EDITORIAL

Killing pain

An estimated eight out of 10 heroin addicts in Ohio started their addiction with prescription opioids

2/16/2014

By overprescribing painkillers, well-meaning Ohio physicians — perhaps hundreds of them — contribute to an opiate epidemic that kills 22 or more Ohioans each week, while inflicting the agony of addiction on thousands more.

In northwest Ohio, heroin-related deaths more than doubled last year — to 80, from 31 in 2012— Lucas County chief toxicologist Dr. Robert Forney told The Blade’s editorial page. Most of the victims were middle-aged, suffered from chronic pain, and had graduated to heroin from prescription painkillers.

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As this public-health crisis shifts from prescription painkillers such as Vicodin, Percocet, and OxyContin to heroin, Ohio will need sweeping education efforts aimed at physicians, patients, and the public, as well as treatment programs for those who are already addicted.

Such efforts should not become witch hunts that seek to over-regulate or eliminate prescription painkillers. These drugs have improved treatment and alleviated enormous amounts of suffering for tens of millions of Americans.

But the use of such drugs has exploded in the past 15 years. Everyone, especially those who prescribe them, must understand their potential for abuse and addiction.

Medical-school curricula and clinical practice must include far more instruction on opioid dependence. State medical boards ought to require a minimum amount of continuing education on addiction for physicians. State law should require pharmacies to distribute warnings with opiate prescriptions.

In 2011, sweeping state legislation that regulated pain clinics helped close most of Ohio’s profiteering pill mills, shifting the problem to legitimate doctors. “We have a bigger problem right now with well-intended physicians who just don’t understand the dynamics of this problem and are overprescribing,’’ said Orman Hall, director of Gov. John Kasich’s Opiate Action Team.

Dr. Robert Turner of Columbus was one of them. For 35 years, the orthopedic surgeon ran a successful practice, getting high patient satisfaction scores and garnering awards for community service. The 1973 graduate of Ohio State University’s medical school served as president of the Columbus Orthopedic Society.

Last year, Dr. Turner, 65, received a letter from the State Medical Board of Ohio, stating it had investigated his prescribing habits and found them substandard. The board suspended Dr. Turner’s license for six months, from April to October. He’s rebuilding his practice and working with state agencies to raise awareness about overprescribing.

‘Not alone’

“I was shocked,” he told The Blade’s editorial page. “I didn’t get anything on addiction in medical school, and I wasn’t good at telling patients in pain that there was nothing else I could do for them.

“For those patients who didn’t have a perfect result, Vicodin seemed an acceptable alternative,” he said. “I know now that I was part of the problem, but I also know that I was not alone.”

The number of disciplinary actions, including suspensions and revocations, handed out by the state board for prescribing issues rose from 28 in 2010 to 52 in 2013. Last year, prescribing issues made up more than 25 percent of the board’s disciplinary actions, second only to “impairment,” said Joan Wehrle of the medical board.

An estimated eight of 10 heroin addicts in Ohio started their addiction with prescription opioids such as OxyContin, Vicodin, and Percocet. These drugs affect the same receptors in the brain as heroin, which is chemically similar. They release large amounts of dopamine that give users energy and a sense of euphoria.

The body can become dependent on opiates within weeks, with escalating levels of tolerance. Withdrawal symptoms include spasms, chills, aching bones and muscles, vomiting, diarrhea, intense cravings, and depression.

At least 200,000 Ohioans are addicted to prescription opioids or heroin. In 2011, the latest year for which figures are available from the state Health Department, 1,154 Ohioans died from an overdose of heroin or other opioids, an increase of nearly 50 percent from two years earlier. The Ohio Attorney General’s Office says more than 600 people died from heroin overdoses in 2012, a figure that more than doubled from 2010.

With most of Ohio’s pill mills closed, many addicts have turned to heroin. Part of a pipeline from Mexico and other countries, the drug has become purer, cheaper, and more addictive.

Satisfying an opiate addiction with heroin, which costs about a third of what it did a decade ago, is as much as 10 times cheaper than illicitly buying painkilling pills. A bindle of heroin that costs $10 — a small packet or bag of about 100 milligrams — is far less expensive than buying dozens of pain pills at $3 or more each.

Before the late 1990s, the medical community used prescription opioids sparingly. Physicians undertreated pain, and patients suffered unnecessarily.

Since then, the pendulum has swung too far the other way. Painkillers are now routinely prescribed for dental work, migraines, and backaches.

More overdoses

From the late 1990s to 2010, the distribution rates of prescription opioids in Ohio increased ninefold. The rates of fatal overdoses from these drugs increased in almost equal measure.

Enough opioids are legally dispensed to supply nearly 70 doses to every man, woman, and child in Ohio. In some counties in southern Ohio — including Jackson, Adams, Gallia, and Scioto — the average per-person figure exceeded 100 doses in 2010. Lucas County has been close to the statewide average.

Several changes since the late 1990s led to this explosion. In 1997, the General Assembly passed the Intractable Pain Treatment Act, giving physicians greater latitude to prescribe painkillers.

In 2001, hospitals started to define pain as the fifth vital sign, on the same level with blood pressure, heart rate, breathing rate, and temperature. Patient satisfaction surveys, used by Medicaid and Medicare to grade hospitals and physicians on how effectively they treat pain, also nudged doctors to prescribe opioids.

The release of OxyContin, a powerful synthetic opioid that provides timed release of oxycodone, greatly expanded the use of opioids to treat chronic pain. Pharmaceutical companies aggressively, and sometimes insidiously, promoted this multibillion-dollar industry.

Given these changes, it’s not surprising that physician training and patient education have not kept pace. The statistics on opioid prescription rates, overdoses, and disciplinary actions against physicians, as well as interviews with physicians and students, suggest that medical schools need to do a much better job of teaching how addiction works.

Ohio should not try to choke off the supply of prescription painkillers, or over-regulate their use. Painkillers can be a godsend for suffering patients, including those with cancer, but only if they and their doctors understand the drugs’ potential for addiction.

Last year, Governor Kasich’s Opiate Action Team released guidelines for prescribers. New state statistics suggest physicians are reducing high-dosage prescriptions — those of at least 80 morphine equivalent doses, an amount that equals 16 small Vicodin pills daily.

Still, heroin-related deaths are spiking in Lucas County and Ohio. Expanding treatment options and raising awareness of the dangers of opioid addiction — including retraining the physicians who prescribe them — must become even higher priorities for Ohio this year.