Heroin Overdoses
In September of this year there were 48 heroin overdoses in a 48 hour time span in Central Ohio where I practice. The culprit was a form heroin thought to be laced with carfentanil. Carfentanil has no human use indications and is used to sedate elephants. It is 10,000 times more potent than morphine. It is so potent that absorption of just a small amount through the skin can cause death in humans.
Normally I probably would not have paid much attention to this news, but in the past year I have been approached by three different physicians asking whether I would be willing to help out at their drug addiction clinics as they are being inundated with patients with opioid addictions.
There is no demographic that heroin and opioid addiction spares.
Last month a 42-year-old son of a 72-year-old patient of mine died of heroin overdose (not one of the 48 cases). My patient told me he figured it would always be his other son that would die from a heroin overdose. The son that died was spending $35,000 to $50,000 a year supporting his heroin addiction. His father (my patient) told me, “I can drive you around the west side (Columbus) and point out 30 heroin addicts or suppliers in 5 minutes. They are all over the place.”
At my 30th medical school reunion in September a classmate of mine told me her daughter was a heroin addict (we were talking about the 48 cases earlier that month) and shared all the heartache that it has caused her family. At the present her daughter is sober, but has been in and out rehab facilities, both inpatient and outpatient, and still has intense cravings for the drug.
I commented to my classmate that I don’t understand why suppliers would want to sell their customers heroin laced with such a powerful drug like carfentanil that kills people. Why would they want to kill off their customer base?
She said she wondered the same and asked her daughter that same question. Her daughter replied, “Mom, this won’t make sense to you, but if you are an addict and something is that powerful that people overdose on it, you want it, because that means it is good stuff.”
Just yesterday one of my patients, a 24-year-old male who attended a tech school and works for an auto company, came in asking me to fill out papers so he can take a leave of absence from work to enter a rehab facility to finally deal with his two-year old heroin addiction. He has been quite functional while on heroin and has been able to work a full-time job in spite of it.
His older brother turned him on to heroin and prescription pain medication. He realizes he is entering a downward spiral if he continues and is now motivated to deal with the problem.
The heroin and opioid problem is growing and very rapidly. Many individuals with opioid addictions were prescribed narcotic pain medications for legitimate medial problems frequently orthopedic related problems and then became addicted to the drug.
The Opioid Problem
To give you an idea of the scope of the problem here are data from various sources.
2013 data from the Substance Abuse and Mental Health Services Administration (SAMHSA) show the following:
Current Use of Opioids
- 289,000 users of heroin representing about 0.1% of the population
- 4.5 million users of non-medical use of prescription pain relievers representing 1.7% of the population.
New Users of Opioids
- 169,000 new users of heroin
- 1.5 million new uses of non medical use of prescription pain medications.
According to the Drug Enforcement Agency (DEA) there were 435,ooo users of heroin in 2014. According to the National Survey on Drug Use and Health in 2015 828,000 people used heroin. Â So you can see the exponential growth in just the last two to three years.
The National Drug Use and Health survey also found 12.5 million Americans representing 4.7% of the population misused prescription pain relievers in 2015 and 63% of those took the medicines to relieve pain. Just over 11%Â of the population suffers from chronic pain creating a delicate balance between appropriately prescribing narcotic pain medications and over prescribing them which can lead to abuse.
To put the 48 heroin overdoses in 48 hours in Central Ohio alone in September in perspective consider this. According to the Center for Disease Control and Prevention 78 people die nationwide every day from opioid use with 29 of them being from heroin overdose. That equates to 10,500 deaths each year from heroin and 28,000 deaths from opioid overdoses.
In Ohio, fatal death from heroin overdoses has risen from 87 cases in 2003 to 1,424 in 2015 representing 47% of all fatal drug overdoses. The number of fatalities is 2,590 when overdoses from other opioids are considered. In Akron recently there were 25 heroin overdoses in a 3 day period.
Only a small percentage of those with opioid addictions receive treatment.
Buprenorphine and Opioid Addiction
Just 15% of those with an opioid addiction receive treatment for it in part because of unavailability of treatment. Only 2.5 million out 22.7 million (11%) with any substance abuse disorder received treatment in 2013. Thirty-four percent of those desiring treatment, but not receiving it said they were unable to find treatment.
