As the war in Ukraine grinds on, a look at the economic battlefield and how the conflict might permanently reshape the global economy. Diane talks to Sebastian Mallaby, senior fellow for international economics at the Council on Foreign Relations.
Guest Host: Indira Lakshmanan
The Centers for Disease Control this week issued the first national guidelines on prescribing opioids. Abuse of these powerfully addictive painkillers has become a public health crisis. More than 40 Americans die every day from overdoses related to prescription opioids. And the drugs have fueled a nationwide heroin epidemic. Congress and some states are attempting to address the crisis through legislation. The non-binding CDC guidelines were welcomed by many in the medical community as a step in the right direction. But addiction specialists say more needs to be done. Join our discussion on efforts to stem the abuse of prescription painkillers.
- Dr. Debbie Dowell Senior medical officer, special adviser Division of Unintentional Injury Prevention (DUIP), National Center for Injury Prevention and Control (NCIPC) at the Centers for Disease Control; lead author on the CDC's opioid guidelines
- Dr. Andrew Kolodny Chief medical officer, Phoenix House Foundation; senior scientist, Heller School for Social Policy and Management, Brandeis University; executive director, Physicians for Responsible Opioid Prescribing
- Peggy Compton Professor and associate dean for research, evaluation and graduate programs at Georgetown University's School of Nursing and Health Studies
- Karoun Demirjian Reporter, The Washington Post
MS. INDIRA LAKSHMANANThanks for joining us. I'm Indira Lakshmanan sitting in for Diane Rehm. In 2014, nearly 15,000 Americans died from overdosing on prescription opioids in what has been called the worst public health crisis in decades. Over the opposition of pain doctors and pharmaceutical industry group, the Centers for Disease Control, this week, issued the first national guidelines on prescribing the pain killers. Public health officials and addiction specialists say it's a first step, but much more needs to be done.
MS. INDIRA LAKSHMANANJoining me in our Washington studio to talk about new efforts to combat opioid addiction, Peggy Compton, a pain and addiction specialist at Georgetown University School of Nursing and Health Studies, Karoun Demirjian of The Washington Post. And from an NPR studio in New York, Dr. David Kolodny (sic) of Brandeis University and Physicians for Responsible Opioid Prescribing. Welcome to all of you.
MS. PEGGY COMPTONThank you.
MS. KAROUN DEMIRJIANThank you very much.
LAKSHMANANAnd, of course, to our listeners, you can join our conversation anytime by calling 1-800-433-8850. You can also send us an question or a comment by email to email@example.com. And you connect with us on Facebook or send us a tweet to @drshow. But first, joining by phone from Atlanta, Dr. Debbie Dowell. She's a senior medical officer at the Centers for Disease Control and she's also the lead author on the CDC's new opioid prescribing guidelines. Welcome to "The Diane Rehm Show," Debbie.
DR. DEBBIE DOWELLGood morning. Thank you for having me.
LAKSHMANANSo first, tell us why the CDC felt the need to issue guidelines on prescribing opioids.
DOWELLSo many Americans experience chronic pain. One estimate says 11 percent of Americans experience daily pain. Many of these Americans, probably about -- one estimate says about 4 to 5 percent of adults are prescribed long-term opioids for chronic pain and that's a change from 15 or so years ago when these drugs were mostly used for end-of-life care and acute pain.
DOWELLWe've learned in the last few years that these drugs are associated with significant risks for opioid use disorder, which is sometimes called addiction, or overdose and death. One population-based study recently found that one in 550 people started on long term opioids for non cancer pain died at a median of 2.6 years after starting the medications. In light of that, the CDC felt it was important to reevaluate the benefit to risk ratio of these drugs and provide guidance for providers and help for providers and patients trying to make decisions about how to balance the benefits and risks of these drugs.
LAKSHMANANTell us what the studies have shown on the effectiveness of these drugs, whether they are short-term effective, long-term effective.
DOWELLSo there are a number of studies that have shown some short term effectiveness, usually about a 20 percent to 30 percent reduction in pain. Unfortunately, most of these studies have lasted less than six weeks so we don't have good evidence to tell us whether or not these medications work long term for relief of chronic pain.
DOWELLWe have some indication that tells us we might not be able to apply the short term results of these studies to long term benefits. Opioids have unique characteristics, such as tolerance, that at least in some patients, mean physicians have to increase the dosages of these medications to get the same effects and that the effectiveness is less over time. So we really need those studies to really inform the benefit to risk ratio of using these medications long term.
DOWELLIn the meantime, clinicians are asking for guidance and so we provided, based on the best available evidence, guidance to help providers and patient decide.
LAKSHMANANOkay. Well, outline for us the main points in your CDC guidelines.
DOWELLSo the guidelines have 12 recommendations, very importantly, non opioid therapy is preferred for chronic pain and opioids should only be used when the benefits for pain and function are expected to outweigh the risks. In addition, before starting opioids, clinicians and patients together should establish treatment goals and consider how they're gonna know if the opioids are working or not and have a plan for how to discontinue them if the benefits don't outweigh the risks
DOWELLAlso, very critical, clinicians should prescribe the lowest effective dosage and carefully reassess benefits and risks when considering increasing dosage to 15 morphine milligram equivalents or more today because a number of well-designed observational studies in the last several years have shown a very strong association between prescribed opioid dosage and overdose risk.
