A Physician’s Perspective On How The Opioid Crisis Began

OxyContin

Purdue’s David Sackler Added to Colorado Opioid Lawsuit

The actions of the Sackler family and Purdue Pharma included sharing studies that they knew were misleading, claiming that this was an effective, long-term treatment that didn’t give rise to risks of addiction,” Attorney General Weiser told The Colorado Sun reporters on Monday.

 

“Those claims were verifiably false and ignored expert warnings. And they even undermined studies suggesting that there were addictive effects.”

 

Vanity Fair reports some of those false statements include “that OxyContin was less prone to abuse because of its extended-release formula … The inconvenient truth, as the FDA noted in 2010, was that “the risk for misuse and abuse is greater” for extended-release opioids.

 

The second, and most misleading claim based on a five-sentence letter written by a doctor said, “that less than 1 percent of patients taking OxyContin would become addicted.”

This story cuts close to the heart. During that period, I practiced medicine and was among the doctors who initially believed the drug reps (drug salespeople) claim that OxyContin was not addictive. Fast forward to years later, a similar claim made of Fentanyl, now responsible for many deaths from opioid overdoses. [There is something wrong with the preceding sentence]

 

In 2016, about 2.1 million people in the US had a substance abuse disorder related to prescription opioid pain medications.  In 2019, about 130 people die each day from opioid overdoses related to prescription narcotics, Heroin (cheaper street form), and Fentanyl use.

 

It wasn’t difficult to accept the claim that a long-acting narcotic such as OxyContin would be less addictive.   For several decades, that was the basis for using Methadone to treat opioid addiction.  Now Buprenorphine is used.  Research showed long-acting Methadone produced less euphoria and as such, led to less addiction.  When Purdue Pharma and its drug reps used the same argument to market Oxycontin, it wasn’t difficult to get physician buy-in.

 

In the late 1990s physicians started prescribing Oxycontin in large doses once a day but patients complained of breakthrough pain which forced a twice a day dosing.   Doctors were discouraged from more frequent dosing despite patient complaints of breakthrough pain.  We were encouraged to increase the dose of Oxycontin rather than the frequency.  According to some experts, there was no limit on the maximum dose of OxyContin that could be prescribed to control pain.

 

OxyContin and Percocet are both termed Oxycodone.  OxyContin is long-acting while Percocet is short-acting.  In the medical community, it is widely believed that the short-acting opioids increased the potential for addiction or abuse by causing euphoria, while long-acting OxyContin, because of its slow release, did not cause euphoria and so reduced the potential for abuse and addiction.

 

Many physicians who had chronic pain patients combined OxyContin with short-acting Percocet to control breakthrough pain.   The treatment pendulum had swung to the extreme where to not address the subjective pain needs of patients was sometimes characterized as a form of assault. A scale used to measure the severity of pain asked patients to rate their pain on a scale of one to ten. One being barely any pain and ten being severe pain. Drug-seeking patients often rated their pain level 10 or above.  The absence of physiological evidence, such as increased heart rate or blood pressure that accompanies weren’t as important as the patient’s perception of pain.  That was a 180-degree change in the approach to pain.

 

The most common diagnoses among drug seekers were (not in order of frequency):

  1. Back pain,
  2. Dental pain,
  3. Abdominal/Pelvic Pain, especially among women,
  4. Migraines.

 

Some patients would injure themselves to receive narcotics while others would doctor shop to find doctors willing to dole out narcotics without asking questions. The number of “frequent fliers” with back pain, migraines, and toothache grew as more primary care physicians, and specialists turfed their pain patients to the emergency room.

 

In retrospect, OxyContin wasn’t less addictive. Had the risk of addiction from OxyContin been so low, as the drug reps touted, “why did patients break into pharmacies and doctor’s offices to steal OxyContin?” The burglaries of many doctors’ offices and a few small pharmacies resulted in their refusal to prescribe OxyContin and the unwillingness of some pharmacies to stock it. It was common to see “No OxyContin stored on site.”

 

There were forgeries of doctor’s signatures to get not only OxyContin but Percocet and Morphine.  In my opinion,  such forgeries and burglaries were not taken seriously by law enforcement or the criminal justice system.   On apprehension, perpetrators received a slap on the wrist,  while a war on drugs was raging in communities of color.

 

The Sackler family should not be solely held accountable.  Purdue Pharma provided misleading information that led to the use of hefty doses of Oxycontin to control pain rather than increase the frequency of OxyContin.  Hospital administration also forced the hands of doctors. When patients complained that their pain needs were not addressed, doctors were singled out.  There were tremendous patient, peer, and administrative pressure to control pain aggressively.

 

In one emergency room, some patients called me the “Black bitch” who should return to Africa. My car was keyed. I let the history and physical exam guide the indication of narcotics. Other doctors like myself were teased as narcotic police because they identified drug-seekers.

 

On a typical day in the emergency room (ER), it was not uncommon to see up to 5-15 patients with toothaches. The exam would reveal poor dental hygiene with no objective signs of infection as well as normal vital signs for someone with a pain score of 11 out of 10. Such patients routinely got as many as 30 Percocets with their 10-day supply of Penicillin. Patients knew which doctors were generous suppliers.  During busy periods, most of my colleagues found it more convenient to prescribe narcotics, rather than be subjected to the hostilities of dissatisfied patients.

 

The number of narcotics given in the ED by “generous sympathetic physicians” was jaw-dropping, dangerous and extremely alarming. However, such doctors enjoyed a respected status for their opioid generosity.  In one ER, I saw patients receiving massive shots of Demerol beyond what was considered the maximum dose. Often these patients were then discharged from the ER with a hefty supply of Percocet for their subjective complaints of pain.

 

When patients died from prescription drug OD, the connection between doctors and narcotics was never uttered or even a thought.

 

Later, when I worked in the office setting as an Internist, I discovered many patients on chronic narcotic pain medications often had no opioids in their urine. That suggested some patients did not use the prescribed narcotic drug, so why were they prescribed massive doses which they religiously filled monthly?   One patient,  I recalled was on 80mg of OxyContin twice a day with 2 Percocets every 4 hours as needed for breakthrough pain.  There was little concern that this patient drove while taking such massive doses of narcotics.

 

Indeed, the Sackler family played a significant role in deceiving doctors about the abuse potential of Oxycontin. But so did hospitals and their administration who also knew what was going on.  Law enforcement found the burglaries and forgeries not worthy of pursuit although their war on drugs was devastating many communities of color.

 

Unfortunately, the pendulum once again has swung to the opposite extreme, where patients with objective findings of pain are treated with suspicion when they request pain relief. These patients are now victims of a pendulum swinging healthcare system where common sense takes a back seat to politics and policies of Big pharma, insurance companies, and politicians.

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