Time drug art

Stephen Lewis for TIME

Jeffrey Kluger has a story about the boom in prescription drug addiction in the Sept. 13 issue of Time magazine. Full story not on the website, but here are some tidbits from the issue that came in the mail:

  • In 15 states and the District of Columbia, unintended drug overdose is now the leading cause of accidental death, having surpassed car wrecks—and in three more states, it’s almost a tie. … No telling which drugs are doing it, he writes, but most experts agree that the “exploding availability of opioids could be behind the exploding rate of death.”

Written in true Time alarmist style, but consider the statistics Kluger lines up:

  • In 2007 (the most recent year for which data are available!! for godsake) 3.7 million people filled 21 million legal prescriptions for opioid painkillers
  • 5.2 million people 13 and older said they used these drugs “nonmedically” in the previous month.

Which is probably an underreport. Just taking my own case as an example: if you’d asked me back in 2000 whether I was using my Lorcet “nonmedically”? I’d have said, “No indeed,” despite the fact that I was chewing the pill that I took every day, which is a “nonmedical” way of using an opioid painkiller. I had pain, and I was taking one pill a day—one pill a day! how could that do anyone any harm—was my thinking. I had been to meetings where drug addicts had talked about selling the entire contents of their houses, selling their bodies, risking their lives for drugs… I couldn’t relate. I thought, Surely I can’t be an addict… I take one pill.

Here’s what I wish had happened: I wish a physician had asked me point-blank, “Do you chew your medication?” (I wish I could tell you how many people get here by Googling “chew Vicodin” or “chew Lorcet.” It’s a lot. I’m sure Analytics could give me the exact number… it’s hundreds.) Not the nurse, not the fellow-in-training—the physician. The prescriber. … I might have blinked too many times, or stuttered, or sweated, or given some clue. (I’m a terrible liar. Both my blood pressure and heart rate were sky-high at my doctor visits toward the end of my active addiction.)

And then I wish the doctor would have said, “You know, G, chewing pills is a way of taking medication ‘not as prescribed,’ and it’s a sign that your behaviors have changed from appropriate use into inappropriate, dangerous use. I’m concerned that you could be addicted. Addiction is a fatal illness. I’d like you to see an addictions specialist for an evaluation, and I have the names of some here that I trust. But don’t worry about being kicked out, because we’re going to make sure that you’re taken care of throughout this process so that you can keep doing your life to the best of your ability. It might be difficult for a while but we’ll help you.”

This is my dream for pain patients who cross the line into addiction. I would have gone along with the above scenario and saved myself a lot of pain. I’m not naive enough to believe that everyone would… But I think there are a lot of people suffering actual pain and actual addiction, who simply don’t know how to get out of the bind.

Anyhow, I saw my own story in the history Kluger outlines. He talks about how the “epidemic” had its roots in the campaign to make pain the “fifth vital sign.” In the late 1990s the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the body that accredits hospitals, nursing homes and other facilities, wanted to get staff to treat pain more assertively, so they developed methods to evaluate pain along with the other vital signs—temperature, blood pressure, heart rate, and respiratory rate. As a result, these days, during assessment, nurses will quite often ask you to rate your pain on a scale of zero to ten (sometimes, I notice, nurses get it wrong and say “one to ten”), with zero being no pain and ten being the worst pain you can imagine.

So, over time, more attention was brought to the phenomenon of pain. And to the treatment of pain. The sensibility that developed was that pain was an illness in and of itself, and as such it should be treated aggressively with medications tailored specifically for that purpose.

During this time I was in the position of talking with people who had participated in the writing of JCAHO’s fifth-vital-sign policies—as well as prominent physicians and policy analysts who were trying to bring attention to pain treatment. During my reporting, I happened to mention to a few of them that I was having intractable migraines and other pain. And they encouraged me to get myself to a pain clinic. And I did. And I was given daily opioids in great quantity: hydrocodone to morphine to OxyContin to fentanyl.

At that first appointment, as I recall, the physician and her fellows asked me if I’d ever used street drugs, and I hadn’t, so I said no. Good girl that I was, I’d never even smoked pot. They asked if I drank and I said no, because I didn’t—not then. This apparently proved to everyone’s satisfaction, even mine, that I had no problem with addiction. Meanwhile, if you’d turned over the rock of my life, you’d have found crawling under there the facts that my mother had died of lung cancer having failed ever to quit nicotine, and my father was well on his way to a nasty end via cirrhosis and GI cancer due to alcoholism. And I myself was chewing Lorcet—which I thought (insisted to myself during lengthy subconscious arguments even then) was no problem, because it was Just One Pill Per Day.

I was a white professional middle-class mom with two neurological disorders. Hell, I remember being down with a migraine during my first appointment at the clinic. I was practically prostrate with pain—truly. But it was all good because, says one source in Kluger’s piece:

When you’re well dressed and you have insurance, they don’t think of you as an addict.

More importantly, I didn’t think of myself as an addict.

So I saw myself in Kluger’s story. It had unrolled just as he said, and I could hear the voices of the players.

Do I blame them? Hell no. As they say, nobody shoved anything down my throat. I did it my own self.

Even so, I can hear the voices of the blowback, the chronic pain patients and those in the same bind as I was in, as well as the drug companies…  wanting to protect patients’ sources of medication (and profits) by vilifying and calling to lock up the “junkies” who “just can’t control themselves.” When in fact we should all be able to work together.

A final point: Kluger did get the drugs wrong. OxyContin/OxyIR and Vicodin/Lorcet were much more widely prescribed than any fentanyl preparation during the 1990s. And he misses methadone altogether. Some pain clinics were using methadone exclusively: they believed it to be “unabusable” because they thought its long half-life would prevent people from using it to chase a high. But people with addiction will always use ANY opioid (yes: even Suboxone) to chase some kind of feeling. And the data show that many overdoses (perhaps not always fatal, but nevertheless) are due to methadone.