LAKSHMANANAll right. But Dr. Dowell, doctors don't legally have to abide by these new guidelines so what is the CDC hoping to accomplish?
DOWELLSo that's right. These are guidelines. They are not laws or regulations. We hope that providers follow these guidelines in most instances. They are designed to be flexible. We anticipate that providers will take the unique circumstances of their patients into considerations, but they will kind of use these as a benchmark for how to make these decisions, how to talk to patients about risks and benefits in most cases.
LAKSHMANANAll right. Thank you, Dr. Debbie Dowell, lead author of the CDC's new guidelines on prescribing prescription opioids. Peggy Compton, I want to turn to you now. You're a pain and addiction specialist. What do you think of these new guidelines?
COMPTONWell, firstly, something had to be done so I am -- there are many things I like about the guidelines. Number one, I really appreciate the fact that they recommend careful screening and monitoring of these patients after they've been put on opioid therapy. I consider that that may be also a way to do some case identification, if you have somebody who appears to be having difficulty modulating or moderating their opioid use. You may be handling somebody who's got an addiction problem and therefore, by identify them via the CDC guidelines, we might be able to move those people towards treatment.
COMPTONI also like the fact that the guidelines talk about using non pharmacologic interventions. I think, with pain treatment, we often run right to the medicine cabinet without thinking about things like physical therapy, stress reduction, massage therapy, other things that have been shown to be very effective in treating chronic pain. I also like the fact that the guidelines emphasize the risks associated with benzodiazepine and alcohol use in -- well, actually, they talk about benzodiazepine.
COMPTONI'm going to add alcohol use because both of those substances are shown to be intimately related to overdoses within patients who are using opioids. And finally, they do talk about -- and it's not specific in the guidelines, but they do talk about the use of injectable naloxone for the treatment -- or of patients to experience an overdose or who are at high risk for experiencing overdose. So I think there's a lot of good in these guidelines. My major concern is that the patient's voice feels lost to me.
COMPTONThere's a considerable sub-population of chronic pain patients who do very well on opioid therapy. They're able to get out of bed and take care of their kids and live a much more functional, higher quality of life. And I do have concerns that because of these guidelines, we may see clinicians tending to want to taper or take opioids away from the patients. And opioid taper and...
LAKSHMANANThose patients who've done well with them, who have not developed an addiction.
LAKSHMANANAll right. Well, I want to dig deeper on that later in the hour, along with your discussion of alternative therapies, but first, Dr. Kolodny, you're the executive director of Physicians For Responsible Opioid Prescribing. What do you see as the primary problems here that need to be addressed and do these guidelines do it?
DR. ANDREW KOLODNYYeah. I think that the guidelines are gonna go a long way toward helping reduce over-prescribing. The CDC is responding to a severe epidemic of opioid addiction and overdose deaths. Since 1999, more than 250,000 Americans have died of opioid overdoses and from the beginning of the epidemic, what we kept hearing from the pharmaceutical industry and from organizations receiving funding from the pharmaceutical industry is that all of this bad stuff we're hearing about, well, that has nothing to do with the pain patients.
DR. ANDREW KOLODNYIt has nothing to do with doctors taking care of their patients. It's all about the so-called drug abusers. And let's not do something about the drug abuse problem that will penalize the pain patients who are being helped by these medicines. That was the message over and over again and the focus of federal policy makers was on reducing so-called non-medical use, stopping the teenagers from going into grandma's medicine chest. And that's been what we've trying for the past decade and it hasn't worked.
DR. ANDREW KOLODNYPrescriptions have continued to increase and overdose deaths an addiction have increased right along with the increase in prescriptions. What the CDC is saying is that the focus shouldn't be on non-medical use. The focus should be on over-prescribing, that the medical community is fueling this epidemic by prescribing opioids for common conditions where they're not safe or effective. And this idea that all of the harms are limited to the so-called drug abusers and millions of pain patients are being helped it totally helped.
DR. ANDREW KOLODNYWe've had millions of patients with pain become addicted to opioids and thousands have died of overdoses. So advocates for people who might be suffering from chronic pain should be welcoming the guideline. They should be welcoming more cautious prescribing.
LAKSHMANANAll right. Dr. Kolodny, in the one minute we have left before we go to a break, quickly tell us who is allowed to prescribe opioids? Do you need special training or can any doctor do it?
KOLODNYThat's a great question. Any physician with a DEA registration can prescribe opioids and in most states, nurse practitioners and physician's assistants are also allowed to prescribe opioids, even schedule 2 opioids, which are the most addictive. Buprenorphine is a treatment for opioid addiction, unlike opioids like oxycontin where we allow nurse practitioners and physician's assistants to prescribe it, we allow an unlimited number of patients to be treated, there are strict limits. So that's one of the problems we've got.
