Breaking the Bond of Heroin and Painkillers
Using the tragic death of a celebrity as a basis to discuss national drug problems is usually pointless. For one thing, the actor Philip Seymour Hoffman, who died with a syringe in his arm and packets of drugs found nearby, had the wealth and access to insulate himself from some mundane forces -- price and availability -- that affect so many people struggling with addiction.
Yet his death is calling attention to the ways in which many individuals can be helped.
A definitive cause of what killed Hoffman hasn’t been determined yet. If he moved from prescription pills to heroin (he entered a rehabilitation program last May after a reported reliance on painkillers led him back to heroin briefly), he was following a familiar path. Many individuals who have become addicted to prescription painkillers (a group that includes OxyContin, Vicodin, Percocet and Roxicodone) at some point realize that, depending on where they live, heroin, which is pharmacologically similar, is cheaper and easier to get.
Heroin users in Los Angeles, for example, can get a baggie containing it for as little as $8 to $10, officials told the Los Angeles Times. In New York City, $8 is a going price. Compare this with the price of an OxyContin pill, which typically costs about 50 cents to $1 a milligram (the lowest strength is 10 milligrams, but addicts use more; the highest strength is 160 milligrams).
People who lose their insurance may also switch to heroin. This isn’t a new phenomenon. As the Department of Justice noted in 2000 “many OxyContin abusers whose health insurance will no longer pay for prescriptions and who cannot afford the high street-level prices are attracted to heroin.” I’ve seen a number of patients in my methadone clinic who have turned to heroin from prescription pills to maintain a habit more cheaply.
When the police and the Drug Enforcement Administration crack down on pill mills and the diversion of prescription painkillers in an area, local scarcities arise. Another factor may be the new preparation of OxyContin, released by manufacturers in 2010, that turns into a sticky mush when crushed, instead of a fine powder that can be snorted or injected.
Doctors are a big part of the equation for how people get hooked on prescription painkillers in the first place. Recently, a colleague asked me whether it was all right for his wife to take another 10 milligrams of OxyContin because her mouth was still throbbing after extensive dental work. I was surprised (though I probably shouldn’t have been) that a surgeon would have prescribed the drug in the first place to a healthy young woman who was a one-day post-operative patient recovering at home. OxyContin is slow release -- that is, it is slow-acting. It is used for unremitting pain lasting weeks or months, not for bursts of pain.
My colleague’s wife was fine. The pain stopped within two days, and she flushed the remaining pills down the toilet. But it’s very common for elderly people with cancer to be prescribed large amounts of opiates for pain. Medicine cabinets are easy targets for theft by friends and relatives. That is how some of my patients with a painkiller addiction obtained their drugs -- from unsuspecting grandmothers.
Opiates such as OxyContin aren’t gateway drugs to heroin in the sense that every person who abuses a painkiller goes on to use heroin. Only a minority do. But there is little question that it represents a common route to first-time heroin use. (Important note: The chances that patients in pain without a history of alcoholism or drug abuse will go on to abuse prescribed painkillers are very small.)
According to the 2012 National Survey on Drug Abuse and Health, four out of five new heroin users had previously abused painkillers. And as the number of heroin users (defined as having used heroin at least once in the preceding month) increased, from 239,000 people in 2010 to 335,000 in 2012, use in the past month of prescription painkillers for nonmedical reasons dropped from 566,000 in 2010 to 358,000 in 2012.
To the extent that prescription pills and heroin bear a morbid relationship to each other -- as the cost goes up and availability goes down for one, the other looks more attractive -- some interventions can profitably be aimed at both simultaneously. And targeting addiction to pills can ameliorate the heroin problem and vice versa.
In emergencies such as overdoses, for example, OxyContin and heroin are treated the same way: with an antidote. More precisely, with an injection of an opiate receptor blocking agent called Narcan, which revives people after they lose consciousness but before they stop breathing. Some cities now equip police officers with Narcan in the form of a nasal spray and save many lives each year.
Needless to say, better treatment and more access to opiate replacement medications, such as methadone and buprenorphine, would help people who are addicted to either heroin or painkillers, especially in rural areas.
The primary strategy for reducing painkiller abuse is to keep the pills off the street. Doctors have a large role to play. Keith Humphreys, a psychiatry professor and addiction expert at Stanford University, suggests that successful strategies being adopted piecemeal across the country should become universal: prescription monitoring programs that catch drug-addicted “doctor shoppers” and education programs that teach doctors not to overprescribe. “Doctors need to break the habit of automatically writing refillable prescriptions for 20 or 30 Percocets for minor pain that will resolve in a few days,” Humphreys says.
His colleague, psychiatrist Anna Lembke, is concerned that well-meaning doctors feel they have no choice but to prescribe opioid painkillers for patients who are already addicted.
For one thing, counseling requires time, which isn’t valued in reimbursement models. Also, doctors have the additional pressure of consumer-ratings sites: Disgruntled patients may leave a less-than-favorable review online. At some institutions, patient surveys can even affect doctors’ reimbursement levels and job security.
“The problem of doctors prescribing addictive analgesics to patients with known or suspected addiction will be solved,” Lembke wrote in the New England Journal of Medicine, when addiction treatment is “financially compensated on a par with care for other illnesses.”
No, not all of these issues may be relevant to the loss of an Oscar-winning actor -- someone with ready access to treatment, to drugs and to a lot of cash. But if this one tragedy stirs discussion of how to help people struggling with drugs and what to do about it, some deaths might be averted.
(Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.)
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