Of the estimated 21.5 million Americans 12 and older with a substance abuse disorder in 2014, 1.9 million, have a disorder specific to opiate pain pills, and another 586,000 had a use problem involving heroin. As a gross parody of old reefer madness scare tactics, opiate pills have become a true “gateway” drug, as 80% of heroin users report that they started on prescription painkillers. Because of these staggering numbers, drug overdose has become the leading cause of accidental death in America, causing 47,055 deaths in 2014 of which 40.2% were related to opiates. In Kentucky, since the introduction of OxyContin in 1995 to 2001, there was a 500% increase in the number of patients entering methadone treatment, three-fourths of which were specifically OxyContin dependant. As the sales of opiates go up, so do the deaths, the overdose death rate in 2008 was four times that of the rate in 1999, paralleling the four times increase of opiate sales from 1999 to 2010, painting an inexorable link between the sale of these drugs, and a rash of tragic overdose deaths across America.
When talking about opioid strength we look to what is called the Equianalgesic or opioid chart. This chart compares the relative strengths of various pain relieving medications as compared to a ten-milligram oral preparation of morphine, for instance, Aspirin sits at around 1/360th the strength of oral morphine, whereas diamorphine or heroin sits at around four to five times relative strength. One of the most prevalent prescription opioids, oxycodone, is about 1.5 times as powerful as oral morphine, while the up-and-coming Fentanyl is 50 to 100 times as powerful, Carfentanil, one of the most powerful known opioids, can be 10,000 to 100,000 times more powerful than oral morphine, as it was originally intended as a general anesthetic for large animals. Lately, Carfentanil has become infamous for overdose deaths, as legal-yet-shady Chinese laboratories produce and distribute the powerful painkiller around the world. Carfentanil is so powerful, its initial use was as a chemical weapon, allegedly seeing action in 2002 against Chechen separatists in Russia during the Moscow Theater hostage crisis. During the raid on the theater, an aerosolized variant of the drug killed over 130 people, because of a lack of communication between the counterterrorist forces and Russian first responders resulted in them bringing insufficient amounts of naloxone, an opiate antagonist, to treat the affected hostages. Today, it has become one of the most deadly opiates found in the American opiate crisis, as streams of the drug pass through Canada and Mexico.
Functionally, opiates work through the opioid receptor system in our bodies, normally these receptors are activated by endogenous, or naturally occurring peptides, such as enkephalins, dynorphins, and endorphin, opiate drugs act at these binding sites, specifically the three receptors mu, delta and kappa. According to researchers at the European College of Neuropsychopharmacology, genetically modified mice are one of the keys that unlocked our understanding of the receptor system. Researchers discovered that mice lacking the mu-receptor gene showed a loss of pain relief, reward, and dependence when given morphine, as well as reduced reward to non-opioid drugs. Mice without the delta receptors showed increased level of anxiety and depressive behaviors. Beyond merely illustrating the function of the opioid receptors, both findings also offer some therapeutic solutions in the future for recovering addicts.
Untypically for the war on drugs, the opioid crisis began in America with a marketing campaign. According to the Center for Public Integrity and the Associated press, big pharma, and their lobbying apparatus have spent over $880 million dollars on lobbying and political contributions. That’s eight times the amount that gun lobbyists spend and 200 times more than groups advocating for stricter prescriptions. This trend can trace back to Purdue Pharma. In his article “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy” Dr. Art Van Zee discusses the marketing strategies of Purdue Pharma and links them back to the current crisis. From 1996 to 2001, Purdue Pharma held conferences at resorts across America to promote their new drug OxyContin. Purdue’s marketing plan made use of cutting edge marketing data, which compiled “prescriber profiles” on physicians, detailing their prescribing habits. Using this data, Purdue targeted physicians who prescribed the highest amounts of opioids, identifying doctors with high numbers of chronic-patients. Unfortunately, this data also allowed them to select physicians who merely prescribed opiates frequently, at times indiscriminately. Traditionally powerful pain medication like OxyContin was generally relegated towards the “malignant pain market” or people suffering from cancer-related pain, which made up 86% of the total opiate market in the late 90’s. Purdue shifted their marketing to the “non-malignant pain market,” now, the powerful Schedule II narcotic was being marketed and sold to doctors treating non-life-threatening cases, such as back or chest pain. Purdue doubled down on their marketing, instructing their sales representatives to claim that the risk of addiction to their product was “less than 1%,” citing a study conducted on burn patients, in reality however, patients with chronic pain and continued use of opioids are -very- likely to shift into a habit of abuse, recent studies putting the chances of addiction in chronic pain patients at anywhere from 12-50%. Not only does the pharma industry lobby for painkillers, they have a vested interest in lobbying against alternatives to opiate drugs, such as medicinal cannabis and pushing plans that would directly help their industry, like bills requiring insurers to cover abuse-deterrent painkillers, by using the novel drugs, the pharma companies can charge more for non-generic medicine, without significantly changing the propensity for abuse. Purdue knows that their product is easily abused, in fact, in 1995, Purdue specifically tested the possibility of their product being abused and found that 68% of oxycodone can be extracted from a crushed tablet. Instead of admitting their role in the crisis, however, pharma companies instead invest in developing more drugs to combat opiate side effects.