LAKSHMANANAll right. So in other words, even people at a minute clinic at a pharmacy might be able to prescribe some of these opioids it sounds like you're saying.
LAKSHMANANAll right. When we come back, we're gonna hear from Karoun Demirjian about a sense of the scope of the opioid addiction in the United States. I'm Indira Lakshmanan sitting in for Diane Rehm. Stay with us.
LAKSHMANANWelcome back. I'm Indira Lakshmanan sitting in for Diane Rehm. This hour we're talking about the epidemic of opioid prescription addiction in the United States and the deaths associated with it, with Peggy Compton, professor and associate dean for research, evaluation and graduate programs at Georgetown University's School of Nursing and Health studies, with Dr. Andrew Kolodny, chief medical officer of the Phoenix House Foundation, a senior scientist at Brandeis University and executive director of Physicians for Responsible Opioid Prescribing, and Karoun Demirjian, reporter for The Washington Post, who has covered this very closely.
LAKSHMANANKaroun, I want to go to you now. Tell us about the scope of opioid addition in the United States.
DEMIRJIANWell, we've been hearing about various types of stories with heroin addiction for a while. Starting in New England, there were several reports about it over the last few years. But at this point, it's become a national discussion and not just about heroin abuse but about pain-killer abuse as well. You can, I mean, not that this should be the only measure of how big the problem is, but it's taken over the political campaign trail as well. You hear presidential candidates talking about it. You've got Congress trying to tackle it in a bill. So it's basically -- it's not a question of is this a problem anymore.
DEMIRJIANEverybody's accepted that it is a problem that has to be addressed in a much wider -- as you were speaking about earlier in the show -- with a much wider response than just talking about, oh, you know, drug addicts shooting up in their parents' basement, that it's -- affects every age group, every level of wealth. And it's cropping up in all parts of the country, more acutely in some states than others.
LAKSHMANANI've talked to addiction counselors who say that really it has affected perhaps disproportionately the young. And that there are now a huge percentage of clients who are coming through rehab clinics -- young ones, teenagers, young adults -- who started out addicted to prescription pain killers and then have moved into heroin or other drugs. Dr. Kolodny.
KOLODNYYeah. Actually, the opioid addiction epidemic is affecting all age groups. But we're seeing with younger folks, people in their 20s and 30s, when they get addicted to prescription opioids -- whether it was from medical use for maybe a sports injury or wisdom teeth, or from recreational use -- when that young group gets addicted, they have a hard time maintaining their pill supply visiting doctors. Because unless the doctor is a drug dealer, they really don't want to give a healthy-looking 25-year-old lots of pills on a monthly basis. So that group winds up on the black market. The pills are very expensive on the black market.
LAKSHMANANI've heard that they can cost as much as $80 for one Oxycontin that is one the black market.
LAKSHMANANThat's right. It's a dollar a milligram. So an 80-milligram pill would go for $80. And so they're switching to heroin, if they're in a part of the country where heroin is available. And over the past 15 years, heroin has moved into more regions of the country to meet the demand for it by these young people who are opioid addicted. But it's very important to remember that there's an older group -- people in their 40s, 50s, 60s, 70s and 80s -- who are becoming addicted usually through treatment for chronic pain. That older group, when they get addicted, they don't have to turn to the black market.
KOLODNYThey can find doctors who will prescribe them as much opioids as they would want. And even when their own primary care doctors get uncomfortable -- maybe the patient is coming in early, having run out of medicine -- the patient is complaining of pain, the doctor doesn't want to label the patient with a stigmatized condition of being addicted, so those patients get referred to pain management, where often they're given even higher doses of opioids. The overdose death rate is actually much higher in the older group. The age group with the highest rate of drug overdose death in the United States is 45 to 54 years old, higher than in the young people switching to heroin.
LAKSHMANANInteresting. Well, I've also been told by addiction counselors that drug cartels are now making a pill form of heroin in order to compete on the black market with these prescription drugs. Once it's become part of the criminal underworld like this, how can CDC guidelines even hope to make a dent in a problem like this?
KOLODNYWell, what the CDC is really trying to do is primary prevention, meaning they're trying to prevent new cases of opioid addiction and trying to prevent chronic pain patients from winding up stuck on long-term opioids, medicines that aren't going to help their pain and could even make their pain worse. I think their recommendations related to dosing will help reduce overdoses in pain patients who are on these very high dosages. But their main goal is to prevent new cases of addiction. Overdose deaths are likely to remain high until we do a better job of seeing that people who have become addicted are accessing effective treatment.
LAKSHMANANAll right. Peggy, as a medical practitioner who is following these guidelines -- or you will be as of today, I suppose...
LAKSHMANAN...how do you balance these competing needs? On the one hand, you have people across America -- we heard the figure, 11 percent -- who are in debilitating pain for a variety of chronic conditions -- rheumatoid arthritis, lupus, spinal injury -- you know, who say they really benefit from these drugs. And on the other side, you have this chronic cycle of opioid addiction and death.
