, doctors really kind of have to step back and start thinking about if I have someone who's had knee replacement surgery, do I want to give them a long course? Do I want to give them 90 days of the most powerful pain killer available.
MEIERDo I want to give them a shorter course and make them come back to me if there is a problem? I have a very good friend whose son was given 90 days of Dolodon, very, very powerful pain killer for back...
MEIERA 90-day supply right off the bat for Dolodon. Unfortunately, young college student is now in drug addiction treatment. So doctors really have to be mindful. I think that was part of the FDA action this week was basically to say to doctors, hey, we want you to treat people with pain. Pain is a serious problem. But before you use the most powerful drugs that you have in your arsenal, think long and hard before you do that.
GJELTENOkay. This new ruling from the FDA came from the government. What has the medical provider community said about this? What does the AMA said? What's going on in the medical literature? What are doctors saying about this?
MEIERI think there is a strong growing feeling amongst many doctors that the widespread use of these powerful opioids has been a problem. It's been a mistake. There are patients that benefit from them. There are patients that need them and those patients need to get them. But their widespread use, their excessive use has created a huge range of problems that we really have to address. And we have to address reading this kind of pain in more ways than just, you know, a massive pharmaceutical assault.
GJELTENIs there any way to identify those patients? Because one of the -- and I want to make this clear, you say in your book that there certainly are patients who have been greatly helped by narcotic pain killers, the opioids. How do you identify those patients? How do you possibly sort of reduce the population of people that take these, narrowing into that group that really can benefit?
MEIERIt's a huge dilemma and it's a great question. And doctors have been trying to do this for a decade. And unfortunately they have failed by and large for a decade. They first started out with these contracts. They make patients sign contracts. Say, I'm only going to go to you for my opioids. And if I go to another doctor, if I need more of them, you can fire me as a patient. Then they started coming up with these questionnaires to try to identify people who had underlying conditions that might conditions that might lead them to abuse drugs, be it genetic conditions or whatever predisposition.
MEIERAnd they came up with these screening tools. They finally did some studies about whether the screening tools worked. They don't. They failed dramatically, this one widely used screening tool. Now they're screening the urine of patients. So basically you go to the doctor, you leave a urine sample. So we're trying to, you know, stick our fingers into this dike.
MEIEREvery place, it pops. Here, we stick a finger in it. We're not grappling with the big problem and that is we're not providing patients with alternative treatments, which are useful and valid in treating pain. The medical community is not doing that. Insurers are not doing that. And until we start doing that, this problem is going to keep evolving and we're going to have more and more bad consequences from it.
GJELTENSo tell us again, we mentioned at the beginning of the show this new labeling requirement that the FDA announced. Is that sort of in your judgment -- well, tell us what exactly the FDA is saying here.
MEIERRight. So essentially these drugs, the opioids were labeled for moderate to severe pain, which could mean anything to anybody.
MEIERSo, you know, what's moderate pain? As you mentioned before, it's subjective. It's in the eye of the beholder. So is severe pain. But what they basically do is they knock the moderate pain out. And so now only severe pain. So it's basically saying to doctors, try not to use these if you don't have to. I think more consequentially, they also are now requiring companies to do studies of these drugs. They're basically saying to these companies, you know what, you've sold millions, billions of these pills.
MEIERWe've had thousands of bad outcomes. Well, maybe we should have the kind of data to show what are the outcomes for these drugs? How many patients truly benefit from that? What percentage of patients don't benefit from it? And we've been using these drugs sort of helter skelter for 15 years without the type of data you would want to have before you even consider prescribing this kind of drug.
GJELTENCan you tell us anything about this group, Physicians for Responsible Opioid Prescribing?
MEIERYes. It's a group basically of folks who filed a petition with the FDA.
GJELTENThey're the ones that actually prompted this.
MEIERThey filed this petition asking both for labeling changes. They wanted limitations on the amount of opioids that could be prescribed or the time period during which they could be prescribed. They are -- the number of the doctors in that group are people who are viewing from the kind of the endpoint of addiction. They're addiction specialists. And throughout this whole controversy over these drugs, you've had people looking at it from different perspectives.
