Health beyond the headlines
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When the Prescription Becomes the Problem

The rise of prescription opioid abuse in the U.S.

Part one in a four-part series about America’s prescription painkiller epidemic

by Elaine Meyer

Published July 30, 2013

On Father’s Day of 2011, 33-year-old David Laffer, a gaunt, unemployed Army veteran wearing a disguise, shot up a Long Island pharmacy, murdering the pharmacist, the pharmacist’s 17-year old assistant, and two customers who came in as he was loading his backpack with prescription bottles. It was later discovered that the pharmacy was missing 11,000 pills of hydrocodone, the main ingredient for the prescription painkiller Vicodin.

Around the same time, the office of New York City’s special narcotics prosecutor was conducting an investigation into Stan Xuhui Li, a then-57-year-old anesthesiologist from New Jersey who operated a weekend pain clinic in Flushing, Queens. Investigators suspected that Li’s clinic was actually a “pill mill” that churned out prescriptions for painkillers like Vicodin and OxyContin for addicts and drug dealers after discovering that he was allegedly seeing as many as 120 patients a day and had written as many as 17,000 prescriptions over the course of 2 ½ years.

“When we saw that [the pharmacy homicides] occurred, we had not yet indicted [Li], but we knew many of his patients were desperate addicts,” says Bridget Brennan, New York City’s special narcotics prosecutor.

Brennan’s office reviewed its information and then looked at the surveillance photos from the pharmacy crime scene. Sure enough, Laffer had not only been a patient of Li’s but had been prescribed 2,500 pills by the doctor over the course of 20 months, according to Brennan’s office. That information led to Laffer’s arrest. Five months after Laffer’s shooting spree, Brennan’s office indicted Li—who is currently awaiting trial—for selling prescription drugs illegally, for manslaughter in connection with two overdose deaths of his patients, and for illegal sales of prescriptions to 20 patients, one of whom was David Laffer. (Li’s lawyer Aaron Wallenstein, did not respond to a request for comment.)

Homicide, robbery, drug dealing, and addiction are not typically associated with medicine prescribed by a doctor. But prescription painkillers, also known as opioid analgesics, like Vicodin—the drug Laffer allegedly stole in bulk—OxyContin, and Percocet have proven in recent years to have a serious dark side.

The “pharmacy murders,” as they became known, shed a light on a drug epidemic that has remained under the radar compared to the cocaine and heroin epidemics of the recent past, even though opioid analgesics can be just as addictive as heroin.

A medicine cabinet epidemic

Overdoses from opioid analgesics tripled over a decade, the U.S. Centers for Disease Control and Prevention reported in 2011. In 2010, more than 40 people died every day from overdoses, nearly 75 percent of the 16,651 pharmaceutical overdose deaths that occurred that year, according to the CDC. Among teens, abuse of prescription drugs is second only to marijuana.

Despite these figures, the response has been slower than to other drug epidemics, even though, by 2007, opioid analgesics were responsible for more overdose deaths than heroin and cocaine combined. Only in 2011 did the White House develop a plan to deal with the crisis. States have lagged at cracking down on illegal sale and use of opioid analgesics for non-prescription purposes and have struggled to monitor doctors’ prescribing practices. Doctors, often lacking proper guidance and education on how to prescribe opioid analgesics, have given them to patients who did not need them.

The response against opioid abuse has been slow to build, say experts, because people perceive painkillers as milder than other dangerous drugs.

“You can get it from your grandma’s medicine cabinet. You can get it from your parents,” says Dr. Katherine Keyes, an assistant professor of epidemiology at Columbia University’s Mailman School of Public Health who researches drug addiction.

Opioids have a number of substantial benefits. For some patients, they have meant freedom from a life of crippling pain. The risks, however, are also profound. Opioids can be highly addictive and dangerous, especially for patients who have a history of substance abuse, depression and other mental illnesses, as well as for those people seeking to get high.

“People have told me, ‘The minute I took this first pill, I thought, this is it. This is what I’ve been missing my whole life,’” says Erin Daly, a journalist who runs the website Oxy Watchdog, which reports on prescription drug addiction. “Opiates are downers. The person is seeking numbness or calm.”

In this tension between the immense relief to sufferers of chronic pain and the potential for addiction, the use of prescription painkillers epitomizes a dilemma that societies have long confronted: how to balance the medical benefits of a drug with its harms.

An ancient drug

Hailed as “God’s own medicine” and denounced as linked to the devil, opiates for the treatment of pain have been controversial since ancient times.

“The line between medication and abuse of medication has been with us for thousands and thousands of years,” says Dr. Traci Green, an assistant professor of medicine and epidemiology at Brown University.

The first opiate painkiller was opium, an extract of the poppy plant. Historical records suggest that Hippocrates, known as “the father of medicine,” was the first person to endorse opium for medical use. Because of its potency, it was used during this period as an anesthetic during surgeries.

“In early medicine, opium was an indispensable tool in the doctor’s and surgeon’s arsenal, used to treat insomnia, pains, diarrhea and even cholera,” according to the Science Museum in London. Because most people rarely if ever saw a doctor, they often relied on opium to treat their physical pain.

The Portuguese were the first to discover its hallucinogenic effects through smoking opium, a practice that many societies later tried to ban, even as the opium trade ramped up from the 1500s through the 1800s. The other-worldly feeling of being high led some to addiction, which became rampant in early nineteenth century China, causing debate within the emperor’s court over whether to prohibit the drug or promote legalization and taxation.