COMPTONWell, I think that's a very difficult balance. And I think that's what the professions in fields have been really trying to, you know, to -- what is the best way to handle both meet the needs of patients who do have chronic pain and do do better on opioids and then make sure that we're not contributing to the addiction problem in people who have difficulty managing their problems. I think one of the biggest issues, as clinicians, that we're going to be facing with these guidelines coming out is, okay, how do we take these 5- to 8-million people who are currently taking opioids on a daily basis, what do we do with them? Are we going to attempt to detoxify or taper them all off?
COMPTONThey're very difficult patients to detoxify. Their pain gets worse. They can't sleep. There's many issues associated with detoxifying or tapering patients off. And the guidelines don't provide any support or guidelines -- excuse me, guidelines on how to really manage that within patients. I think another thing that the guidelines recommend using these alternatives to medication and yet many patients don't have access to physical therapy or to stress-reduction techniques. Their insurance may not cover it. The primary care clinician may not have access to those resources. So, in a sense, the guidelines feel a little Pollyanna to me and don't necessarily match the infrastructure of treatment services that are out there.
COMPTONAnd I'll just add to that by saying, addiction treatments as well. I mean the thought that we can take a patient that we're very concerned about with respect to their opioid use and easily refer them into a treatment setting that's readily available to take them, again, is not necessarily consistent with the practice environment.
LAKSHMANANAll right. Well, we hear about all these alternative methods -- physical therapy, meditation, relaxation, other things that could help people. Peggy says these alternative methods are not being offered more, possibly because of drug companies, possibly because of insurance coverage offered by providers.
DEMIRJIANWell, I mean, I think part of what the CDC is trying to do with these recommendations is, even though that they're not binding, that they hope that it starts to try to influence, you know, how health insurers and other -- and states, et cetera, actually go about structuring these -- their own systems, so that they can actually be responsive to what these new guidelines are and that there can be more of these, you know, more attention and diversion into the alternatives, more of these checks kind of about how -- what drugs people are taking worked into the insuring process. That's going to take some time. It's not going to be overnight.
DEMIRJIANI mean, the other side of things right now is also you're trying -- you see different states around the country writing -- signing, or at least considering their own laws right now to try to improve resources or up the number of facilities that exist, improve education, improve prevention training. That's happening nationally, it's happening in a smattering of states around the country. So you're seeing people at least try to tackle this problem and think about how to divert more money and resources to actually what people need.
DEMIRJIANNow, I don't know if that's going to be necessarily more money and resources towards making physical therapy a viable option for everybody. We may be talking more about, you know, beds in treatment centers and things like that. That seems like a much more linear link. And you do hear politicians discussing that stuff more. But if the conversation around the CDC guidelines does expand, then you might start to hear a little bit more streamlined discussion of those alternatives and how to support the result.
LAKSHMANANDr. Kolodny, has Obamacare, the Affordable Care Act, had any effect on the availability of these alternative treatment options? Or is it just cheaper and easier for doctors to hand out painkillers rather than tell someone to take yoga?
KOLODNYI think you're hitting on the issue. It takes only a few minutes to write a prescription. And if a doctor has five, ten minutes to spend with a patient, even if health insurance is willing to pay for the physical therapy, that's -- it's going to take a lot more time from that doctor to find a physical therapist and make that referral. So doctors are doing what's easiest. I'd like to respond to something that Peggy had said. I think Peggy and I would agree that we've got millions of Americans already on chronic opioids. And how we handle that population is going to be a challenge.
KOLODNYMany of these patients may not be able to come off of their opioids because they've been made dependent on them. And we wouldn't want to just strip them away from their pills that would -- possibly even worse than the heroin problem. So we need a compassionate approach for that population. Where I disagree, I think, with Peggy is, Peggy seems to believe that there's a subset of patients with chronic pain who are doing wonderfully on these medications. I don't think that's true. I think there is a subset that's doing okay despite being on opioids. But the data...
LAKSHMANANAren't there some people though who aren't addicted actually? Who are able to manage their prescription in a way that we would not consider addition?
KOLODNYIt depends on how you would define addiction. If you define addiction as continued use of a drug despite negative consequences, then maybe 80 percent of these patients would have an opioid use disorder to some degree. Because what we see is a decline in function. A study was done showing us 80 percent are not doing well. And for that 20 percent who seem to be doing okay, we still don't know that they're really getting pain relief. The patient may feel the opioids are working because before they take their first does in the morning, they're feeling agonizing pain. They take the medication, the pain goes away. But a heroin user, before they use heroin the first time in the morning, is also feeling pain.
KOLODNYIt's very likely that the opioids are treating withdrawal, not treating an underlying pain problem. Again, the best evidence is telling us that the opioids don't work and can even make pain worse. At our leading pain centers at the Cleveland Clinic, at the Mayo Clinic, they're treating chronic pain patients by getting them off of their opioids. And they're seeing that their pain improves. So when you have a treatment that's dangerous, whether it's surgery or medication, and you don't have evidence that it's going to help patients, a dangerous treatment that may not work, that's a treatment that should be prescribed rarely.