MEIERThe people from the addiction end see all the problems of people who become addicted. And so they have a very specific view towards these drugs. Then you have the pain management people who are the ones who are doubling these drugs out. And they've got a particular view of these drugs. So you've got people in the medical profession looking at what is essentially problems for both of them from very different perspectives.
GJELTENYou know, Barry, this is a case, this is an issue where our audience can really be very helpful to us because everybody has had experience with these pain killers and you can share your experiences with us. Our number, remember, is 800-433-8850. And I want to go now to Zoya from Maryland. Good morning, Zoya, thanks for calling us.
ZOYAGood morning. I'm calling because my experience with opioids specifically oxycontin has really been directly counter to what your guest is describing. I found that oxycontin, like, really a life saver when I developed a rare neurological condition in 2005 after dental work. So I had (unintelligible) there are many, many doctors who were puzzled by it. I went to many different doctors, tried many different drugs over the 18 months before that condition was successful cured with a brain surgery.
ZOYABut during those 18 months, oxycontin was really a lifesaver. And friends were very surprised when I completely tapered off that medication just two weeks after having brain surgery. After the pain was gone, I no longer needed that medication. But I'm really concerned to hear more proposals being -- more restrictions being proposed for oxycontin and opioids because I think that, you know, that really should be between the doctor and the patient, not someone else commenting about it.
GJELTENWell, Zoya, I do want to point out that Barry Meier said -- and we just discussed this five minutes ago -- he certainly acknowledges that there are many, many people who have benefitted from opioids. Right, Barry?
MEIERAbsolutely. I mean, the big question, and it's a valid question that your caller brings up, is how many patients are there that benefit? What we don't know is is it 30 percent of the patients who have good outcomes? Is it 50 percent? Is it 20 percent? Is it 5 percent? Clearly, these drugs do work for some people. And that's a great thing. And you're absolutely right, you do not want to restrict the availability of these drugs or those kinds of interactions that make them available to patients.
MEIERThe big problem, 50 years after these drugs began to be widely used, we don't have these answers but we do see plenty of evidence along with them working for some patients, they also don't work for lots of other patients. Let me give you a little analogy. Let's say we had an operation, a common operation that's being performed all the time. We suddenly found out that it works really great for 30 percent of the people, which may be the rate at which opioids work for pain patients.
MEIERBut we also learned that 30 percent of people that undergo this common procedure had terrible outcomes. They had terrible consequences. Meanwhile, there's another bunch of people who are walking around the streets outside this hospital who are dropping dead because these procedures are going on inside the hospital. And so, it's, you know, if this was happening in the common medical procedure, there'd be a huge public outcry. There'd be demands for alternatives. And that's really what's go to on here.
GJELTENLet's go now to Gregory who's on the line. I think, Gregory, you're calling us from Brandenburg, KY. Is that right?
GJELTENOkay, thanks. Thanks for calling.
GREGORYWell, thank you for taking my call.
GREGORYI actually practice emergency medicine. And...
GJELTENYou're a physician?
GREGORYI am a physician. And in Kentucky we started restricting the use of narcotics about a year and a half ago. And from my experience, we used to have people literally dying in the waiting room because all of our beds were full of people who came up with all these crazy symptoms that we'd have to sort out. And the bottom line was they want a pain shot. And they would go through any procedure.
GREGORYThey would go to any length of evaluation as long as they have a pain shot at the end. We stopped catering to probably what we used to the drug trade and we don't have people dying in the waiting room anymore. And it's amazing how many beds you free up for true medical emergencies when you don't have to cater to the drug trade to keep up your satisfactions.
GJELTENNow, Gregory, was that a change that you just made, you know, locally there in your own institution then?
GREGORYNo. Well, it was the administrators were very courageous in taking this step. But the legislation is about a year and a half old.
GJELTENOkay. Stay on the line, Gregory, because I want to go back to you. I do want to remind our listeners that you are listening to "The Diane Rehm Show." Barry, you had -- you're familiar with this legislation?