I talked with Jennifer, an RN in Vancouver about the emergency treatment of opiate overdose on hospital wards. “The paramedics are now all carrying Narcan nasal spray,” one of the recent ancillary drugs to come to the forefront is naloxone, also known by the trade name Narcan. Although it’s been a standard part of paramedic kit for a long time, other first responders, like police and firefighters, have started to be issued the opioid antagonist, which works by binding to the same receptors as the opioid more readily than the drug, but without activating the site. “Sometimes they’ll have Narcan on order PRN [as required by a doctor] but sometimes not. Some veteran nurses will administer it first and get permission later.” When a patient goes into an opiate overdose, they start to exhibit symptoms known as the “opioid overdose triad.” The symptoms are decreased level of consciousness, pinpoint pupils, and respiratory depression. Seizures and muscle spasms can also present during an overdose. The best and primary treatment for overdose is basic life support focusing on airway management and emergency oxygen, combined with the administration of naloxone. In the field, this can sometimes be challenging, Corban is an EMT in Ohio, “You establish whether the patient can maintain their own airway and whether they’re having spontaneous respirations. If they’re not breathing on their own we go ahead and start ventilating them, we then take a 2ml pre-prepared syringe of Narcan and attach a MAD device, a Mucosal Atomization Device, to the end. We administer 1ml in each nostril, and we kind of look and see. If the patient starts breathing on their own but is still unconscious, we bring them back to the hospital without doing anything else.” The reason behind this is that when a patient is administered Narcan, they immediately go through the symptoms of withdrawal, which can be violent and quite unpleasant. “Whenever we get an overdose patient, we’re told to consider using restraints, because they fight us.”
There is a growing problem for people in the emergency medical field. Following recent trends, the price of Narcan has skyrocketed. Considered a fairly basic drug, naloxone used to cost only a bit more than a dollar in the states, and even less than that overseas. Recently, however, because of growing demand for the drug from emergency medical personnel and hospitals, the prices for naloxone have increased, in some cases by over 1000%. Kaleo, a maker of Narcan autoinjectors increased their unit price in two years from $690 to $4500.
All of us suffer pain in our everyday lives. For an addict, that pain is not just physical. There is a certain part of our brain that tells us to consume, and a part of us that will do anything to dull our own existential pain. There is a part that will always rationalize and explain away the harm we do to ourselves and our families. It’s sometimes hard to realize, but truly anyone can be an addict: addiction is not a disease that holds at social boundaries, rich and poor, all lives can be touched and affected by an addiction. In the last ten to fifteen years, the United States has slowly been changing its understanding of addiction. For the first time in the history of our war on drugs, we are learning to treat addicts as people, not criminals, and, in some large way, the opiate crisis has unmasked the ubiquity and pervasiveness of addiction. It’s an embarrassing farce, but now that the hospitals are not merely full of urban, disaffected poor that are easily overlooked by our medical system, now that we see our middle and upper class alike affected by this crisis in such a profound way, we have realized that we must fight our drug war with treatment and compassion, rather than the heavy-handed approaches of the past.