Opiates in American medicine from physician’s perspective

Paul Swanson, M.D., director of the Emergency Department at Eastern Plumas Health Care speaks passionately about opiates at a special presentation given Feb. 21. Photos by Lauren Westmoreland

Paul Swanson, M.D., director of the emergency department at Eastern Plumas Health Care, presented an in-depth look at the opiate crisis from origins to present-day, at the EPHC Education Center on the evening of Feb. 21.

Swanson spoke to a full house, opening with, “The opioid crisis is something that I feel strongly about. Over the years, I have run into patients that were on high doses of narcotics, oftentimes needing or wanting more, and I was very aware of the struggle back and forth that doctors felt, with patients, over this issue.”

Swanson pointed out the way things shifted significantly in the medical community in the late 1990s. “The whole mood and the ideas around prescribing narcotics had shifted in terms of a lot of pressure on doctors to prescribe narcotics,” he said. “I’ve watched this unfold, and now I want to talk about what has happened as a result of it.”

Swanson shared a tweet from President Trump in October 2017, which declared the opioid crisis a national public health emergency under federal law.

Swanson then moved to a graph, which showed the trajectory of drug overdose deaths in the United States between 1980 and 2016.

“This is a graph that tells much of the story here,” Swanson stated. “We’ve been shooting straight up with a nearly vertical slope from 1980 to 2016 on this graph. Drug overdose in 2016 alone was at 62,497 —  meaning there were more drug overdose deaths in 2016 than deaths of Americans in the entire Vietnam War, which had a death toll of 58,220.”

Swanson then showed a slide showing overdose deaths per 100,000 in the U.S. between the years 2003-2014, with the maps illustrating the rapid growth of drug overdose deaths over the years.

“There are more males overdosing than females, overall, with the most drug abuse occurring in the 25 to 34 age range, with all ages rising. The primary increase of abuse has been seen amongst the white population,” Swanson noted. “The U.S. has 4.6 percent of the world’s population, but consumes 80 percent of its opioids. We don’t have 80 percent of the world’s chronic pain.”

Swanson went on to note that current heroin users are most likely to be white, middle class and live in suburban or rural areas. “It’s the same population that has a rise in the abuse of opioid pills,” he added.

Swanson noted that between 2000 and 2015, one-third of overdose deaths were from prescription opioids, such as morphine, oxycodone, hydrocodone or methadone; one-third of overdose deaths resulted from the abuse of diamorphine, which is also known as heroin; and one-third of the deaths were from fentanyl, which is a street drug that is 20 times as potent as heroin.

“Fentanyl is a synthetic narcotic, 20 times as potent as heroin, and very popular on streets as a substitute for heroin,” Swanson stressed. “But deaths from prescribed drugs have about leveled off from 2011 on, largely due to the fact that it has become such a big issue.”

“There had been a lot of pressure on doctors to prescribe opiates,” Swanson went on, in describing the turning point that he feels led to the current crisis.

The infamous Jick letter.

“This is a key point — this crisis has been caused by doctors over-prescribing opioids. The key thing that I want to get across here is also that the overprescribing has caused the illegal drug use,” Swanson said.

Swanson followed the statement with a slide showing a letter that went out to all doctors in August 2016 from the U.S. Surgeon General. A key part of the letter reads, “It is important to recognize that we arrived at this place on a path paved with good intentions.

“Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Most of us were even taught — incorrectly — that opioids are not addictive when prescribed for legitimate pain. The results have been devastating.”

The room was silent as the audience absorbed the statement and Swanson moved on to the next key item, which was in fact the marketing aspect that assisted in creating the crisis in our society today.

Prescription vs. illegal

According to Swanson, America has the largest drug market of any country, with $300 billion spent on prescription drugs in 2009, and $215 billion spent on illegal drugs in 2012. “So America’s illegal drug market is essentially two-thirds as big as the prescription drug market,” Swanson stated.

Swanson also noted that the U.S. has the highest annual drug trafficking revenue in the world, at an average of $215 billion, followed by Spain at $95 billion and Italy at $83 billion.

Swanson also showed a graph of prescription and illegal drug use among youth, with prescription opiates coming in at 9.5 percent of high school teens that have used in the past year. “This is something that has come to our area — recently, a PHS student was found selling shots of percocet ground up and mixed with water to other students.”