MEIERWhy, I'm familiar and I'm also thrilled with the idea that Gregory mentioned, which is that as part of this war on pain, there's tremendous pressure on doctors to treat pain, to -- it was called the Fifth Vital Sign. And that helps spur the increased use of narcotic pain killers in hospitals and other settings. More recently, there has been a push to have so-called patient satisfaction scores.
MEIERAnd a lot of the doctors pay their ranking, the ranking of the hospital is based on feedback they're getting from patients saying how are you treated at the hospital. Was your pain treated adequately? And that puts a lot of pressure on doctors to prescribe drugs that they might not normally prescribe to treat pain. And so, I think what Gregory is saying is that, you know, the administrators at his hospital basically said, you know, we're going to do what we think is best medically.
MEIERYou know, we're not really that worried about whether our patient satisfaction isn't -- we'll deal with the consequences with practicing medicine correctly rather than to generate a high patient satisfaction score.
GJELTENYou know, Barry, you had an article this summer, I think, in the New York Times in which you pointed out that the number of cases in which an opioid other than heroin was cited as a reason for emergency room treatment went from about 300,000 in 2004 to closer to 900,000 in 2011. I mean, what we're talking about here is really -- at least as far as overdose and emergency room treatment, a real shift from heroin as the problem drug to opioids as the problem drug.
MEIERWell, the, you know, that's related to prescription drug abuse now are about 24,000 a year. They're more than car accidents, the leading cause of accidental death in the United States. And opioids represent about three quarters where an opioid is involved in that overdose. So basically you see all the kind of consequences, be it in overdoses, emergency room visits, they track the growth in the use of these drugs.
GJELTENWell, Gregory, I think you're still with us. I wanted to see, have you had heroin overdoses there in Kentucky? And have you -- does this statistic sort of jive with what you have found, a big reduction in the percentage of emergency issues due to heroin as opposed to prescription pain killers over the last 10 years?
GREGORYWell, unfortunately, my experience of drug abuses, mostly through the white pages. I understand that heroin abuse has actually increased in Louisville. I practice in a rural emergency department, that isn't as much of a problem for me. It's overwhelmingly prescription drug abuse that we were seeing.
GJELTENRight. Okay. Well, thank you very much, Gregory. The -- in terms of the illegal -- we're talking here a lot about over prescription. But how much of a trade, Barry, is there in prescription pain killers illegally?
MEIERHuge. I mean, in Florida for example, until very recently, there were hundreds of so-called pain clinics, which were basically pill mills where doctors, for whatever reason, sat there and wrote prescription for powerful narcotics for people who would come in and would pay for these prescriptions in cash, pay for these treatments. They weren't really being examined. They were just kind of the illicit pill mill.
MEIERAnd, you know, thousands upon thousands of these pills were winding up on the street because of these types of practices.
GJELTENBarry Meier is the author of "Pain Killer: A 'Wonder' Drug's Trail of Addiction and Death." It originally came out in 2000. It's just been updated as an eBook with new data, new findings, new commentary. We're going to take a short break right now. When we come back, we'll go straight to the phones. I'm Tom Gjelten. Stay tuned.
GJELTENAnd welcome back. I'm Tom Gjelten sitting in today for Diane Rehm. And we're talking about the use, usefulness, abuse problems with narcotic pain killers. My guest is Barry Meier. He's a New York Times reporter and he, ten years ago, wrote the book, "Pain Killer: A 'Wonder' Drug's Trail of Addiction and Death." He's just updated it now in e-book form and we have a lot of experiences represented in our audience.
GJELTENFirst I'm going to begin with Terry -- no, I'm going to start with Ryan in Ypsilanti, Mich. who writes us, "As someone who has been in chronic pain for years as a young adult opiate medications allow me to have a more normal life. I don't know what not being in pain is due to the arthritis in my spine. Making opiate medication less available would make my life even more difficult. To have a sense of normalcy and to force those of us in pain to go into the black market or gray market of pain clinics, also known as pill mills." OK, that's one view. That's Ryan's view.