KOLODNYAnd instead it's become routine in the United States, which is why this announcement from the CDC yesterday that opioids are not appropriate for common conditions, is so important.
LAKSHMANANI'm Indira Lakshmanan and you're listening to "The Diane Rehm Show." Karoun Demirjian, you've been covering this really closely for The Washington Post, not only the CDC announcement yesterday, but also the states have been taking action. You've told us a little about that earlier. Tell us about what Congress has been doing to address these issues. What kind of legislation, legal action, are they actually considering taking?
DEMIRJIANSo the idea of actually tackling this has been kicking around Congress for a few years. But it all came together this year. And that is, it's the Comprehensive Addiction and Recovery Act is what they call it. It's basically a bill that is trying to reduce -- is trying to combat heroin and painkiller abuse. It's trying to reduce the incidence of deaths due to overdoses from opioids.
DEMIRJIANAnd the approach that they're taking is trying to basically incentivize states and issue grants that will go to support education, training programs, prevention programs, get more naloxone into the hands of first responders who are going to be answering emergency calls or dealing with potential, you know, people who are dealing with overdoses because it can save lives. Trying to go into prisons, trying to deal with veterans, trying to address issues of people that have compound prescriptions.
DEMIRJIANAnd, you know -- and also trying to get rid of excess drugs. Because I think that was part of the CDC's report too, is that there's so many prescriptions out there because people -- when you get prescribed these drugs, oftentimes -- even if you're getting prescribed it for an acute condition -- you're getting more than you actually need. So you have these leftover pills. How to get those off the market and just out of people's cabinets so that there's less temptation, I suppose, to be able to overuse the drugs and not just kind of stop yourself at the point at which you don't need to anymore.
LAKSHMANANNot to mention that it's not just about doctors who are carelessly handing this out like candy. There's also the issue of prescription pads being stolen. And, you know, an entire black market that exists in these otherwise legal drugs being sold illegally. To what extent does the pharmaceutical industry itself have a responsibility to say, this -- these are how many pills are out there. And not all of them are actually legally being prescribed.
KOLODNYI think the pharmaceutical industry bears a tremendous responsibility for this mess that we're in. And if you look at the overprescribing of opioids that led to this epidemic, prescribing began to take off in many ways in response to a campaign that was sponsored by pharmaceutical companies that minimized the risks of addiction and over-exaggerated the benefits of using opioids long term. So we really have...
LAKSHMANANDo you connect that campaign to the start of this opioid addiction and death problem?
KOLODNYAbsolutely. In fact, you can look at the year the opioid prescribing really begins to take off is in 1996, when Oxycontin was introduced by Purdue Pharma. They launched a campaign that didn't just encourage doctors to prescribe Oxycontin, the campaign focused on making doctors feel comfortable with opioids as a class of drug. The medical community was told that the risk of addiction is much less than 1 percent. That we've been allowing patients to suffer needlessly by under using -- underprescribing opioids. Opioids are a gift from Mother Nature. We should be using them for just about every complaint of pain.
KOLODNYSo all of the opioid prescribing begins to really explode in the late '90s. And as the prescribing went up, addiction and overdose deaths went up right along with it. And that's a point that the CDC has been trying to get across for quite a few years.
LAKSHMANANPeggy Compton, you wanted to jump in.
COMPTONWith respect to the pharmaceutical industry, I think that the pharmaceutical industry is -- clearly, there's blame. I would agree with that. I think the pharmaceutical industry was also kind of picking up on something that was happening in the medical profession as well, which was this concern that we weren't managing patients well. So the pharmaceutical industry did see an opportunity to capitalized on this new idea about needing to prescribe opioids and chronic opioids for the management of chronic pain. So I think they did play a role. I wouldn't attribute all of the issues that we have specifically to the pharmaceutical industry. But certainly they drove the increased use of opioids in chronic pain patients.
LAKSHMANANWell, there's also the question of patients who can give Academy Award-winning performances to fake pain in order to get pills. I would think it would be hard for a nurse or a doctor to know exactly when to prescribe, especially if you have less and less time with each patient.
COMPTONAbsolutely. Absolutely. And the mantra has become, over the last 20 years, that the patient's pain is what they tell you it is. There's no sympathetic nervous...
LAKSHMANANThere's the Wong-Baker scale, where you're supposed to point to how much pain you have.
COMPTONExactly. Exactly. But the patient would be the one pointing. And so we're encouraged, as clinicians, to believe the patient's report of pain and to manage it in that way. So it's -- it is difficult to know whether or not a patient is feigning pain or really is suffering pain with respect to physiologic source of measures. It's more behavioral indicators around their use of opioids that lets you know if a person is actually using the medication to manage pain or using the medication for more psychoactive effects.
LAKSHMANANAll right. We are going to take a short break. And when we come back, we're going to go to your comments and your questions. You can reach us on 1-800-433-8850. You can send us an email to firstname.lastname@example.org or reach us on Facebook or Twitter. Stay with us.
