#1 – Why America Can’t Kick Its Painkiller Problem

Photo Natalie Keyssar for TIME

“An estimated 100 million Americans suffer from chronic pain, and a quarter of them say it is severe enough to limit their quality of life, according to the Institutes of Medicine.”

“It took a tragic combination of good intentions, criminal deception and feckless oversight to turn America’s desire to relieve its pain into such widespread suffering. Most everyone has played a role. Weak research opened the door to overuse of opioids. The Food and Drug Administration (FDA) approved ever more powerful drugs for long-term use based only on evidence of their short-term safety and efficacy. Two pharmaceutical companies pleaded guilty to criminal charges that they misleadingly marketed the drugs as safe. Too many doctors embraced the easy solution of treating pain by writing a prescription. All now agree that the opioid epidemic is a terrible problem, but few are taking responsibility. It has fallen to local law enforcement and health professionals to clean up the mess as addiction and abuse ravage their communities. It’s not easy.”

How this happened:

“One particularly influential 1986 paper by Dr. Russell Portenoy and Kathleen Foley looked at the experience of 38 patients and concluded, cautiously, that if you were in pain, you might be able to safely take opioids for months or even years without becoming hooked. ‘Drug abuse is highly prevalent, especially in some cities, in some subpopulations and in some patients with psychiatric diseases,’ Portenoy tells Time. For others with no personal or family history of addiction, he says, drug abuse is a ‘very, very low risk.'”

“In 1998 the Federation of State Medical Boards (FSMB) issued new guidelines for doctors prescribing opioids, saying they could be “essential” for the treatment of chronic pain and neglecting to warn of the risk of overdose. The standard-setting Joint Commission on Accreditation of Health Care Organizations in 1999 required doctors to measure pain as part of their basic assessment of a patient’s health, which had the effect of elevating pain to the same level of importance as objective measurements like temperature and heart rate. Hospitals began displaying posters bearing smiley and frowny faces to help patients indicate levels of pain. (The FSMB says it had to offer doctors its best guidance for using opioids once the FDA approved the drugs.)”

In 2007 the Department of Justice accused Purdue of deceptively telling doctors OxyContin was safer and less addictive than other drugs. The company and several executives pleaded guilty to misleading doctors and were fined $635 million. In 2008, Cephalon paid $425 million in fines partly for marketing its Actiq opioid, which was shaped like a lollipop, for use against migraines and sickle-cell pain, conditions for which the drug had not been found safe and effective. Actiq withdrew its lollipop, but by then there was no shortage of other opioids available.

By 2011 the number of opioid prescriptions written for pain treatment had tripled to 219 million. By 2014, in some small towns in the southeastern U.S., between one-sixth and one-eighth of the population was taking opioids for more than a month, according to one survey. Such extended use can create resistance to the drug’s effects, leading abusers to increase the amounts they take and putting them at risk of a fatal overdose. By 2011, 17,000 Americans were dying every year from prescription-opioid overdoses.

“In Scott County, however, officials have learned that national attention doesn’t always mean things get better. Two years ago, the FDA noted in a letter to the maker of Opana, Endo Pharmaceuticals, that its new, supposedly ‘abuse deterrent’ version of the drug appeared to be driving addicts to inject it intravenously rather than snort it. Now local law-enforcement, health care and social-welfare officials are scrambling to contain the HIV outbreak that has since overwhelmed the county.”

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