GJELTENTerry meanwhile says this. "I broke my back 37 years ago and have dealt with chronic pain ever since. For decades I rejected the pressure to use narcotics. Then in 2004 I had another surgery and finally gave in and started seeing a pain specialist. During the next five years I withdrew from life, lost most of my friends and then two years ago my wife of 27 years left me. These drugs ruined my life." So two very different perspectives there. Two very different experiences with drugs. I want to go now to our callers' experiences. Frank is on the line first from Conroe, Texas, good morning, Frank. Thanks for calling.
FRANK...Very much for taking my call. I'm a physician. I'm a neuro pharmacologist as well as a behavior neurologist and I used to run the pain clinic at the M.D. Anderson Cancer Center in Houston so many years of experience at it. I have to really dispute much of what your guest is saying about opioids and about pain itself and pain treatments.
FRANKFirst of all there's a tremendous amount of opiophobia in this country because of the press and the DEA. What we have in this country is medical Calvinism where we're afraid to treat people properly. Part of that, a large part of that, is because of the medical profession. We are allowing such people as primary care physicians who are untrained in this area to actually treat pain and use these medications.
FRANKThese medications are elegant, excuse me, elegant in the right hands. They are wonderful. They have been around for a long time. The first noted use of it was with the Samarians in 6000 B.C. and have been used ever since then, so historically they've been here. It is driven largely by ideology and like addictionologists or basically ideologists. They have a dislike of opioids which they don't understand and they call it addiction for which there really is, if you take a look at all the definitions of it, there is really no real definition. Let me point out that...
GJELTENCan I just interrupt you for a second, Frank? Are you disputing whether these drugs are addictive?
FRANKI'm disputing the fact that they are not addictive just because you use them, yes, absolutely.
GJELTENIn other words, you're saying that they can be used in such a way where they do not become addictive.
FRANKCorrect. If they're used for pain purposes, if there is pain -- and yet when we talk about there is no objective way of defining how much pain a patient has actually there really is. The amount of pain that somebody is experiencing can actually be objectively measured by the amount of opioid that they are safely using without side effects. We have -- my biggest case was intravenous use of morphine at 36,000 milligrams over 24 hours in an intensive care unit and Kathy Foley who is at the cancer center in New York had a similar experience.
FRANKAnd those are huge doses.
GJELTENOkay, all right, Frank.
FRANKIf used correctly they're helpful.
GJELTENOkay. I want -- Frank, I want you to stay -- I want you to stay tuned because, as I said before, we have a lot of callers and some of them are going to -- you have just disputed Barry Meier's findings. Some of our callers are going to challenge, I think, your views, as well. This is a good healthy debate. Barry Meier, how do you respond to what Dr. Frank has to say that these drugs properly administered are not addictive and actually serve really important purposes?
MEIERWell, they serve extremely important purposes. I think the physician is certainly looking at this from the standpoint of a cancer doc -- the way Kathy Foley was, the use in palliative care. For him to suggest that they don't have an addictive potential is absurd. Furthermore, for him to suggest that -- he is right in suggesting that these drugs should not be used by untrained physicians.
MEIERBut the greatest barrier from a requirement that these drugs be used by trained physicians is the AMA, the American Medical Association, which lobbied against a proposal that was before the FDA that doctors who prescribe the most powerful pain medicines undergo at least six hours -- that's just six hours -- a couple of golf games worth -- of mandatory training in how these drugs should be used. So I believe his comments would be better directed towards groups like the AMA which have been the principle barrier to getting doctors the required training they need to use these drugs properly
GJELTENWell, let's get another perspective on this very important issue now. Peter is on the line from Gibson, N.C., good morning, Peter. Thanks for calling.
PETERGood morning. How are you today?
PETERWell, back about three, four years I had a back injury and the doctor administered OxyContin, a very low dosage. I was on it for a couple months. That was four years ago and I'm still dealing with the addictive aspects of that medication.
GJELTENSo you were prescribed this medication.
PETERYes, I'm sorry?
GJELTENYou were prescribed OxyContin, oxycodone.
PETERI was on it.
PETERAnd for the past three years I've been illegally obtaining it and also have been in methadone treatments and now dealing with legal aspects of my addiction as well.
GJELTENAnd what happened to your doctor? What -- presumably the course that you were prescribed you ran out of your legal course. Did you stay in touch with your doctor?
