Pain Management, Substance Abuse and the Rise of the Opioid Epidemic

Beth Hawkes MSN, RN-BC - 07/04/18


Jeff worked in the coal mines in a poverty stricken community in West Virginia. In high school, he and his friends from the football team had easy access to pain pills mostly stolen from their parents’ and grandparents’ medicine cabinets. His drug of choice was OxyContin because it gave him confidence and made him feel invincible. His friends taught him to suck gently on the pill until the red coating came off. Then they would crush the pill to a fine powder. Using a credit card they would next painstakingly form the white powder into fine lines and finally snort the drug with a rolled up dollar bill. Jeff enjoyed the whole process of preparing and ingesting the drug.

He was never concerned about becoming addicted or about withdrawal. In his mind, that was for the losers who shot up, not for high school kids like him. Recreational pill use was completely acceptable in his crowd. But weekend use gradually became daily use. Fun became need.

The day came when his drug connection couldn’t be reached and withdrawal symptoms hit. Jeff was desperate to get his pills. A dealer offered him relief by using an alternative drug-“Try this, Jeff”. The first bag of heroin was free. At first Jeff and his girlfriend Julie snorted heroin but soon the high wasn’t enough. There was no pleasure, just the avoidance of withdrawal symptoms.

They started shooting up. Jeff missed work and Julie dropped out of school. They didn’t even know she was pregnant until Julie was 18 weeks along.

When baby Zach was born and given to agonizing and continuous screaming cries, the nurses immediately recognized the signs of addiction. Zach was treated with morphine and released to Child Protective Services. Less than one year later, Jeff died of an overdose when he injected some greenish-tinged heroin purchased from a new dealer. Julie is trying to get clean and get her son back but relapsed one month ago.

This is a story that is repeated across the country in thousands of different iterations. An estimated two hundred thousand Americans have died since 1999 from OxyContin and other prescription opioid overdoses. Jeff survived his OxyContin abuse, but not his resultant heroin addiction. Read about Substance Abuse and Addiction to learn more.

Opioids are readily available in medicine cabinets across the United States, in hospitals, doctor’s office, and on the streets.

How did OxyContin become as available as candy to Americans? How did abuse become so prevalent?

The Beginning of the Crisis

Starting back in the 1990’s, two important trains of thought were pushed by the drug industry. One was that pain medication was not as addictive as previously thought, despite the well known history of heroin and opium addiction. 

The second belief was that patients had a right to the alleviation of pain. In a widely circulated paper in Anesthesia & Analgesia, doctors were admonished, “Unreasonable failure to treat pain is poor medicine, unethical practice, and is an abrogation of a fundamental human right.”

Nurses and doctors were taught, “pain is what the patient says it is”.  Soon pain became the fifth vital sign. The only way to measure pain is by the self-reported pain scale. Patients seeking drugs quickly learned to claim pain levels of 10 to obtain narcotics.

Fear of addiction by the medical community was seen as outdated and exaggerated. Nurses were taught to reassure patients that pain meds were not addictive when used as prescribed and to not be afraid of becoming addicted.

The FDA endorsed OxyContin as safer and less subject to abuse than because it was time released. The FDA went so far as to approve a label that claimed the drug had “abuse deterrent” properties. Meanwhile the abusers negated the “abuse deterrent” time-release properties by crushing and snorting or injecting the drug. 

Even the Joint Commission, in a pain management guidebook sponsored by the makers of OxyContin, advised increasing medication doses if patients developed tolerance.

Big Pharma

The so-called opioid epidemic was not a coincidence or accidental.

Doctors were aggressively wooed by sales reps. Millions of dollars were spent marketing OxyContin to doctors. Lavish pain management conferences were given in luxury locations. 

Doctors were wined and dined by sales reps that were trained to allay any objections with pat answers. Sales reps reported as fact that OxyContin was safer than short-acting pain medications and was not subject to abuse.

Meanwhile, abusers quickly learned to crush and snort OxyContin to get high. Crushed, broken or chewed, OxyContin provided the desired effect.

Patients soon became physically dependent. Even those who stuck to the 12 hour prescribed schedule found that the effects could wear off and they could experience withdrawal symptoms after 8 hours. Doctors then increased the dosage, or the frequency, and prescribed breakthrough medication, such as Percocet.

Doctors were urged to prescribe OxyContin for chronic pain: arthritis, back pain, sports injuries, fibromyalgia, and migraines. It seemed that OxyContin could treat an unending number of conditions.

The maker of OxyContin strategically targeted poorer rural communities in Kentucky, West Virginia and many other states.

Dirty doctors fell into the temptation of selling prescriptions and so-called pain mills were born. Other doctors were manipulated by their patients and began over-prescribing.

As more and more doctors prescribed OxyContin for an ever-greater range of symptoms, some patients began selling their pills on the black market, where the street price was a dollar a milligram.

The pain mills flourished and the black market grew.Prescriptions skyrocketed and poor communities saw their addiction rates rise.Few heeded the words of David Kessler, the former commissioner of the Food and Drug Administration, “few drugs are as dangerous as the opioid.”

From Pills to Heroin

OxyContin’s active ingredient is oxycodone, a cousin of heroin. Oxycodone creates risk for tolerance and dependence. People addicted to prescription opiates are at risk for developing a heroin abuse problem. The problem is, these people cannot be identified ahead of time.

The National Institute on Drug Abuse tells us that approximately 80% of heroin users reported using prescription opioids prior to using heroin. The American Society of Addiction Medicine confirms these statistics, stating that four out of five heroin users started with prescription painkillers. The Centers for Disease Control and Prevention report that that a hundred and forty-five Americans die daily from opioid overdoses.

The Future

The opiate crisis left major societal problems and broken families in its wake. Many communities continue to struggle with the consequences. 

But with a growing awareness of the dangers of opioids, the days of over-prescribing are ending. Some pharmacies are filling only one week’s worth of narcotics at a time. Doctor’s prescribing habits are being scrutinized.

New non-narcotic drug cocktails are being formulated and administered pre-op. A pre-op drug cocktail may include Tylenol, gabapentin, and an anti-emetic.  Epidural blocks are used intra-op and IV Tylenol is being given after surgery.

For chronic pain, acupuncture, massage, physical therapy can be used to help with pain management and improve outcomes.

Read here for what you need to know about Pain Management, nonpharmacological and nonopioid therapies and to stay up-to-date in your clinical practice.