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Health officials do not tease out which drug is responsible for every death, and it's not always possible. "There may be lots of drugs on board," says Cathy Barber, director of the Injury Control Research Center at the Harvard School of Public Health. "Is it the opioid that caused the death? Or is it the combination of opioid, benzodiazepine and a cocktail the person had?" Still, most experts agree that nothing but the exploding availability of opioids could be behind the exploding rate of death.
Contrary to stereotype, the people most at risk in this epidemic are not the usual pill-popping suspects the dorm rats and users of street drugs. Rather, they're so-called naive users in the 35-to-64 age group mostly baby boomers, with their aching bodies and their long romance with pharmaceutical chemistry. "People with pain complaints get a 30-day prescription for Oxycontin, and it's like a little opioid starter kit," says Barber.
The Food and Drug Administration (FDA) has, in its dilatory fashion, begun addressing the problem, but it doesn't promise any action before next year if then. That leaves millions of people continuing to fill prescriptions, tens of thousands per year dying and patients in genuine pain wondering when a needed medication will relieve their suffering and when it could lead to something worse.
The U.S.'s opiate jag began, like so many things, with the best of intentions. In the 1990s, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) the accrediting body for hospitals and other large care facilities developed new policies to treat pain more proactively, approaching it not just as an unfortunate side effect of illness but as a fifth vital sign, along with temperature, heart rate, respiratory rate and blood pressure. As such, it would have to be routinely assessed and treated as needed. "It was a compassionate change," says Barber. "Patient-advocacy groups pushed hard for it." And, she points out, drug companies did too, since more-aggressive treatment of pain meant more more-aggressive prescribing.
But the timing was problematic. The new JCAHO policy went into effect in 2000, which was not only about the time the new opioids were hitting the market but also shortly after the Federal Trade Commission began allowing direct-to-consumer drug advertising. When market, mission and product converge this way, there's little question what will happen. And before long, patients were not only being offered easy access to drugs but were actually having the medications pushed on them. No tooth extraction was complete without a 30-day prescription for Vicodin. No ambulatory surgery ended without a trip to the hospital pharmacy to pick up some Oxy. Worse, people with chronic pain were getting prescriptions that could be renewed again and again.
"For me, it started with lower-back pain," says Jason (not his real name), a carpenter in his late 50s. Jason is a 90-day inpatient at the Hanley Center, a residential addiction facility in West Palm Beach, Fla. "I went to my doctor, and he prescribed Oxycontin. After a little while, I was finishing a one-month prescription in three weeks, then in two. I started complaining of more pain than I had so I could get more Oxy, and finally I started buying it on the street. In a pharmacy, I paid $8 for 160 pills. On the street, I was paying $25 each."
Jason's demographic profile is typical of Hanley's older, whiter and generally wealthier than addicts of previous generations. And while some people do wind up buying on the street, many never need to, thanks to the gray market that has sprouted up around opioid sales. As long as the drugs are legal and real M.D.s are prescribing them, it's a simple matter to hang out a shingle and call yourself a pain clinic. Pay-to-play patients are given prescriptions based on little more than their word that they're in pain sometimes backed up by self-evidently altered MRIs.
Says Evelyn (another pseudonym, and another baby boomer at Hanley), "When my physician refused to prescribe me more pills, he sent me to a clinic. The doctor there didn't even ask me my name at first. He wrote me a prescription while he was on the phone dealing with some court case he was involved in. When you're well dressed and you have insurance, they don't think of you as an addict."