LAKSHMANANWelcome back. I'm Indira Lakshmanan, sitting in for Diane Rehm. This hour, we're talking about the new CDC guidelines that just came out yesterday for prescribing prescription opioids and the epidemic associated with those drugs. Joining me are Peggy Compton of Georgetown University School of Nursing and Health Studies, Karoun Demirjian of the Washington Post, and Dr. Andrew Kolodny of Brandeis University and Physicians for Responsible Opioid Prescribing.
LAKSHMANANI want to go to some of the really interesting comments we have gotten from our listeners. I have a Facebook comment here from Sharon who says, "in the recent past, I've had two dental extractions. I was handed a prescription for Oxycodone, even though in both cases, there was no justification for it. I believe the dental practice was getting kickbacks from the pharmaceutical company. Big Pharma is keeping medical practices afloat by doing this."
LAKSHMANANAnd then, we have a very different email from Jane, who says "I have real reservations about the CDC's move, as it creates suspicion between doctors and patients. I was treated in the ER for a dislocated shoulder five years ago and was treated like a drug seeker, rather than a patient with a severe injury and I suffered immensely as a result. Recently, when I was scheduled for dental surgery, the dentist and nurse were so critical of my request for a small amount of Percocet for recovery that I cancelled my surgery and terminated my relationship with them."
LAKSHMANAN"Stop treating responsible patients with serious needs as drug addicts." Peggy Compton, can you respond to those two very different views?
COMPTONI can. I think that -- that's one of my concerns with these guidelines is that we're going to see more and more clinicians be more and more concerned about patients that ask for medications, concerned about patients misusing their medications when perhaps they aren't. So, I do worry that the guidelines will -- the pendulum will swing too far the other way and we'll see clinicians who are uncomfortable prescribing medications. But the first question about the, you know, the dentist giving out more medication than needed post dental surgery.
COMPTONIs a very common, common scenario. We hear a lot about -- sometimes, that's the adolescent's first experience with an opioid is when they've had their wisdom teeth pulled out. And I was speaking not too long ago with a mother whose son was having the wisdom teeth taken out. The child's friends at school knew that he would be coming home with a large prescription of opioids and so friends from school were asking if they could buy or get those opioids from the patient, from the student.
COMPTONSo, we do need to be careful about what's prescribed out there and there are good data that show that most dental extractions can be treated with anti-inflammatory medications, that opioids are not necessary.
LAKSHMANANAll right, let's take a call from Don in Jacksonville, Florida. Don, you're on the air.
DONHello, thank you for taking my call.
DONI, you know, I had been 16 years on morphine for a leg -- a knee. My knee was completely fractured, just totally a mess. I had had an operation some 16 years before that where they -- the doc looked in and he said, you're done. You know? And I'm a carpenter by trade, so I needed these drugs to function. But...
LAKSHMANANDid you need the morphine for all 16 years or was it something that you became dependent upon?
DONYes. Oh no, no, it had come to the point -- I had about 580 milligrams, which was a lot.
DONAs far as I know. Per day. And I was very, very conscious about, you know, not overdoing and not underdoing. You know, in other words, if I took too many, I would run out. And I couldn't function. One of the things that is really bizarre about this is I had been a junky in the '60s. Okay, and also, when I was growing up, I had ear infections and my mother used to give me this -- you could buy it over the counter and it was an opioid, tasted like licorice. And I forgot the name of it.
DONBut anyway, she would put it in, in a glass of, you know, water or something and I would drink it. So, I have been, more or less, on and off drugs my entire life.
LAKSHMANANSo, tell us Don, how did you manage to kick it finally? How did you get off the morphine?
DONI just, I -- I went, I had a knee operation and they replaced my knee, which was brilliant. I mean, and when I was in the hospital, they had to keep giving me, I forgot what it's called, but it's a nerve block. Because there wasn't enough medication on the planet to keep me out of pain. And so they did that for a while and when I got home, I just -- I said, they wanted to put me on something to reduce and reduce and reduce. And I said no, I'm done. And I called my doctor and I said, look, I don't know what's going to happen.
DONBut this is going to be ugly. And he helped me through it. And, you know, I am so -- I love my primary physician. He is just wonderful, but he helped me get through this. And, you know, I don't need it anymore. (unintelligible).
LAKSHMANANWell, good for you, Don. Congratulations. That's...
DONMy comment, really, is that when people need it, they really, they really need it. And when people are going after, and I know there's a lot of people going after it that are just, like you say, actors. But, I wasn't one of those, and I saw a lot of people in a lot of pain, you know?
LAKSHMANANAll right, well, Don, thank you so much for sharing your story. And as I say, congratulations that you were one of the lucky ones able to get off your addiction. I just want to mention, for listeners, that there is a national help line for people out there who might be addicted to prescription or non-prescription opioids, for that matter. The Substance Abuse Mental Health Services Administration has a free confidential, 24/7 hotline. 1-800-662-HELP. I think you wanted to jump in and respond to what Don was saying, Peggy.