Swanson stressed the fact that it is easy to be prejudiced about the types of people that use heroin. “It really can be anyone,” he stated.

When it comes to the circle of addiction and the next generation, Swanson highlighted some statistics from the DEA, which show how prescribed opioids such as oxycontin cost $80 a tab, and hydrocodone is $5 to $7 a tab, with heroin at $5 to $10 a bag.

“Ultimately, heroin is cheaper,” he said. “It’s more readily available on the streets — and to get a sense of that, I visited Street Rx, a website that actually shows currently available drugs on the streets, the locations and how much they cost as users input the information.”

One example was a post from San Francisco from Feb. 12, which listed a 5 mg oxycodone pill at $20 on the street at that location.

Common household medications included throat pastilles such as these, with heroin and cocaine listed as the main ingredients.

“The incidence of heroin initiation is 19 times higher among those who report prior opioid pill abuse than those who don’t,” Swanson noted. “Ninety-four percent of those in treatment for heroin addiction reported turning to heroin because prescription opioids were more expensive and harder to obtain.”

Statistics from the National Institute on Drug Abuse show that 4 to 6 percent of those who misuse prescription opioids end up transitioning to heroin.

One abuser’s story

Swanson shared a piece of one opioid abuser’s story with the room, from the perspective of a 51-year-old who had been using heroin for nearly six years, and was originally prescribed percocet for the pain from a knee injury.

“Like a lot of people, you start on the pills, and then the doctor gives you some and some more, and then you get cut off by the doctor … [so] every morning we would go to the [dealer’s house] and they had both things, but … they never were out of heroin … [but] three times a week they didn’t have the pills. So I’d have to scramble around, and then I finally had enough and said … the hell with this, give me a bag and was off to the races.”

Swanson then showed photos of the view from the street, with parents overdosing in vehicles as young children watched from the backseat, young people passed out with belts wrapped tightly around their arm, and even a video clip of a Pennsylvania man caught shooting heroin on a public bus and ultimately keeling over and out of his seat onto the floor.

Effects

Swanson then went over the effects of opioids, which includes euphoria, pain relief, sedation and respiratory depression.

An opioid overdose involves respiratory arrest, which is currently combated by drugs such as Narcan, which can reverse an opioid overdose rapidly most commonly through a nasal spray.

Swanson went on to explain that long-term use of opiates typically cause drug tolerance issues, where doses must be raised to achieve the same effect; and hyperalgesia, which is, oddly enough, an increased sensitivity to pain in opioid users.

“Addiction and chronic pain are really intertwined,” said Swanson. “Chronic pain is very real and it can be very difficult to sort out the two.”

Some history

Swanson then took the room to the roots of the opium trade, showing images of the opium poppy fields in Afghanistan, and gave a brief overview of opium in China in the 1800s. Various images of opium users and opium dens of a bygone era flashed past on the screen, with sunken ribs, lethargy and vacant eyes.

The Opium Wars, the two wars that England fought with China over the coveted substance, really changed the global face of opiate use, according to Swanson.

Dr. Swanson takes the audience at his recent presentation on a look into the opium dens of days past.

Swanson then neatly integrated the conversation into the chemical makeup of opium, which contains 10 to 25 percent morphine and 1 to 3 percent codeine.

“Morphine was discovered by extraction from the opium poppy in 1804, in Germany, by a man named Friedrich Sertürner,” Swanson said. “Morphine is extracted from the crushed opium poppy with dilute acid.”

Commercial production of morphine began in 1827 in Germany by the Merck Company, now an easily recognizable pharmaceutical giant. In 1852, Dr. Alexander Wood invented the hypodermic syringe, which, according to Dr. Swanson, “completely changed the way that the drug was used.”

Morphine was used extensively in the Civil War, with one tale of Union Surgeon Major Nathan Mayer diagnosing the wounded from atop his horse. “If Mayer thought a soldier needed morphine, he would pour out an ‘exact quantity’ into his hand, and let the soldier then lick it from his palm,” Swanson said. “Morphine addiction was actually known as the ‘soldier’s disease’ at that time.”