PETERYes. He said that I would have needed to -- this is all at the time I lost my insurance, as well.
PETERAnd I was not eligible for Medicaid or Medicare. And he told me just -- I didn't even have a doctor to administer paper. I mean, I believe if I had that I would have had more of a chance to successfully get off this medication.
GJELTENYeah, okay. All right, Barry, here we have a case -- Peter's case where it did start with a prescription from a doctor and then it got out of hand.
MEIERWell, it's not that uncommon. I mean there is a significant segment of the population that has an underlying genetic or family history of abuse. And so folks who enter doctor's offices with back pain, with other kinds of pain who are prescribed these drugs it can trigger off a cycle that can lead to abuse and, at the very end of that, result in drug addiction, as well.
GJELTENLet's go now to Bruce who's on the line from Clearwater, Fla., good morning, Bruce.
BRUCEOh, good morning. How are you?
GJELTENGood. I'm good. How are you?
BRUCEI'm okay, thank you. Yeah, I just wanted to say I don't agree with a lot of the things that area being said and the topic was supposed to be the effects on long term treatment and everything...
BRUCE...Squares off that and examples like giving people dying in emergency rooms and addiction and those are not symptoms with long term treatment. I mean these are one of the safest things to use over the long term, in my opinion. I've been using oxycodone for four years now, quite heavy amounts, and I got there by pretty much trying everything. And I definitely know I don't have an addiction. I probably have a dependency issue by now since I've been taking them for so long, but I mean I tried everything and nothing helped.
BRUCELike, I broke my ankle and literally I went through that with some aspirins. I'm pretty tolerant of pain, but I have five or six herniations with (word?) problems. I have the bone chards pushing against my spinal cord and I have all sorts of pain. And it's the only thing that keeps me going through the day. If I don't take my oxycodone in the morning I can't even get out of bed. And my main issue is because of all the phobias and now the restrictions in Florida because of all those pill mills, etc., now they won't allow pharmacies to dispense over a certain amount and I had gone up to as much as 210 milligrams a day of oxycodone. Then I went down and 150 was what worked for me.
GJELTENUm-hum. And I'm assuming -- I'm assuming, Bruce, that you're under a doctor's care. Your medication is closely monitored by your doctor, I'm assuming.
BRUCEYes. Once or twice a month, I give urine samples so they just to make sure I don't take more than I'm supposed to do, like the example of giving, you know, he was given 90 days. I don't believe that either because you can't get more than 30 days.
BRUCEAnd you can't get refills. You have to actually physically see your doctor.
GJELTENOkay. Well, Barry, Bruce actually raises a good point which is that we're lumping a lot of -- we're, sort of, talking about a lot of problems at the same time. We're talking about pill mills. We're talking about people going to emergency rooms. Long term issue -- long term treatment, long term medication is sort of in a different category.
MEIERYes, and, you know, that really, sort of, becomes the focus of the -- of my writing in the last year or so which is just how good are these drugs? How many patients benefit from their long term use? There are patients like the ones -- like this gentleman and the lady that called before who are benefiting, but there is also a large category of patients who are not benefiting, who are having consequences for this. And the fact that we don't have data means that every patient, such as your caller just now, is seeing it through his own lens, through his own perspective. That's totally understandable, that's how we see life.
MEIERWhat they may not be realizing is that four or five other people like themselves...
MEIER...are having bad outcomes.
GJELTENAnd maybe they don't have the same discipline, for example.
MEIERAnd they don't have the same discipline or they're just -- they're being -- their bodies are such they're being affected in a different way.
MEIERAnd so rather than just having their pain treating and having the same level of activity they're becoming housebound.
MEIERThey're losing their energy. They're becoming -- they've become disabled. They can no longer work anymore. Yeah, they feel their pain is under control, but they're not engaging with life anymore and that's really the issue.
GJELTENNow he said that -- he admitted to, perhaps, having a dependency, but not an addiction. Is that a distinction that is recognized medically?
