Pubdate: Sat, 07 May 2016
Source: New York Times (NY)
Copyright: 2016 The New York Times Company
Author: David A. Kessler
Note: David A. Kessler was the commissioner of the Food and Drug 
Administration from 1990 to 1997 and is the author of "Capture: 
Unraveling the Mystery of Mental Suffering."


BEGINNING in the late 1990s, pharmaceutical companies selling 
high-dose opioids seized upon a notion, based on flimsy scientific 
evidence, that regardless of the length of treatment, patients would 
not become addicted to opioids.

It has proved to be one of the biggest mistakes in modern medicine.

An epidemic of prescription drug abuse has swept across the country 
as a result, and one of the latest victims, according to The New York 
Times, may have been Prince.

The paper reported that he had developed a problem with prescription 
painkillers, and that just before his death, friends sought urgent 
medical help from a California doctor who specializes in treating 
people addicted to pain medication. Whether pain pills played a role 
in his death won't be known until the results of an autopsy are released.

How did we get this so wrong?

The so-called proof that patients would not become addicted was based 
on a limited number of patients. This was coupled with the idea that 
opioids should be used for a broad range of indications - including 
all types of moderate to severe pain when, in fact, they don't work 
against all forms of chronic pain.

Equally dangerous was the notion that there was virtually no dose 
ceiling. The mantra was: "Prescribe until patients achieve pain 
relief." And then there was the flawed concept of pseudoaddiction: If 
the patient comes in and is showing signs of drug seeking, that 
doesn't mean the patient is actually addicted to opioids; it more 
likely means that he or she just needs more opioids to control pain. 
So the first response should be to prescribe more.

In turn, the Food and Drug Administration relied too heavily on 
doctors to figure out how to appropriately prescribe these medicines. 
For many of them, a pill was an expedient way to try to help their 
patients. Figures published by the Centers for Disease Control and 
Prevention for the period 2008 to 2011 show that among those who were 
at the highest risk of overdose, 27 percent used their own 
prescriptions and another 49 percent either got or bought opioids 
from friends and relatives. Only 15 percent bought them from a drug dealer.

Doctors, regulators and drug makers also mistakenly divided the world 
up into those patients who had legitimate pain and who they believed 
would not become addicted, and drug addicts. Moreover, they missed 
one fundamental: The more opioids prescribed, the more opioid abuse 
there will be.

One thing that all experts agree on is that opioids have a role in 
cancer pain, end-of-life palliation and some forms of acute pain. The 
question is whether we make people with chronic pain better by 
treating them with opioids.

No doubt they sometimes work in the short term. And some pain experts 
believe that there are patients who function well on moderate doses 
of opioids and do not require more. But over time, the biology of 
opioids makes tolerance - and thus the need for higher and higher 
doses - a reality for a considerable number of patients who stay on the drug.

Continued opioids are needed to keep the physical withdrawal symptoms 
at bay. Those withdrawal symptoms are associated with their own pain. 
Thus, whatever pain that occurred at the beginning of treatment is 
replaced by the pain that is generated by the drug's withdrawal symptoms.

Some patients will make heart-rending pleas that they cannot live 
without their opioids. But we have failed to see this for what it is, 
the signature of addiction: "I need it. I can't get better or normal 
without it."

Some experts believe that lower doses taken over a long period may be 
appropriate in certain instances. But that requires careful 
monitoring on the part of both the patient and the doctor. We need to 
recognize that there are many forms of pain, and not all respond to 
opioids. All are real. Some are caused by tissue injury, others by 
nerve injury. In a number of conditions, we can become hypervigilant 
to signals in our body that keep us trapped in a vicious cycle of 
pain. Certainly in those where we become keenly alert to the pain, 
treatment strategies including cognitive behavioral therapy are more 
effective than opioids.

What we have learned with addictive substances is that how society 
perceives them will predict how widely they will be used. For 
decades, cigarettes were made out to be something that we wanted and 
would give us pleasure. Then that perception changed as people came 
to understand that cigarettes actually were deadly addictive products 
that had no place in a healthy life. Opioids are trickier because 
they have some value in certain conditions. But we need to view them 
for what they are: addictive and potentially deadly drugs.
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MAP posted-by: Jay Bergstrom