Friday, November 30, 2012

Pain Pills Wane - Heroin Moves In

HeroinAggressive efforts in the United States to grapple with the so-called “epidemic” of prescription opioid abuse is paying off, but not as officials expected. With pain pills coming under stricter controls the door is now open for a resurgence of heroin abuse with its attendant burden of morbidity and mortality, according to news reports describing the scene in states like Kentucky. The wrath of unintended consequences is set to take a terrible toll.

A recent Associated Press (AP) report appearing in the San Francisco Chronicle [November 29, 2012] describes how Kentucky officials cracked down on opioid prescribers, set up an electronic system to track pills, and plugged a pipeline of pain pills coming into the state from Florida. Those efforts worked, as opioid analgesics become more difficult to obtain, whether legally or on the street, but law enforcement then made a surprising discovery — heroin, which had long ago faded into the background, was returning with a vengeance.

According to Dan Smoot — law enforcement director of Operation UNITE, which handles drug investigations in Kentucky counties where pain pill abuse had been rampant — in the news article, “There's always some type of drug to step up when another gets taken out. We didn't know it was going to be heroin. We knew something was going to replace pills.”

Law enforcement officials in Kentucky said the heroin, which is generally snorted or injected, is imported into the United States from Mexico and Central America. Availability and cost are prime incentives: “Where a single oxycodone pill can run from $80 to $100, heroin can cost as little as $15 to $20 for a hit that will give the user the same high for 24 hours,” said Van Ingram, executive director for the Kentucky Office of Drug Control Policy.

The AP report notes that Kentucky State Police submitted 451 suspected heroin samples to its lab in 2010 and by 2011 that number increased to 749. Through September 2012, state police had submitted 1,074 cases to the lab. “I expected to see a 50 or 60 percent increase, but not double,” Ingram observed.

Furthermore, the trend in Kentucky mirrors what the U.S. Drug Enforcement Administration is seeing nationally. While seizures of marijuana, cocaine, and methamphetamine have either held steady or dropped in the past 3 years, heroin has soared 72% from 619 kilograms confiscated in 2009 to 1,067 kilograms seized in 2011.

Along with that, heroin-related deaths are on the rise. In 2011, Kentucky medical examiners reported that heroin and morphine [metabolized from heroin] were responsible for 121 of 684 overdose deaths statewide — an increase of 42% from 85 heroin/morphine deaths in 2010.

Meanwhile, seizures in Kentucky of pain pills — primarily oxycodone, hydromorphone, and methadone — peaked in 2010 and then declined 89% by 2012. Since the Kentucky All Schedule Prescription Electronic Reporting (KASPER) System, which tracks the number and types of controlled substances prescribed in the state, went into effect in 2005, the use of 4 common opioid analgesics — codeine, hydrocodone, oxycodone, and fentanyl — for nonmedical purposes has leveled off. This has been attributed to closer monitoring, which thwarts drug abusers who go from one doctor or clinic to another seeking prescriptions.

Kentucky law enforcement officials describe users as young people in their 20s who were not around during heroin's last wave of popularity. “Now, it's just the guy down the street using it. It's a whole new demographic,” said the state's chief medical examiner, Dr. Tracy Corey, in the AP news report.

The news report goes on to observe that neighboring Indiana is also seeing a rise in heroin as OxyContin gets tougher and more expensive to acquire. According to Indiana State Police Trooper Jerry Goodin, “Heroin is much deadlier due to no controls on formulation or ingredients as in prescription pills.”

COMMENTARY: We cautioned in spring 2011 [here] and again last June 2012 [here] that the crackdown on prescription opioid analgesics in the United States was fueling a resurgence of deadly heroin abuse. This new report on Kentucky is unsurprising since the state has been so focused on pain pill problems; in fact, just last summer the state legislature enacted further stringent rules governing the prescribing of controlled substances [PDF here].

Ironically, those states that have been most aggressively taking actions to control opioid analgesic prescribing are seeing the earliest and strongest comebacks of heroin, which experts claim is inexpensive, potent, and more destructive to individuals and society than prescription opioids. Besides overdoses and deaths, heroin’s return will no doubt provoke upsurges of HIV/AIDS, hepatitis, tuberculosis, and other deadly infections. Trends suggest that many victims will be young Caucasians coming from both poor urban areas and wealthy suburbs, and increasingly female.

Meanwhile, according to various reports, patients with pain are finding it increasingly more difficult to legitimately obtain much needed opioid analgesics. Many healthcare providers — burdened by onerous rules and regulations, as well as concerns about law enforcement scrutiny of their prescribing practices — are shunning opioids and turning away patients. Some pharmacies are not adequately stocking opioid medications. Left without alternatives, patients with undertreated or untreated pain may be among those joining the new generation of illicit heroin users.

Clearly, the United States has serious substance abuse problems, as do many other countries. History tells us that curbing the supply or outright prohibition have little impact on the demand for mood altering substances — whether opioid analgesics, heroin, cocaine, alcohol, or any other drugs.