MEIERIt's a very critical distinction. These drugs create a natural, physical dependency. There's nothing addictive about that dependency. The issue becomes that people who have that dependency also then develop a fear that if I come off this drug I'm going to go through a drug withdrawal process. And as a result of that people tend to stay on these drugs for a long period of time because they don't want that painful experience of a withdrawal, which really has to be monitored and controlled by a doctor.
GJELTENLet's go now to John who's on the line from Grosse Pointe, Mich., good morning, John, thanks for calling "The Diane Rehm Show."
JOHNGood morning, thanks for taking my call. I had knee replacement surgery about a year and a half ago and after two days in the hospital I was discharged. And with my discharge was given both OxyContin and Vicodin. Because I was a volunteer at that same hospital I knew the surgical nurse who called me to the side and said, look, these are not good for you. You will go through some pain.
JOHNIf you can handle it I would recommend use ice on your knee and at night before you go to bed take a couple of arthritis strength Tylenol. That'll be enough to knock the pain down so you can sleep. And I was absolutely fine. Within four weeks or so, although the rehab was more painful than the surgery, I was fine. Never had a problem with the pain and thank goodness for that nurse who also asked me not to tell the doctor that she had told me that.
GJELTENJohn, thanks very much for calling. I'm Tom Gjelten. You're listening to "The Diane Rehm Show." So what we see here, Barry, just like every other caller has a completely different experience.
MEIERI know, I know. Yes, absolutely, you know, the thing that is really, sort of, critical here is that pain is a fundamental problem in our society. And there are people with serious pain and there are people whose lives are being affected by this pain and really we have the responsibility to those people to provide other methods of treating that pain. There is plenty of evidence to show that nonpharmaceutical methods work as well, even for the worse chronic pain patients than pharmaceutical methods do. And it really is imperative both on the medical profession, on insurers, on employers to start making those treatments available. And I think that's the way out of this mess for everybody.
GJELTENWell, we're really appreciating all the medical perspectives that we're getting and we have time for one more call now and we do have another physician on the line. This is Dr. Jason from Peoria, Ill. Jason, thanks for calling.
DR. JASONHi, Jason here.
JASONThanks for taking the call. I completely agree with Mr. Meier. He's done an amazing job. I don't have anything to say that's not in his book, But 36,000 people died last year from prescription narcotic overdose. That's as many people as dying from breast cancer in this country. You can't turn on an NFL game without seeing pink ribbons all over the place, but there's much -- just as many people being harmed from narcotics as the disease that we're so concerned about.
JASONThe FDA yesterday made a motion to put a new warning on Vicodin so it's very important that we decrease prescribing these medications to safe levels and the previous physician who called is just off base. I got to the point in my office that I could not even give a prescription to a patient because I became so disgusted of people being on chronic narcotics. I gave prescriptions to family members or somebody else.
JASONAnd I required that they lock up their narcotics in a safe because I did not think that anyone -- I became so disillusioned. People would just leave the office with their prescription and immediately take a two- or three-day prescription in the first of getting the prescription. And people do not use these drugs safely after being on them for a few weeks.
GJELTENAnd, Jason, have you found that prescribing the drugs to family members as opposed to the patients themselves...
JASONGiving them the prescription.
GJELTENYeah, has that -- has that been a successful way to deal with this issue?
JASONIt was a frustrating way to get people to wean down on their medications after they'd become addicted either from me or from another physician. And it was extremely difficult to get people to use their drugs responsibly. There's a study that came out last year that showed that most of the drug overdoses were within the first week of getting a new prescription because people essentially -- they'd run out of their medications early.
JASONAnd then go refill their prescription and take a couple days supply so they had withdrawn for a couple days and then -- and then they overdosed.
GJELTENOkay. Really good and that's really helpful commentary, Jason. Thanks for calling us. So, Barry Meier, we're out of time here. We've seen, really, a wide variety of experiences and comments on this, but it is clear that this is an issue that really does cause concern and thanks for coming in and talking to us about it. Barry Meier, reporter for The New York Times. His book is "Pain Killer: A 'Wonder' Drug's Trail of Addiction and Death." It's just come out in new e-book form. I'm Tom Gjelten. Thanks for listening.
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