COMPTONWell, I -- the fact that he was receiving relief from these pain medications for 16 years, again, I do believe that that's a problem. That that's an issue that perhaps his opioid use could have been looked at before he went in to the surgery. But his story is common, that once the painful, you know, the knee was taken care of, he no longer felt the need to be on the opioids. So the patients who may look like they're having difficulty controlling their opioid use, if the pain is taken care of via other modalities or via surgery, they may be much less likely to crave or to want to use opioids after that.
LAKSHMANANAll right, well we have another email from someone who is saying that they're one of those people who they think are using these opioids responsibly. The person says, "I use three Norco a day for spinal stenosis pain. Several doctors have told me this is better than the NSAIDs, the non-steroidal...
LAKSHMANAN...anti-inflammatories that I had been taking. This dose is keeping me from surgery. I can miss a dose and I don't take more than prescribed and I'm tired of being described as addicted and having to sign away my life to get a prescription every month." Dr. Kolodny.
KOLODNYYeah, I'd like to jump in. Because you've now had a few callers, or people write in, with a similar theme, which is that they don't want to be penalized because of the bad behavior of the so-called junkies or drug seekers. And I think there's this notion that there's this subset of our population of this group of people that want to take drugs to get high off of them, and have a good time, and that group is accidentally killing themselves in the process of using these drugs irresponsibly.
KOLODNYAnd so let's not penalize the pain patients. The idea that we've got these two distinct groups is just totally false. Opioids are highly addictive. Pain patients are getting addicted. And the caller who was able to come off and never look back and came off pretty easily, that does happen, but that's the exception rather than the rule. A patient who's been on opioids for a long period of time, when they come off, there are up to six months of withdrawal symptoms, six months of insomnia. Leg kicks in the middle of the night, irritability, depression.
KOLODNYIt's very hard for people to do what he did. And another point that's very important to understand that I think is getting lost here. When we talk about opioid pain medicine, drugs like hydrocodone and oxycodone, these are drugs that come from opium. Just like heroin comes from opium. And the effects that these drugs produce in the brain are indistinguishable from heroin. When we talk about opioid pain medicines, we're essentially talking about heroin pills, which doesn't mean we should never prescribe them.
KOLODNYIt means they need to be prescribed very cautiously. They're excellent medicines for easing suffering at the end of life. Or when used on a short term basis. But as the CDC director's been saying, Dr. Tom Frieden, putting a patient on a highly addictive drug is a momentous decision that needs to be made very carefully. And balance is important. It's the balance of risks verse benefits that prescribers need to make.
LAKSHMANANOkay. Thank you. Let's take another call from Gary in -- who's calling from New York. Go ahead, Gary.
GARYHi, how are you?
LAKSHMANANGood. How are you?
GARYGood. And I would like to echo all the comments that have been made. I've been listening to the show since -- for the last 45 minutes.
GARYAnd completely applaud the CDC for the work they've done throughout 2015 to develop these guidelines and the courage and the strength to issue these a couple days ago. Extremely important. I guess the comments I would like to make is a couple of things. Number one, this continual conversation about, which is a very important conversation, about 30,000 people will have lost their life in 2015 related to an overdose of an opiate, which is five times the number of people who died 15 years ago. And you've been talking about that one the show.
GARYThe one thing that hasn't been mentioned is the three million plus who are currently addicted.
LAKSHMANANAll right, well, Gary, tell us, what's your connection to this story? You obviously know a lot about it. How are you related to this story?
GARYSure. Well, tragically, I'm too related. You know, I'm very related to it. My older son struggled with addiction and mostly to opiates for almost 10 years. And -- Brian. And he passed away in October, 2011.
LAKSHMANANI'm so sorry.
GARYAnd -- thank you. And from that, really struggling to make sense of what had happened, I was really struck by how many other families in this country had gone through a similar tragedy as I had. And that there were evidence based solutions to significantly reducing this issue. And so, I decided to promote someone to run my business and I left my career in the business world four years ago. I spent a year and a half creating a business plan and launched an organization a little over two years ago. Because what I really saw was a need was.
LAKSHMANANAnd what does your organization, what's it called and what does it do?
GARYIt's called Shatterproof, Stronger than Addiction. And what I was really struck by, as I mentioned, the size of this issue. And that there were evidence based solutions. And that for every major disease in this country, there was one well-funded national organization that was funding research, advocating for changes in public policies, working to get that research implemented. And providing information support to families. You know, think of American Cancer. Autism Speaks, MS Society, American Heart.
LAKSHMANANSo, you're a voice for the families of people who have been through this.
GARYWell, no. And yes. In addition to that, what those organizations do is they fund research for both prevention and treatment, not just treatment. And they also advocate for changes in public policies related to both prevention and treatment. And giving information to families, both prevention and treatment.
LAKSHMANANAll right, Gary. Thank you so much for sharing your story. I'm Indira Lakshmanan and you're listening to The Diane Rehm Show. Peggy, you know, Gary brings up a point here, you know, from his very personal story. You know, we're getting a lot of emails from people in both directions, some who say that pain medication is being given out too easily. This is Sharon here, who emailed to say, "when I was rear ended and suffered whiplash, my insurance company would not pay -- would pay for pain medication, including addictive drugs, but would not pay for massage therapy or other alternatives."
