Doctors Must Lead Us Out Of Our Opioid Abuse Epidemic

As of 2011, 75% of the world's opioid prescription drugs are prescribed and swallowed up in a country that makes up less than 5% of the world's population, leading to the most common cause of unintentional death in America today -- drug overdoses. It is a horrifying. Shameful statistic.

And, having traveled all over the world covering natural disaster, wars and famine, I am fully confident we Americans don't have 75% of the world's pain.

Who is at fault?

There is plenty of blame to go around. Drugs are cheaper than a multidisciplinary approach to treating pain, and cost savings are what insurance companies like to hear.

For decades, certain pharmaceutical companies misled the FDA about the risks of opioid dependence in an effort to sell more of the drugs, and three top executives from Purdue Pharma even pleaded guilty to those criminal charges.

America's opioid epidemic

Our federal government has created nearly insurmountable hurdles to studying other therapies such as medicinal marijuana, which has for years been used safely and effectively in other countries for chronic neuropathic pain, one of the most difficult types to treat.

Addicted? How to get help

If you're addicted to prescription drugs, help is available. You can call the Substance Abuse Mental Health Services Administration 24/7 hotline at 1-800-662-HELP(4357) or visit their website.

Most of the blame, however, belongs on the shoulders of the American doctors themselves. I am a practicing neurosurgeon, and this is not an easy thing to acknowledge. The fact is, we have accepted the tall tales and Pollyannaish promises of what these medications could do for too long. As a community, we weren't skeptical enough. We didn't ask enough questions. We accepted flimsy scientific data as gospel. Preached it to our patients in a chamber that echoed loudly for decades.

Even worse, too many doctors who didn't actually believe the hyperbole surrounding opioids doled out long-term prescriptions regardless, in the same way doctors write antibiotic prescriptions for viral illnesses. In both cases, they don't work. In both cases, they can cause colossal harm.

The King of Pain

It was a particular American doctor who, in many ways, started all of this. If you want to identify a specific moment this opioid epidemic sprouted wings, many would point to a paper written 30 years ago this month.

Based on a study of just 38 patients in 1986, Dr. Russell Portenoy challenged the conventional wisdom. Up until that time, opioids had been reserved for cancer patients and palliative care and only for short durations because of the concern about addiction. Dr. Portenoy, armed with his small study, believed prescription opioids could safely be used in all patients with chronic pain for years on end. He maintained that the drugs were easy to quit. That overdoses hardly ever occurred.

Prescription and illegal opioids are commonly abused because they are so addictive.

Opioid medications bind to the areas of the brain that control pain and emotions, driving up levels of the feel-good hormone dopamine in the brain's reward areas and producing an intense feeling of euphoria.

As the brain becomes used to the feelings, it often takes more and more of the drug to produce the same levels of pain relief and well-being, leading to dependence and, later, addiction.

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Oxymorphone hydrochloride - Oxymorphone hydrochloride, under the name Opana ER, was at the center of an HIV outbreak in Indiana in 2015. Some addicts began injecting. Shared needles increased the spread of HIV.

In June, the Food and Drug Administration requested that Opana ER manufacturer Endo Pharmaceuticals pull the drug from the market. It was the first time the agency has asked that a opioid pain medication be pulled "due to the public health consequences of abuse." Endo announced in July that it would pull the drug.

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Codeine - Codeine is one of the weakest opioids, often given when painkillers such as acetaminophen or ibuprofen fail to work. Because it decreases activity in the part of the brain that controls coughing, it's frequently mixed with other liquids to develop cough syrups for colds and flu. It has frequently been used for pain relief after removal of tonsils and adenoids in children.

After an investigation, the FDA restricted the use of codeine and tramadol in children under 12 and recommend against their use in children between 12 and 18 years of age. Additionally, the FDA has warned breastfeeding mothers not to take these medications due to the risk of serious adverse reactions in breastfed infants.

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Heroin - You can't get heroin by prescription, but many heroin users start off abusing prescription opioids, then turn to this illegal opioid.

CNN's Chief Medical Correspondent Dr. Sanjay Gupta has reported on recent research that shows today's typical heroin addict starts using at 23, is more likely to live in affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.

According to the CDC, deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.

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Fentanyl - Fentanyl citrate, pictured here, is a Class II controlled substance and one of the most powerful opioids on the market. It's often administered via injection or transdermal patch, or in lozenge form for pain after surgery, for difficult-to-manage chronic pain and for people who have developed a tolerance to other opioids. The type of fentanyl usually associated with overdoses is bought on the street in powder or pill form. Is often mixed with heroin in a clandestine lab to increase the high it produces. Street names include Apache, China girl, goodfella, jackpot, murder 8, TNT and Tango and Cash.

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Hydrocodone - These pills are a more powerful form of codeine, called hydrocodone, and are often mixed with acetaminophen. Hydrocodone is the most frequently prescribed opioid painkiller, according to the U.S. Food and Drug Administration, and the most abused. An overdose of hydrocodone can cause "cold and clammy skin, severely constricted pupils, and slow breathing that can lead to a loss of consciousness and death."

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Oxycodone - Oxycodone is a powerful narcotic pain reliever prescribed for moderate to high pain relief. It's often given in an extended-release formula for patients who will need to be on pain medications for long periods of time.

Patients are warned not to break, chew, crush or dissolve extended-release tablets because the rush of oxycodone into the system could cause serious health problems, including overdose and death.

