Wrecked in a Mist of Opium – The Effects of Prescription Opioid Abuse
The English author and cultural critic Matthew Arnold described fellow poet Samuel Taylor Coleridge as a “philosopher wrecked in a mist of opium.” Using laudanum (a tincture of opium) to treat various ailments led Coleridge to lifelong addiction. Although laudanum is more closely controlled today, non-prescription use of opioid painkillers leads to addiction and remains a significant health threat.
These drugs include morphine and methadone, and the more commonly prescribed Vicodin, codeine, pethidine and tramadol. These drugs are typically only used against the most extreme forms of pain – following surgery or severe injury. They reduce pain perception by slow and steady release of opioid that acts with proteins in the brain and other organs. They can cause confusion and euphoria even when used properly, but people who abuse opioids to intensify the euphoric feelings they produce risk serious medical complications and overdose.
The rise in the abuse of opioid painkillers – by crushing, injecting, snorting or chewing oral formulations – mirrors the increase in prescriptions throughout the 1990s and 2000s. In 2010 the total amount of prescription painkillers sold in the U.S. could have medicated every adult in the country with a typical dose of 5 mg of hydrocodone every four hours for one month.1
Perhaps as a result, non-medical use of prescription opioid pain killers has largely been viewed as a U.S. problem. The social costs of this abuse are indeed large since overdose deaths led to 830,652 years of life lost – comparable to motor vehicle accidents.2 In 2014 opioids were involved in 28,647 deaths; 61% of all drug overdose deaths – almost 19,000 – involved “legal” pain medication.3,4 Compared to non-abusers, emergency department visits were four times as likely, mental health outpatient attendance 11 times, and an inpatient stay 12 times.5
In the U.S. this has resulted in legislation creating prescription-drug monitoring programs. However, the effectiveness of this “impressive response” is yet to be fully felt.6 Less attention has been paid in Europe even though significant levels of non-prescription use have been identified. Estimations of the levels of abuse range from 0.7 per 10,000 individuals in Spain to 13.7 in France.7
Most people obtain opioid painkillers through their own prescriptions, people they know or from a single doctor. Others “doctor shop” or buy drugs from friends or relatives. Some visit emergency departments and claim dental pain so that they can obtain opioids; they are dispensed in 75% of cases. Paying with cash rather than through insurance helps evade detection. Thefts from pharmacies and delivery trucks have increased as have reports of care workers stealing from elderly clients. Genuinely rogue clinicians are of course rare, but many doctors simply lack the training to spot and manage opioid abusers.
In addition to monitoring programs, other measures include better access to treatment and reformulating medication. Training is at the heart of the response to this problem. Many opioid abusers have actually experienced chronic pain at some time but clinicians are not well-schooled in pain management.8 (Read Dr. John Delfosse’s blog, Feel the Pain – Empathy and Treatment in Pain Management.)
Insurers will frequently receive applications from people who are at risk of prescription opioid abuse. Screening tests that help clinicians identify them are available but they are complex with extensive questions on addiction susceptibility and patterns of use that make them unrealistic for insurers to ask in an underwriting context.9 Nevertheless, underwriters’ concerns should be raised when a review of the medical evidence does not clearly necessitate painkillers. Other clues include rapid, multiple increases in dose, previous substance abuse and the presence of other mental health problems.
- Shepherd, J (2014), Combatting the prescription painkiller epidemic: a national prescription drug reporting program, American Journal of Law and Medicine. 40. 85-112.
- Center for Disease Control and Prevention (CDC) vital signs: overdoses of prescription opioid pain relievers — United States, 1999–2008, MMWR Morb Mortal Wkly Rep 2011;60:1487–1492.
- Brooks M (2015), Opioid overdose deaths hit record high http://www.medscape.com/viewarticle/856242 (accessed 30/12/2015).
- Lin KW (2015), Opioid abuse: a primary care-created problem? http://www.medscape.com/viewarticle/856112 (accessed 30/12/2015).
- White AG, et al (2011), Economic impact of opioid abuse, dependence and misuse, American Journal of Pharmacology Benefits. 3. 59–70.
- Dart, RC et al (2015),Trends in opioid analgesic abuse and mortality in the United States, New England Journal of Medicine. 372. 241-8.
- Shei, A et al (2015), Estimating the health care burden of prescription opioid abuse in five European countries, ClinicoEconomics and Outcomes Research. 7. 477-488.
- Brooks, M.(2015), Opioid overprescribing not limited to a few bad apples http://www.medscape.com/viewarticle/856063 (accessed 30/12/2015).
- Manchikanti, L et al (2008), Monitoring opioid adherence in chronic pain patients: tools, techniques and utility pain physician, Opioids Special Issue: 11.1-26.