To address the growing opioid addiction epidemic and make it is easier for patients obtain treatment and to de-stigmatize the problem there has been a movement to provide for outpatient addiction clinics which enable patients to still work and live at home while being treated (treatment is more discreet than inpatient rehab). The main stay of out-patient opioid addiction is a drug called buprenorphine. It is frequently administered in combination with naltrexone going by the names of Suboxone, Zubsolv, and Bunavail.
Physicians have to request a waiver from the DEA to prescribe buprenorphine. And, to do that physicians must take an approved course. Currently, the DEA restricts the number of prescriptions a physician can write each month containing buprenorphine. For the first 12 months physicians can only write 30 prescriptions a month. Beginning the second year physicians can write 100 hundred prescriptions a month.
To make opioid treatment more available the new law now allows physicians to write up to 275 buprenorphine prescriptions a month beginning the third year and allows nurse practitioners and physicians assistants to be able to write prescriptions for buprenorphine. These legal changes should highlight the growing magnitude of the problem.
Prevention of Drug and Opioid Addiction
Treatment of opioid addiction is one thing, preventing such an addiction or any addiction is quite another. Certainly, educational programs that highlight the dangers of drug use can be effective, but are not enough. Many individuals with opioid addiction developed their addiction while taking properly prescribed narcotic pain medications for legitimate medical problems. Careful monitoring of those individuals and limiting duration of narcotic use in them would seem to be wise.
Treating pain with narcotics presents a dilemma for physicians. Some say we already under treat acute pain with narcotics and over treat chronic pain with them  and suggest that we should be more aggressive treating severe acute pain with narcotics for brief periods (up to a week for instance) to break the pain cycle so that the pain does not become chronic. Other physicians feel the opposite way.
We also need to understand why people turn to any substance for non-medical use. Are they unhappy? Are they trying to cope with a problem? Are they in physical or emotional pain?
Personal Opinion
We need to take a look at our society and priorities. There has been a breakdown in the family unit. People seem to have less direction. It is harder to be a kid or young adult. We seem to be making life more and more unnecessarily complex. The more time-saving technologies we develop, the less time we have. An increasing number of individuals are stressed. They are stressed at work, stressed at home, and stressed at school. According to the American Institute of Stress (AIS), 44% of us feel more stressed than five years ago. Why? Go to this page on the AIS website to see what stresses us.
People are not allowed to fail anymore. We think everybody deserves a trophy. Self-esteem is no longer earned. We expect instant gratification. We are a coddled society. We feel no one should experience any emotional pain.We no longer see pain, disappointment, Â or setback as a part of life and the growing process.
We have become a society in search of the quick fix for just about everything, but especially our health. And, drugs have become that quick fix. We live in an over-prescribed medicated society.
We are a drugged society in America. After returning to practice internal medicine after having practiced sports medicine for 20 years (where I prescribed a relatively short list of drugs and where there was more emphasis on exercise and nutrition) I was taken aback to see how much prescription writing occurs in primary care. It is not unusual to see patients on five or six prescription drugs – in fact that is the norm, especially anyone mid-50s and older.
I have inherited patients on as many 20 prescription drugs. Some of these medications are prescribed to treat side effects of the other medications. Some of those medications exacerbate existing problems (statin drugs make blood sugar control more difficult in diabetics). And, trying to wean people off some of their medications is challenging. Internal medicine has evolved into the practice of clinical pharmacology. Primary care physicians are increasingly conditioned that nearly every symptom or disease requires a pharmaceutical solution as a first option. Rarely is that true.
We are conditioned to use drugs, and beginning at a young age.
As Americans we account for 99% of the world’s hydrocodone use, 80% of the world’s oxycodone use, and 65% of the world’s hydromorphone use. All of these are narcotics. Thus, Americans account for 80% of the world’s opioid use. Nearly 70% of Americans take one prescription drug and more than half take two. Though only representing 5% of the world’s population, Americans consume 75% of all the world’s prescription drugs according to the National Institute on Drug Abuse.
We need to adopt healthier lifestyles and look for healthier non-drug therapies for medical problems. It seems unlikely we will be able to lessen recreational drug (including opioids) use as long as we use medications of all kinds to address our health problems at the rate we use them. Both problems go hand in hand. We need to quit looking at drugs as the quick and only fix for our health, mental, and emotional problems.
If you want to get high, get high by becoming the BEST YOU!
