Curbing Prescription Opioid Dependency: An Epidemic of Overdoses and Deaths from Opioids Is Fuelled by Increased Prescribing and Sales in North America

He didn't know it at the time, but Dr Andrew Kolodny had begun to witness the beginnings of a major drug addiction crisis in the United States of America (USA). A public health expert on drug dependency at New York City's health department in the early 2000s, Kolodny worked in poor neighbourhoods from South Bronx to central Brooklyn blighted by crack cocaine and heroin. It was while we were working on the illicit drugs problem that we noticed drug overdose deaths were increasing in middle-class communities in the New York City area, he says. Before 1995, the prescription of opioid painkillersln the USA was limited to people with pain from advanced cancer, severe injuries or after major surgery. That restraint was founded on the fear that patients might become addicted and the bitter experience of two opioid epidemics: in the early 1900s when heroin was sold legally for various ailments and an epidemic of illegal heroin dependency in the 1960s during the Vietnam War. Opioids are a class of drug used to reduce pain. They include heroin, as well as prescription pain relievers, such as oxycodone, hydrocodone, codeine, methadone and morphine. In 1986, a study based on 38 patients suggested that these powerful prescription drugs could be used safely with minimal rates of addiction for chronic pain, and a few pain specialists began advocating for broader use of them in this way, says Kolodny, who is now the director of nongovernmental organization Physicians for Responsible Opioid Prescribing and a researcher at Brandeis University in Massachusetts. This movement to increase opioid prescribing was catalysed in the 1990s by patient and professional groups that received funding from pharmaceutical companies, he says. Since then, the USA has been facing a growing epidemic of opioid dependency, including a rise in heroin use and record high levels of opioid overdose deaths. From 1999 to 2015, more than 183 000 people died from overdoses related to prescription opioids and in 2012, more than 250 million opioid prescriptions were written in the USA, according to the Centers for Disease Control and Prevention (CDC), more than enough for the entire population of 319 million people. Some of these prescriptions were for palliative care or acute pain, but many more were for patients with chronic non-cancer pain, such as backache, headaches and fibromyalgia. Patients like Dan Schoepf, a self-employed contractor, who was first prescribed oxycodone for a severe back injury by a pain physician in Long Beach, California in 1999. As time wore on he needed ever larger doses to relieve the pain because of increasing tolerance. Sometimes I used up my supply of prescribed medicines too quickly and went into withdrawal, until I received my next prescription, Schoepf says. When I ran out, I couldn't talk to anyone [because] I was so sick. I couldn't live with the drugs, I couldn't live without them and I was destroying my family. Then, 13 years later, Schoepf was offered physiotherapy. The pain stopped and he received addiction treatment that got him off the opioids for good. The over-prescription of opioids for chronic, non-cancer pain outside palliative care is driving the epidemic of opioid dependency in the USA, according to Dr Debra Houry, Director of the CDC's National Center for Injury Prevention and Control. When I was in medical school we didn't know that these medications were so addictive and we were encouraged to treat pain. Now we have better evidence that they aren't safe for long-term prescribing, Houry says. The number of patients with chronic pain prescribed opioids for long periods of time has increased in other high-income countries as well, including Australia and the United Kingdom of Great Britain and Northern Ireland. But it is mainly the USA and Canada that are seeing epidemics of dependency and a large toll of overdose deaths. …

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