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The opioid epidemic, my take

By on March 1, 2018 in Columnist with 0 Comments

Jim BrownBy Jim Brown, M.D.

I suspect that many of you readers are as puzzled as I was about how the opioid epidemic with its high death rate seemed to spread so quickly throughout our country.

When I was younger, drug overdoses and death were primarily due to heroin and seemed to be confined particularly to large cities like New York, Chicago and Detroit. The overdose death rate then was nothing like it is now with death rates daily in the hundreds.

The poison has now seeped into every corner of the U.S. The per capita death rate in rural America is even worse than what we are now seeing in urban America.

How did this happen?

Opioids are an opium-like compound class of drugs that includes illegal heroin, but also synthetic opioids such as fentanyl and other pain relievers available legally by prescription and sold as oxycodone, oxycontin, hydrocodone, codeine and others. Opioids come in capsules, tablets and liquids.

Prior to 1990, doctors generally avoided prescribing opioids for chronic pain such as back pain and other non-cancer pain.

In the 1990s Purdue Pharmaceuticals developed Oxycontin and marketed it for moderate to severe pain. In 1995 the FDA recommended approval for this drug.

This was the first opioid to win the stamp of approval from the FDA, despite the fact that there had been no testing to assess its potential for abuse. The FDA said in their review that there was no proof of potential addiction and stated, “if used legitimately in the management of pain the potential for addiction was rare.”

Purdue sent 15,000 videos to physicians promoting the drug, stating that oxycontin was less than 1 percent addictive. In response to these promotions, health care professionals began prescribing the opioid for all sorts of chronic pain including arthritis, dental pain, low back pain and migraines.

The FDA first approved 40 mgm pills, then 80 mgm and then eventually, 160 mgm pills.

In 2003 the FDA sent a warning letter to Purdue about its advertisements, accusing the company of minimizing the safety risks associated with oxycontin and failing to warn about abuse.

In 2007 Purdue’s holding company and three executives pleaded guilty to misdemeanor charges of misbranding oxycontin. Between 1999 and 2014 prescriptions for opioid painkillers nearly quadrupled, and so did the deaths caused by these drugs.

Why are these opioid drugs so dangerous?

Our brains are wonderfully designed to reward us with feelings of pleasure when we engage in activities that benefit our species like eating, exercise and sex.

These activities trigger the release of dopamine, which gives us feelings of pleasure.

Opiate drugs from the opium poppy and synthetic man-made opioids can trigger similar feelings.

The problem is that our bodies develop a tolerance to these drugs and thus cause users to want increasing amounts of them. These drugs can and do suppress the respiratory system and slow the heart rate. Most all the overdose deaths are due to the suppression of respiration.

Many of the deaths are attributable to the intravenous injection of fentanyl.

Physicians who do many outpatient procedures such as colonoscopy and other outpatient surgeries are trained in and are very familiar with the use of fentanyl.

Gastroenterologists are  trained in “conscious sedation,” which includes the use of a sedative called versed accompanied by doses of fentanyl as needed for pain during the procedure.

Fentanyl, used in this manner,  is not only easily reversed but  safe and not addicting.

When we use these drugs, our patient’s respirations, oxygen levels and blood pressure are continually monitored. If necessary, a reversal agent such as Narcan can be used to immediately reverse the effects of the fentanyl. Rarely is that necessary.

I used these drugs regularly for endoscopies for over 30 years without any adverse effects. That is obviously very different from addicts injecting these street drugs into themselves, frequently causing death when they quit breathing.

Synthetic opioid drugs are “man-made” drugs rather than making them from natural ingredients, like the poppy. These include drugs like methamphetamine, LSD, Ecstasy and many others.

A designer drug chemically-made version of an illegal drug can be slightly altered to avoid having it classified as “illegal.” Currently these drugs can be sold over the internet without any regulation.

In the U.S. some 200-300 new “designer” drugs were identified between 2009-2014. Most of these drugs were manufactured in China.

Why is that no surprise?

More than 650 of these designer drugs have flooded Europe in the past 10 years as well. Some contain chemicals that haven’t been completely identified, and the effects on the brain and body are unknown.

You might wonder how these drugs made in China get into this country.

It will not surprise you to learn that they are advertised over the internet, but the big shocker is that they are sent untracked into this country through international mail including express mail by our own U.S. Postal Service.

This is the primary source for how fentanyl has become the primary street drug in this country.

Four of the five biggest online sellers of fentanyl are based in China.

A Senate investigating committee on drug use subpoenaed Western Union for payment information related to six online sellers.

They identified $230,000 in payments in financial transactions with U.S. based individuals and businesses. That amount translated into $760,000,000 worth of fentanyl based on U.S. street sales.

Many cities have developed pain clinics offering methadone, a non-addicting opiate substitute for drug addicts who are trying to control the cravings of their habit.

The reason people relapse is that the cravings for opioids are persistent for the rest of your life.

Unfortunately, babies born from opioid addict mothers also have a great risk of these cravings and potential addiction.

This is a terrible, costly U.S. problem and epidemic.

It is depressing to think about the ramifications and costs financially and health-wise along with the inevitable fatalities. The only hope I see is to go after the illegal drug makers and distributors (especially China).

We all need to be informed about what is going on. Public outcry might make a difference.

Jim Brown, M.D., is a retired gastroenterologist who has practiced for 38 years in the Wenatchee area. He is a former CEO of the Wenatchee Valley Medical Center.

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