This is the so-called “balloon effect” — squeeze a balloon in one place and it will expand somewhere else; stem the supply of one drug and another will take its place. According to the AP news report, they knew this was going to happen in Kentucky, as has occurred everywhere else, but they apparently developed no plans to detect and deal with the looming problems.

Certainly, giving up on the problems in frustration or abjectly liberalizing the availability of controlled substances are untenable solutions. However, it is time that decision makers at all levels — federal, state, and local — come to realize that past and current strategies have not succeeded in “popping the balloon.” Drug problems are complex and multifaceted, and simplistic solutions seeking only to restrict supply will do little to reduce demand.

Furthermore, the crux of the problem is centered less on the drugs themselves than within the people who misuse and abuse them. Individuals, families, and communities need to accept responsibility for the attitudes, beliefs, and misbehaviors that galvanize drug problems in society and find new solutions that address those at the core.

Meanwhile, as we have said before — in the case of prescription opioid restrictions, rules, and regulations — legitimate patients should not have to pay a terrible tariff in pain due to the misbehaviors of a small minority of the population and the misguided, ineffective attempts at turning the tide of drug-use problems. Perhaps, readers have solutions to propose in comments below.

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Pain With Dignity said...

Does this mean that many of the doctors wrongfully accused and convicted of "overprescribing" (sometimes with NO input from the patients) are now going to be held to be the ones responsible for the heroin growth? Perhaps the DEA should bear some responsibility for this for letting the true drug dealers walk...Perhaps the DEA's actions that have led to the resurgence of heroin, much like the ATF was responsible for misuse of firearms by the drug cartels in Fast and Furious operation!

Bob Twillman said...

I don't talk about "popping the balloon" because I don't think drug abuse will ever go away completely. Instead, what I talk about is letting some of the air out of the balloon. We do that by addressing the "demand side" of this equation, i.e., by increasing effective drug abuse prevention and treatment.

The best model that I have seen, by far, is that or Project Lazarus in North Carolina. They are able to document continuing reductions in drug overdose deaths, while prescribing for pain appears to be unchanged. This kind of comprehensive, community-focused intervention is what ultimately will give us the best results.

SB. Leavitt, MA, PhD said...

I agree with Dr. Twillman that “popping the balloon” is probably asking way too much. Also, to keep my article brief, I didn’t mention the Project Lazarus model, which very successfully uses naloxone distribution in the community to stem opioid (including heroin) overdose deaths. I’ve written about this in prior UPDATES and questioned why naloxone distribution is still being largely ignored. It isn’t a solution for ending drug abuse problems, but it would certainly save many lives.

Celeste Cooper said...

I totally agree with Bob Twillman. Our DEA is more concerned with criminalizing physicians, legitimate pain patients, than it is about treatment for those who desperately need help for their addiction, regardless of how they became addicted. Power seems to be quanta with neglect.

total results said...

While presenting a class on Marijuana at one of the local Health Care Centers many Physicians & Nurses were surprised that I knew they had instituted a new policy on opioids. (Their NEW policy is to Not accept any patients that require opioids, and to refer out any current patients that require opioids for chronic/intractable pain.) Of course this backwards policy is not available for patient or public review. Yes, my MRO works there but apparently they must have missed that one. I told them that my job of putting AOD Treatment Centers together is getting more and more difficult due to these new policies.

They were not too happy when I told them that their new policy is turning far too many patients in need into heroin addicts. That, and by the time the person requests care they often have been arrested on crimes related to supporting their habit..Shop Lifting, Burglary, and many Child Endangerment charges related to heroin possession. This only complicates treatment. If a patient requires opioids for pain then the goal of treatment must include a plan of action for the person to obtain pain help. The costs of AOD Treatment, Court costs, Legal Fees, Probation, Fees, Fines, and increased Jail Costs ends up affecting us all.

For every misguided policy there are many that are hurt by misguided attitudes.

SB. Leavitt, MA, PhD said...

Thank you, ‘total results,’ for your comment above. For the benefit of readers who might not understand the acronyms; AOD = Alcohol and Other Disorders, MRO = Medical Review Officer. And, you do not indicate where your presentation took place, but my guess (gleaned from your profile) would be Oregon.

You do raise quite a dilemma. Once a person with chronic pain has engaged in illicit behavior -- for whatever reason -- can they be trusted with a take-home prescription for opioid analgesics?

Mark S. Barletta said...

And history repeats itself, take away the pain medication that was much needed for those suffering in chronic pain and heroin takes its place, what did you all think would happen. One way or another suffering pain patients will find pain relief, no one wants to suffer even if it means turning to heroin. All that suffer from chronic pain should have their God given right to pain control. Now we will see how holding back these pain medications to much needed pain sufferers will lead to filthy heroin and kill more people using this garbage than the pain medication ever did. This time next year deaths will double from the return of heroin in Kentucky and other places where pain medication was held back from people needing pain relief.
Heroin is filthy, unlike prescription pain medication that is safe when taken as prescribed for those who really need it now this filthy heroin will cause even more overdoses and deaths, not to mention filthy needles that will spread HIV/AIDS, hepatitis, and no telling what kind of infections. Also robberies and burglaries will get out of control.

