My thesis is both stark and simple. Despite the intervention of six federal agencies, the government of Kentucky and the expenditure of billions of taxpayer dollars, citizens of the commonwealth continue to die from drug overdose related to opiates.
Many of these drugs are medications prescribed by physicians legally. Surprisingly, at this juncture, opiates continue to be prescribed as if there was no significant public health problem. In fact, there is a major problem and each of us is at risk.
The history of opioid use for control of pain began more than 2,000 years ago. Opioids have been and are effective for the purpose for which they are prescribed, the relief of pain. Pain is a part of the human condition and severe and unremitting pain will always require treatment. Compounds that are as effective in controlling pain as opioids, while having fewer side effects, are being actively sought.
Unfortunately, our best scientists believe that we are not close to the “magic bullet” that can treat pain safely without the side effects of respiratory depression, tolerance and addiction. Thus opioids will likely be in common use for our lifetimes.
The population that has developed addiction and other high risk behaviors associated with opiates has changed over time. In 2016, many of the affected groups are middle or upper class, adolescents and those with a history of acute rather than chronic pain. This change in the demographic is multifactorial but has arisen, in part, because of the large volume of pills in the community.
Most homes have old prescriptions for opioid compounds that are available to be stolen, misused or diverted. This diversion fuels the industry of providing medically inappropriate opioids to those at risk.
Americans use more than 80 percent of all of the opiates that are prescribed in the world. Many of those are in our medicine cabinets. No federal law or impassioned plea by the president can rid us of this depot of drugs. Reducing the number of these pills is an individual choice and it is critical to reducing the number of terrible outcomes.
The high-risk behaviors that lead to morbidity or mortality in Kentucky are tracked closely by the federal and state governments. One of the interesting features of the information that is available is the relationship between drug diversion and the increase in the use of heroin. When diverted prescription medications are not available, or too costly, heroin is available and cheap. Thus, there is an established relationship between increasing opioid prescription, diversion and heroin use.
Kentucky now ranks third in the United States in opioid use and abuse. The state government has worked hard on this issue and should be encouraged. But, for a state with a big problem, the opportunity to treat what is essentially a disease is very low. Medical treatment is remarkably effective but there are not very many places to get it. The biggest problem, the least likelihood of treatment; likely an indicator of a continued problem.
Opioids, when prescribed appropriately and used wisely, continue to play an important role in modern medicine. The short-term treatment of acute or traumatic pain, the treatment of cancer pain, use at the end of life and other established medical conditions must continue to be treated with opioids. However, unsupervised prescribing of large quantities of opiates for inappropriate conditions, such as chronic pain, is unsupported by the medical literature, is dangerous and adds to the problem.
There are few drugs that offer as large a differential between risk and benefit as opioids — at one end the relief of unbelievable suffering, at the other end disability or death. As a society we are expending tremendous resources to control the problems of abuse, diversion and addiction. Those resources will not be effective if our medicine cabinets are filled with unused opioids available to be stolen or otherwise diverted.
Dr. Rae Brown is a professor of anesthesiology and pediatrics at the University of Kentucky/UK Healthcare and chairs the Food and Drug Administration’s Advisory Committee on Analgesics, Anesthetics and Addiction Products.