Pubdate: Sat, 09 Apr 2016
Source: Press Democrat, The (Santa Rosa, CA)
Copyright: 2016 The Press Democrat
Contact:  http://www.pressdemocrat.com/
Details: http://www.mapinc.org/media/348
Author: Faye Flam, Bloomberg View

DOCTORS PAVED ROAD TO HELL WITH PAIN PILLS

Now that deaths from opioid overdose exceed those from car crashes, 
the medical community has come to recognize an error of historic 
proportions. In 2014, U.S. doctors wrote 245 million prescriptions 
for Vicodin, OxyContin, and other painkillers in the highly addictive 
family of opium derivatives known as opioids. That practice spares 
many patients from pain following accidents or surgery, but the cost 
is more than 20,000 deaths a year.

In the past, drug addiction was viewed more as criminal behavior than 
as a medical condition, said Nora Volkow, who heads the National 
Institute on Drug Abuse. "But what we are facing now is the 
responsibility of the health care system," she said. "We created this 
epidemic and we have to be responsible to overturn it."

The Centers for Disease Control and Prevention issued new guidelines 
for doctors last month, and President Barack Obama has promised 
better access to addiction treatment. Those measures could help, but 
to get to the root of the problem, doctors need to learn more about 
the science of addiction.

Volkow said most doctors don't know the difference between physical 
drug dependence and drug addiction - a distinction that can be a 
matter of life or death. Dependence can happen to anyone taking these 
drugs for a long enough period. The body's chemistry gets disrupted 
causing withdrawal symptoms when the drugs are discontinued too 
rapidly. Volkow said she experienced this herself when she stopped 
taking opioids following a car accident and then felt sick.

That doesn't mean she was addicted; only about 10 percent of people 
have the physiological predisposition to become addicts. In those 
people, though, once addiction starts it's notoriously difficult to 
get rid of it. Addiction changes the brain so that even years after 
going through withdrawal, Volkow said, patients can still crave the 
drug. After a long abstinence, a dose that an addict once tolerated 
can be fatal.

In an article published last week in the New England Journal of 
Medicine titled "Opioid Abuse in Chronic Pain - Misconceptions and 
Mitigation Strategies," Volkow and her colleague Thomas McLellan make 
a case that doctors should be required to study addiction in medical school.

Doctors long assumed that their patients wouldn't get addicted, said 
Volkow, but vulnerability to addiction is not easy to predict. To a 
large extent it's determined by genes. And once addiction starts, the 
problem isn't that people lack the self control to stop doing 
something pleasurable. Addicts can be driven to take the drugs, 
Volkow said, not to feel good but to stop feeling terrible.

Though archaeological evidence suggests that people have been 
cultivating opium poppies since the Stone Age, and have been using 
them as medicine at least since the time of Hippocrates, the current 
addiction crisis stems from a 30-year-old change in medical practice.

Morphine and synthetic derivatives of opium had been around for 
decades, but they were used primarily for people with terminal 
diseases, said Jianren Mao, a Massachusetts General Hospital doctor 
and neuroscientist specializing in pain. An influential 1986 paper 
said opioids offered a "humane" way to deal with other patients in 
pain. It seemed like a reasonable proposition, he said.

Pain was once undertreated, said psychiatrist Charles O'Brien, head 
of the addiction treatment program at the University of Pennsylvania. 
"But it went overboard the other direction, so now you have people 
getting a wisdom tooth pulled and getting 30 day's worth of 
OxyContin," he said. "It goes in the medicine cabinet where the 
grandchildren get it," he said, pointing to a danger that extends 
beyond the patient to friends and relatives who borrow the drugs for 
a backache, and to teenagers eager to experiment.

While Obama pledged increased access to the anti-addiction drugs 
methadone and buprenorphine, those are themselves opioids. O'Brien 
said a different kind of drug, Naltrexone, works by blocking the 
effects of opioids. In a recent trial published in the New England 
Journal of Medicine, the drug appeared to prevent relapse in people 
who had been released from prison.

Mao, the neuroscientist, said that beyond the addiction problem, his 
research helped identify another serious downside to opioids. When 
prescribed for chronic pain, the drugs sometimes increased patients' 
pain sensitivity, making the problem worse and often leading to the 
need for escalating doses. Even if you took addiction out of the 
equation, he said, the pain sensitivity problem should prompt doctors 
to try other possible treatments and use opioids only if all else fails.

When will the pharmaceutical industry come out with a safer 
painkiller? Mao said drug companies have added a number of new pain 
medicines, but they fall into the same old families. There are the 
opioids, with all their hazards, and the nonsteroidal 
anti-inflammatories, which can pose risks as well. A member of the 
latter family, Merck's Vioxx, became popular among people with 
arthritis. But the company later took it off the market because it 
increased the risk of heart disease and stroke.

Pain, Mao said, is one of the oldest and most basic features of the 
animal nervous system. Pain perception has been essential for 
survival for 500 million years. Making it go away is hard to do 
without unintended consequences.
- ---
MAP posted-by: Jay Bergstrom