LAKSHMANAN"The insurance companies are also to blame." And Larry in upstate New York says, "you can't just blame the prescribers when a third of all TV advertisements after 6:00 PM seem to be for prescription drugs. The first step would be, take those ads off TV."
COMPTONI think that's an excellent point. And I do think that overprescribing is an issue. It has been an issue in this country and I think that we, as clinicians, are all for opioid sparing sorts of therapies to really manage chronic pain. Again, my concern comes with the patients who are currently on these medications on a daily basis for chronic pain. How are we going to manage them and help them to taper off?
DEMIRJIANYeah, and I think that, just, I mean, it's interesting that you bring up the commercials. Because they always say, ask your doctor about this, you know, drug that we're -- and I think what the CDC is trying to do is push the direction -- is push the conversation between patient and doctor in the different direction. And you know, the CDC officials are encouraging patients to question when their doctors give you pain medications right now. And one thing that I thought was very striking when I was interviewing CDC Director Tom Friedman the other day is that he was saying, you know, well, when I was in Medical School, we had one lecture on pain.
DEMIRJIANAnd they told us that these drugs weren't addictive. And so, you've got generations of doctors basically that, you know, did not come through medical school in the last 10, 15 years when this has been a national crisis, and maybe do need a reminder. So, it's shifting that conversation that maybe was circled around drugs before to being circled around other things. And that's a first step that I think everybody is concerned about. You look at states, you look at Congress, again, there's this focus on education.
DEMIRJIANAnd not just treatment, not just, you know, (unintelligible), which is very important. But the education, consciousness training for everybody, basically.
LAKSHMANANWell, you cover Congress and you've written about these hearings where the Senators and the House of Representative members are talking about, you know, the opioid addiction crises in their home states. At the same time, a lot of these members of Congress, as we know, take money from the insurance industry and from pharmaceutical companies. So, I'm wondering what's at stake for them, and when are those chickens gonna come to roost?
DEMIRJIANWell, I mean, at this point, you've seen that that doesn’t seem to matter that much to most members of the Senate. They just passed this bill, which again, is not everything. There's still a big fight going on about whether there's going to be enough funding to actually pay for all these programs, so we're not done with this conversation in the slightest. But in the Senate, they did just pass that bill 94 to 1. So, clearly, the issue is a big enough issue and it matters to peoples' constituents enough that the concerns are not getting in anybody's way for supporting it. The House hasn't acted yet. We'll see what they do.
LAKSHMANANAll right, we have just a very short time for one last call from Christina in New York City. Christina, you have about 30 seconds. Go ahead.
CHRISTINAI just wanted to discuss the fact that a lot of this discussion is well patients taking the pills and such. Very quickly, my daughter actually overdosed at nine months old because a pill fragment of a legally prescribed medication of someone that was not abusing a drug, fell off of a bottle.
LAKSHMANANOh my goodness.
CHRISTINAThis individual, who was watching my daughter, had a piece of fragment that put her in the hospital. She needed four doses of (unintelligible). I don't even take that medication, so I think the discussion needs to broaden that these medications are...
LAKSHMANANWait, how is your doctor? First, tell us how your daughter is doing.
CHRISTINAThank God she survived. This was two years ago in April. She is fine. She has speech delays. We don't know if it's a result of that, but all I wanted to say is this medication was legally prescribed to this individual and we had no idea that a fragment could almost kill her, so this is -- and this is how strong these medications that people are going home with are. So the discussion needs to broaden in a larger public health context. And thank you so much for this discussion, as well.
LAKSHMANANWow. Well, thank you, Christina for sharing your story and I'm so glad that your daughter is okay, despite that horrible experience. You know, we are getting a lot of listeners emailing in on the question of legalized marijuana, and whether it reduces the use of opioids and heroin addiction. And some of our listeners are saying that, look at the states where marijuana has been legalized, like Colorado, and they have seen a decrease in their opioid addiction and death problem. Is that true?
KOLODNYWhat we've seen is that states that have passed medical marijuana laws have not had overdose deaths increase at the same rate as states that haven't passed those laws. It's unclear that passing those laws really had an impact. Advocates for marijuana are saying that this is the answer to the opioid crisis, but then there are also people saying that marijuana is a gateway drug and it would lead to more opioid use. So, I think it may not be a gateway drug, but I don't know that marijuana is necessarily the way out of this.
KOLODNYI do think it's safer to put a chronic pain patient on marijuana than on heroin.
LAKSHMANANWe'll have to leave it there. We'll have to leave it there. Dr. Andrew Kolodny of Brandeis University, Physicians for Responsible Opioid Prescribing. Also, Karoun Demirjian of the Washington Post. And Peggy Compton of Georgetown University's School of Nursing and Health Studies. Thank you all so much. I'm Indira Lakshmanan, sitting in for Diane Rehm.
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