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Office of Neuroscience Research > Did you know? > Inside an epidemic (Outlook Feature, September 2017)

Inside an epidemic (Outlook Feature, September 2017)



Overcoming America’s opioid crisis starts with understanding abuse patterns

From Outlook Magazine... 

Theodore Cicero’s research changed direction when he encountered a 20-year-old who was taking opioids — but not to get high.

The young man was struggling with depression, low self-esteem and social anxiety. He was taking drugs because he believed they made him a better, more popular person. He was more social, more relaxed and was able to approach women in bars and start conversations. And he was taking opioids despite the disastrous consequences he knew they could have.

Cicero, PhD, the John P. Feighner Professor of Psychiatry, has surveyed 25,000 addicts on why they use drugs. It’s stories like the young man’s that illuminate the challenge medical professionals face in fighting drug use.

“The typical survey response is not that they are getting high, but that it relieves their depression, they feel less anxious,” Cicero said. “Many people feel they are actually better individuals when they’re taking drugs because they are more outgoing. People think they function better. That’s a difficult thing to combat.”

This is the power opioids, such as the prescription pain pill oxycodone or the more easily obtained illegal heroin, have on many individuals and is one major reason the drugs are so addictive. In 2014, drug overdoses surpassed automobile accidents as the No. 1 cause of accidental death for the first time in U.S. history. And although not all of these overdoses are due to opioids, 91 Americans die every day from an opioid overdose, according to the Centers for Disease Control and Prevention (CDC). CDC data also show that 60 percent of overdoses occur in patients with legitimate prescriptions from a single doctor.

For 25 years, Cicero has been ahead of this developing crisis, charting addicts’ motivations and predicting emerging abuse patterns around the country. Cicero and colleagues were the first to identify changing demographics as opioid addiction spread from inner cities to the suburbs, and also predicted the shift from painkillers to heroin to synthetic opioids like fentanyl.

How did we get here?

“There are two events that happened in the late ’90s and early 2000s that have led to where we are right now,” Cicero said.

In 2001, the Joint Commission accrediting organization, advocating on behalf of patients, issued a set of standards outlining how the health-care industry was vastly undertreating pain. The report recommended that health-care workers consider pain as the “fifth vital sign,” along with monitoring of a patient’s temperature, pulse, respiration and blood pressure.

As a result, health-care workers routinely began asking patients to rate their pain on a pain scale. The overarching message: patients shouldn’t have to endure pain.

The report also urged physicians to prescribe opioids more freely, based on a letter published in 1980 in The New England Journal of Medicine (NEJM). Written by two doctors, the five-sentence letter stated: “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” Though the letter since has been debunked, drug makers and doctors still cite it as a reason to continue the widespread prescribing of opioids.

Another event that took abuse to a critical level was the 1996 introduction of an extended-release version of oxycodone, one of the most popular opioid painkillers.

Sold under the brand name OxyContin, the new pills could be taken just once or twice a day, rather than every 4 to 6 hours. “For people who had trouble keeping track of their medications, this was an ideal solution,” Cicero said. “Elderly people, for example, especially have memory issues with that.”

This new formulation, however, also was an ideal solution for addicts. For a pill to work over 24 hours, it must contain a large amount of the active drug. Instead of 5 mg, each tablet now contained 80 to 100 mg of oxycodone. Addicts soon learned they could release the drug’s full potency all at once by crushing the new tablets.

The revised formulation also contained no acetaminophen or non-steroidal anti-inflammatory drugs, both of which make snorting and injecting the drug very painful. (Acetaminophen, for instance, burns the nasal passages when snorted.)

“Now all of a sudden we had a pure version of oxycodone that didn’t contain any additives,” Cicero said. The maker of this extended formula and the Food and Drug Administration (FDA) later stated that they did not foresee addicts’ workarounds.

With a new emphasis on curing pain and the discovery of a more potent delivery method, other pharmaceutical companies began producing variations of these pain pills. Doctors became more willing to prescribe opioids in larger amounts. Many of these prescriptions would go unused, stored in medicine cabinets and end up getting stolen, sold and diverted to the streets. “Now you have a ready supply of it on the street because physicians were doing their job and treating pain, but had no indication that this was going to lead to trouble,” Cicero said.

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