In 1804, German Friedrich Sertuerner isolated morphine—the active ingredient of opium—and doctors believed that opium had finally been tamed. Germany’s E. Merck & Company began in 1827 commercial manufacture of the drug, and in the 1850s, following the invention of the hypodermic syringe, physicians began to use it for minor surgical procedures. But it became apparent that like opium, morphine could be abused.

Observing this, pharmacologists set out to develop a non-addictive form of opium that would still maintain the drug’s pain relieving properties. Out of this came heroin, introduced in 1898 by the Germany-based Bayer Company, to be used as a cough, chest, and lung medicine for painful diseases such as tuberculosis. Early reports of the drug claimed that it was not as habit-forming as other opiates.

In the U.S. opiate use increased. Tonics containing opiates were easily available in drugstores, and doctors often prescribed them to middle and upper class white women suffering from a condition called neurasthenia, which was characterized by fatigue and a depressed mood. Some media outlets tried to drum up fears that Chinese immigrants were setting up opium dens to seduce white women. In urban industrial slums, reports of heroin addiction among young men added to the nation’s fears about opiates. Believing it had become the most drug-addicted country in the world, the U.S. government in 1914 passed the Harrison Narcotics Act, which tried to limit the sale of opiates and cocaine only to patients who received medical prescriptions, although the law banned doctors from administering opiates to treat opium, morphine and heroin addiction.

The law had a chilling effect in medicine. Government officials came down hard on physicians who prescribed opiates, and doctors were much more reluctant to prescribe than they had once been, except for using morphine for cancer-related pain.

The thinking was that “if you had cancer pain, that’s a pain you can’t fake, and that’s a pain that shouldn’t have or doesn’t have a psychological component to it,” says Dr. David Walega, an assistant professor of anesthesiology and practicing pain specialist at Northwestern University.

In the mid-to-late 1980s, things began to change. A few vocal doctors began to write articles and give talks arguing that chronic pain was not simply psychological and that it was being under-treated. Groups like the American Pain Foundation campaigned to make pain the “the fifth vital sign,” suggesting it was as important an indicator of health as a patient’s pulse or blood pressure.

Prominent pain doctors like Dr. Russell Portenoy of Albert Einstein College of Medicine in New York City said that opioid analgesics could be used to relieve chronic conditions, such as nerve or back pain; that addiction only occurred in 1 percent of opioid users; that the drugs were easy to discontinue and that overdoses were highly uncommon.

Enter: Oxy

In 1996, the Food and Drug Administration approved Purdue Pharma’s OxyContin, which was championed by Dr. Portenoy and his colleagues. Nearly one hundred years after Bayer touted the safety of heroin, Purdue was making similar claims that its new wonder drug was milder than past prescription opiates, with an extremely small risk of addiction. Unlike other pain relief drugs, OxyContin had a “slow release” over the course of 12 hours, which supposedly meant it was less likely to be abused compared to short-term painkillers.

Purdue aggressively marketed OxyContin in its early years to doctors and consumers through direct-to-consumer advertising, pushing it not just for cancer pain, but for musculoskeletal and post-operative pain. The company targeted primary care providers, who are usually less familiar with painkillers and their effects than doctors who specialize in pain, such as anesthesiologists.

Stories of OxyContin addiction began quickly to emerge. People who wanted a high from the drug found that it was easy to crush the pill so that it could be snorted, smoked, or mixed in a water solution for injection, similar to heroin.

In 2007, Purdue pled guilty for misleading patients, doctors and regulators about the risk of OxyContin, paying $635 million in civil penalties. However, the modern painkiller industry had become much larger than Oxy. Other painkillers, including Percocet and Vicodin—although already on the market—became much more popular, along with new painkillers, like Opana. Sales of painkillers to pharmacies and health care providers increased more than 300 percent between 1999: and 2008, according to data from the Drug Enforcement Administration.

“The sales are a pretty good predictor of health outcomes and death,” says Dr. Leonard Paulozzi, a medical epidemiologist in the division of unintentional injury prevention at the CDC’s National Center for Injury Prevention and Control.

During the same time sales spiked, drug overdose death rates more than tripled, according to the CDC.

Among college students, abuse of prescription painkillers including Percocet, Vicodin, and OxyContin rose 343 percent between 1993 and 2005, according to the National Center on Addiction and Substance Abuse at Columbia University.

Because of the new approach to pain medicine and the rise in use of prescription painkillers driven by OxyContin, individuals who had once been forced to live with their chronic pain or treat it with weaker medicine like Aspirin now had access to more powerful pain relief. From the late 1990s on, for working class areas of the country where people had developed chronic pains from performing manual labor for years, painkillers came to the rescue. But like heroin 100 years earlier, the long reach of opioid analgesics extended well beyond those who legitimately needed the drugs for pain, creating an abyss of addiction that would ravage entire regions of the United States.

Read part two of the series, which looks at how today’s epidemic of prescription opioids spread across the U.S.

Edited by Jordan Lite and Dana March.

One Response to “When the Prescription Becomes the Problem”

  1. July 31, 2013 at 5:19 am, Linda H. said:

    I’ve seen too many of my sons friends end up in rehab. It makes me sick to my stomach when I read the Town News Paper…These kids are growing up in wealthy households, so they have access to many things! I hope to see a change in the near future for I have a 15 yr. old, who I speak to often about all the “bad things” that she could come across, and peer pressure. Back in my day, the only thing kids were doing was smoking pot! Now they smoke stuff I never heard of before, let’s make these kids aware of the dangers, like DEATH!!!

    Reply

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The views and opinions expressed on this website are solely those of the authors and do not represent those of the Department of Epidemiology, the Mailman School of Public Health, or Columbia University.