In 1874, Charles Wright, an English chemist, boiled morphine in acid, creating diamorphine or heroin. Diamorphine was rediscovered in 1897 by Felix Hoffmann at Bayer Pharmaceutical in Germany and officially labeled the drug heroin, which came from the German “heroisch,” meaning heroic or strong.

Heroin really entered the pharmaceutical drug industry in the beginning of the patented drug era and could be found in nearly every common household remedy, from cough syrup to pain medication.

In 1887, one particular home remedy known as Mrs. Winslow’s Soothing Syrup was widely used for teething babies, and was advertised as “The mother’s friend.”

“Mrs. Winslow’s Soothing Syrup contained 65 mg of morphine per ounce,” Swanson said. “That is the equivalent of two Vicodin pills per teaspoon.” The American Medical Association later referred to the syrup as a “baby killer.”

Swanson gave a brief history of opiate epidemics, beginning with morphine and heroin from the 1880s through the 1900s; noting the use of heroin in the jazz era, and the Vietnam era to the 1990s, where heroin was sourced from Columbia.

“Half of the military population in Vietnam tried opium or heroin during their tour,” Swanson stated. “One-fifth came home addicted.”

The epidemic surfaced again on the Sept. 4, 1973, cover of Time magazine, with a headline proclaiming The Global War on Heroin.

The current crisis

Swanson then moved on to the overview of what caused the current crisis, saying, “It began with heavy pharmaceutical advertising, and paid physicians, or “thought leaders,” were giving talks to other doctors nationwide. There were constant seminars advocating opiate prescription very strongly, through the 2000s.”

The statistics speak for themselves, according to Dr. Swanson.

Governmental regulation became a factor, and pain itself became the required fifth vital sign in addition to traditional respiration, heart rate, temperature and blood pressure.

“This was an issue as it was such a subjective measure,” Swanson stated. “There was a strong pressure to treat pain, and lawsuits were being filed regarding inadequate pain relief. This really created paranoia in the medical community.”

“This all led to an environment where doctors felt pressured to prescribe opiates — there was a lot of pressure on the doctors, as well as a lot of anxiety felt among doctors about prescribing to avoid complaints,” Swanson explained.

Much of this period of anxiety within the medical community evolved from a letter to the editor, of all things. “This became known as the infamous Jick letter, which was cited more than 600 times in publications as evidence that opioids were not addictive.

The letter was written by Hershel Jick, M.D., of the Boston Collaborative Drug Surveillance Program, and stated that in one particular study, there were 11,882 patients who received at least one narcotic preparation, and only four cases of reasonably well documented addiction, Swanson said.

This letter went on to be frequently referenced by pharmaceutical companies marketing opioids as nonaddictive treatment for pain management.

Dr. Jick himself spoke with the Associated Press about the letter that was blown out of proportion, saying, “I’m essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did. They used this letter to spread the word that these drugs were not very addictive.”

What’s being done

Swanson then focused on the Eastern Plumas experience, saying, “Five to seven years ago, there was a great concurrence of opinion on opioid reduction from the EPHC Board of Directors and administration. This is key — if the board and administration agree on this, the doctors were very glad to agree as well because they are aware that the opioid over-prescribing is a problem that needed correction.

“EPHC was wonderful and we needed admin on board to ride through the process of tapering opioid prescribing — otherwise we never would have gotten through the process. I certainly see tremendous success thus far in the emergency department, with fewer pain complaints,” Swanson said.

Swanson noted the two models of addiction, past and present: The “personal responsibility model of addiction,” which emphasized personal choice and responsibility; and the “biological model of addiction,” which is the current scientific and medical standard. The latter model states that addiction is uncontrollable and that the addict is a victim.

Swanson stated, “My hypothesis is that the biological model of addiction actually exacerbates addiction. The BMA denies the existence of free will and personal causation, which directly causes victim mentality. It also invalidates the primary tools available to oppose the physiologic process of addiction — personal understanding, choice of moral values and personal decision and effort.”

Swanson feels that it is time for a new model of addiction, which would incorporate the idea that free will does, in fact, exist as top-down causation from high-level understanding to action.

“The view of human beings as mechanisms without power of personal choice has had a huge impact upon culture and society,” Swanson said. “The new model of addiction needs to affirm the existence of personal causation from understanding, and needs to teach that individuals can control their own lives, if they choose to and seek to understand how.”