Though highly addictive, oxycodone is not thought to be as frequently abused as hydrocodone. OxyContin, Percocet, Percodan and Tylox are some trade-name oxycodone products.

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Morphine - Morphine is another powerful opioid often administered via syringe for severe pain. It can come in pill form, usually as extended-release tablets and capsules, and is prescribed only to relieve difficult, chronic pain that cannot be controlled by the use of other pain medications.

As with most opioids, mixing medications, drinking alcohol or taking other meds that contain alcohol, or using street drugs while taking morphine, increases the risk of breathing problems or other serious, life-threatening side effects.

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Meperidine - Meperidine is another narcotic analgesic, similar to morphine. It's often used to help put people to sleep before an operation. To provide pain relief after childbirth.

The most common brand name is Demerol, which comes in both tablet and liquid forms. It is usually taken with or without food every three or four hours as needed for pain.

As with all opioids, meperidine can cause drowsiness, so never drive a car or operate machinery after taking it until you know how you will react.

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Hydromorphone - Hydromorphone is another highly potent prescription painkiller. It's most commonly known by the brand names Dilaudid, pictured here, and Exalgo.

Liquid hydromorphone holds the dubious honor of being frequently mistaken for morphine in hospital "wrong drug" medication errors because of the similarity of the names and appearances.

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Methadone - Though methadone is used to relieve severe chronic pain, it's most commonly known for preventing withdrawal symptoms in patients who were addicted to opioid drugs, as a part of their recovery process.

Methadone has many of the same side effects as other opioids, including weakness, headache, nausea and vomiting, stomach pain, sweating, difficulty urinating, mood changes and vision problems, and difficulty falling asleep or staying asleep.

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Photos: Opioids: Addictive painkillers

Buprenorphine - Buprenorphine is a opioid used as an alternative to methadone to help addicts recovering from heroin use. Buprenorphine is different from other opioids because it's a "partial opioid agonist," which means that when taken in proper prescribed doses, it should produce less euphoria and physical dependence, and therefore a lower potential for misuse. It's also supposed to have a relatively mild withdrawal profile.

However, if abused by crushing and snorting or injecting, it can suppress breathing and cause dizziness, confusion, unconsciousness and death.

Subutex, the brand name for buprenorphine, is taken as a tablet placed under the tongue and allowed to dissolve.

The brand Suboxone is a combination of buprenorphine and naloxone, an opioid antagonist. Antagonists block the opiate receptors in the brain, keeping the narcotic from creating the high abusers crave.

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Along with several others, Portenoy cited a single-paragraph letter to the editor from the New England Journal of Medicine stating that less than 1% of opioid users would become physically dependent or addicted.

As it turns out, almost none of this was true.

When we reached recently retired Dr. Hershel Jick, author of the oft-quoted "1% letter," he was quick to point out that his statistic was misrepresented. It was intended to represent only patients prescribed opioids in the hospital who were carefully monitored. He told us he never anticipated the remarkable impact a one-paragraph letter would have in the decades to follow.

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Even Portenoy, once mockingly referred to as the King of Pain, appears to have recanted and apologized for his part in walking the American people into an abyss of addiction.

There is no question that many people suffer unimaginable chronic pain, and we don't want to solve the epidemic by impeding their ability to obtain pain relief. But the truth is, they deserve medications better suited for the job. They deserve medications that uncouple powerful analgesia from terrible addictive potential. They deserve medications that don't cause hyperalgesia, a syndrome of increased pain necessitating escalating doses of opioids. Most of all, they deserve to have doctors who rely on scientific evidence that is solid, not fanciful.

Where we stand

We have a long way to go. Instead of safer pain therapeutics, patients are now being offered expensive new medications that only treat the consequences of the opioid epidemic. With 259 million opioid prescriptions being written yearly, it turns out side effects -- such as constipation -- are a big enough business to warrant its own Super Bowl commercial.

Unintended consequences: Why painkiller addicts turn to heroin

There are other grim signs. We now know that heroin has made a resurgence and 80% of new heroin users start off using pain pills, which contain the same type of base ingredients.

Most disturbing, however, is a recent study showing that 91% of people who survived an overdose were still able to get another opioid prescription, typically from the same prescribing doctor. Not only are we failing to learn and make progress, it seems we are turning a blind eye to the tragedies unfolding right in front of us.

A doctor call to action

As policymakers begin to catch on, rules and regulations will start to change. As part of a discussion I moderated with President Obama last month, we learned the Centers for Disease Control and Prevention is now recommending against doctors prescribing opioids for most chronic pain situations. When a prescription is written, it should be for the lowest effective dose and the shortest amount of time: usually just a few days.

Obama announces new moves to fight opioid and heroin abuse epidemic

Pills will also come with safeguards to make them difficult to abuse and discourage "doctor-shopping," as well as a strong warnings about addiction -- something we doctors should have been diligent about all along.

But most simply, we as doctors need to engage our patients and discuss treatment with them, whether its short term opioids or alternatives like physical and occupational therapy. We need to help set realistic expectations for our patients: Living entirely pain free is not always possible. As doctors, we need to have follow-up conversations with our patients to see how treatment is going. If we better understand our patients, we can provide better treatment and help develop pain strategies that are effective and safe.

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It is not too late. In order for this American-made epidemic to finally end, however, it is the American doctors who must lead the way.