Pharmacy and Opioids Back Then

This morning’s newspaper had a front-page article about the opioid epidemic. I read the opening, another heartbreaking story of parents losing a child to an opioid overdose. Two full pages inside the front section continued the article, one a graphic of how opioids work in the body, the other a full page continuance of the front page article. The story could be boiled down to “It’s all Purdue Pharma’s fault.”
And let me state outright, Purdue has a lot to answer for. The company had knowledge that was withheld from prescribers. Sales techniques were full of false and mis-represented statements that prescribers (and patients) relied on.
But this article was like many articles on how to solve the opioid epidemic. One calls for reduction in production of opioids. Another states the need for education. Another shouts out for increased money for rehab facilities. The true solution to the opioid problem is not a single response, but a combination of all of the above (and more).

The same is true of how the opioid crisis came to be. As much blame as there is for Purdue Pharma, the epidemic had other contributing factors to its creation. Pharmacists today should have a working knowledge of these to understand how we got where we are today.

Pain is subjective. How much pain is someone having? There is no instrument, no blood test, to accurately measure this. We can look at heart rate, respiration rate, are the eyes teary or glassy, is the patient oriented to surroundings, etc. But overall, we still have to ask, “how is your pain on a scale of 1-10?” and rely on the patient’s lay ability to determine this. Keep in mind that in the 1980s and 90s when pain management came into vogue, the Fifth Vital Sign as it were, the tools for determining how much pain someone was having were few and far between (this has not changed a lot).

Lack of understanding. A few decades ago, research into pain and pain treatment was sparse. Some of that being done, with the inability to show objective standards or have objective tests, was slipshod and faulty. Some of this faulty information was relied on.
One story from the late 1990s: a pharmacist was going to fill an opioid prescription that was a tapering dose. The state board inspector was present; he told the pharmacist not to fill the prescription or face punishment by the board. Pain patients do not need tapering prescriptions to avoid withdrawal, the inspector stated. If the patient was truly in pain, there are no addictive effects from the use of opiates.
We all now know that to be false; pain patients can become addicted as well as anyone else. But that was the understanding of the time. The inspector was acting on what he thought to be reliable research.
And of course, what we did not know in those days was that addiction is a disease. There is a genetic component that can lead susceptible patients to becoming addicted. These people have NO desire or intent to abuse or misuse drugs. No, back in the day, addiction was a choice, a bad one, and the attitude was “let’s throw them all in jail.” There are still some professionals who deny addiction is a disease, usually based on those addicts who became so out of choice.

Eradication, not management. For decades, pain management was the elimination of pain. Being normal, it was thought, meant being out of pain totally. Despite being discussed, usually at length (when a prescriber can find the time these days to do so), statistics indicate that even today “seasoned” chronic pain patients do not seek pain management—reducing pain to a level the patient can live and function with–but the total eradication of their pain. This called (and calls) for higher doses of opioids, ofttimes with additional effects such as euphoria, which led (and leads) to abuse and misuse.

Misuse was abuse. A few decades ago, pharmacists saw all overuse of opioids as abuse. Even today, a substantial minority of pharmacists define misuse as the “abuse of a medication.” Abuse is the use of a medication for purposes other than which the prescription was written for. Misuse, better understood as time went by, is the use of a medication in dosing other than how it was prescribed for the reason it was prescribed. Misuse is a patient having a prescription for an opioid with TID dosing and taking it QID to manage her pain; she is still taking it for the prescribed reason, just more than the practitioner desired.

Rejection of other means. And here I could tell a personal story, because I was one of those who initially considered the use of beta-blockers, tri-cyclics, etc as false means of addressing pain. The idea of employing anti-seizure medications for peripheral pain or migraine prevention back then would have met with a solid wall of skepticism. Pharmacists in the 1980s did see some new and innovative approaches to pain. So what was the issue? It was two-fold: there was little research to back this up, and pain relief was usually not fast enough or strong enough for the patient. Due to these, back then many (not all) pharmacists advised patients away from these practitioners. Our motives, and the basis of them, were good, but we were wrong. So, inadvertently, the profession helped open the door for companies like Purdue.

Unscrupulous prescribers. These still exist today, but in the 1980s and early 90s those practitioners who would write for anything in exchange for cash were much more poorly regulated. These doctors had no desire to help the patients. If nothing else, they created the negative stigma that still attaches to pain management prescribers today.

Pain was and remains a significant problem in this country, and the treatment of it has many issues. Standing out among these is the opioid crisis. Drug companies like Purdue played a substantial role, and they must pay for their sins, but they were hardly the sole means by which this crisis exists today.

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