So what did we learn from this, what did we gain other than make a bad situation worse.
We need more programs like Project Lazarus in every large city.
To all the Pain Specialist that where caring enough to treat pain sufferers that where jailed for no good reason ,free them for they where did no wrong.
I've read a lot of good stories on but when things like this out of control opioid mess gets only worse because of withholding medications from pain sufferers I wonder how could this have gotten so far out of control to begin with. What can we do to make this right and there is no easy way.

Janice Reynolds said...

In some cases withholding opioids from people with pain may not have been for the "implied" reason of curtailing addiction but rather for saving money. The ill-conceived policy for "Chronic" pain patients with MaineCare was initiated to save money. The same would seem to be true of the limit Blue Cross and Blue Shield in Mass. has put on treatment with opioids of 3 years.
As Mark has said when people with pain cannot obtain their medication, some will go to illegal sources. Unfortunately others will commit suicide.
The media has contributed greatly to the whole perception of taking opioids for pain leads to addiction. The other day in “Dispatches” in an inner page of the C-section of the Portland Press Herald there was an article concerning someone selling cocaine on the parking lot of a Junior High and being arrested for having a loarge amount and dealing. Is there a question in anyone’s mind if he had been selling oxycodone it would have been at least the A-section id not the front page?

Dionetta said...

This is no surprise. I have heard from at least 2 pain patients in WA state that they were considering turning to street drugs for pain relief since they have no access to safe and effective pain relief from their primary healthcare provider. And these same 2 patients stated that they knew of others who were thinking the same thing.
If we can not pop that darned balloon...we need to find a successful way to deflate it slowly. Better laws that are balanced and not biased or prejudicial to persons in pain, Compassionate healthcare providers who are WELL educated on Chronic Pain and its management, change the attitude toward persons with chronic pain, Stop the blame game, open communication between HCP and Person with pain, More Open and frequent communication between HCP and the legislators, Start drug prevention in the grade schools. (too late by the time they get to HS) Teach coping skills and stress reduction skills to families with young children.

Anonymous said...

Let's talk about the effect of undertreated/untreated pain on the body, such as the stress on the organs, ie: the heart. Denying pain reduction to these patients is in effect killing them.

The government has no business practicing medicine, or mandating patient care to health care providers.

As is demonstrated by these findings, taking away patient's access to opioids didn't solve a problem. People that are recreational users will always find a way. And it is the legitmate patients who end up paying the price.

Anonymous said...

The article is well put but a couple issues are left out. One those pushing for control are usually giving money to legislators and one big support group is those who supply street drugs since their sales are going up. Also in a few countries they have taken a different approach to illegal drug control, they are providing drugs to the addicts through government drug centers. Interestingly enough drug related crimes and illnesses have dropped.
Pushers are quitting as they have less and less customers. Another surprise is that there has not been the up turn in new users even though they can get it free from the government without penalty. So far as illegal drug use goes for the couple countries that have tried this it has been a win-win situation. And for pain patients doctors can provide the treatment they deem necessary.
I doubt it will happen here as I said earlier big funders of politicians are also the providers of street drugs and they will not like what has happened in those countries.

biggs said...

Im a termanel cancer patient... i hurt every hour of every day and its the worse thing ive ever had to endure. I worked at a hospital and seen people hurt, cry, act like babies, but when i could no longer walk, sleep, eat, and my mother who moved in just to watch out for me starts crying and telling me she wishes she could take some of the pain away. This is why i decided to get pain pills finnaly... first, second, third, nothing had yet touched the pain... then came more surgeries to remove cancer tumors and i finnaly got morphine 60mg long acting pills that let me funtion like a normal person was a god send... i know from my hospital dayd if you get high its to high of a dose. I dont feel any buzz or tingle just pain stops in 30 or so minetts. But thanks to all you f**ks my pills went from 57 dollares to between 500.00 and 900.00 for 120 pills.
So this is why and how you end up on heroin. A bunch of people who do not hurt get together to fix a problem and this is what happens. Only super rich can get the pills, everyone else without senitor jobs and perfect insurance get shit on. This dosent even come close to chemo med... its 9965.00 a month.
I once had a house/ wife/ cars money/ went on vacations... now im alone in my motorhome on social securtity in a god dam rv park. Cancer did alll of this for me... guess what its gonna do to you... love, trust, all bullcrap as you lover is not gonna watch you die ... she/ he will find sombody who works and has a future.. because i now do not have a future... just a past and sad story about what happens when you live a good healthy hard working and helping other life. You get to do heroin and fade away.