THE OPIOID PRESCRIPTION DRUG EPIDEMIC… ISN’T IT REALLY A HEROIN/FENTANYL PROBLEM?
It seems every news broadcast is reporting on the latest American Armageddon, the Opioid crisis. Politicians and pundits are concerned about the epidemic of prescription pain medication indiscriminately killing our citizens. The truth is not quite so simple.
Nearly two decades ago, while working as a detective, I responded to a call for a sudden death. Upon arrival, we found a 22 year-old white male, lying supine on his bed. Rigor had already set in.
The tragic story involved a college student who had been partying with his friends, snorting brown heroin. He overdosed and his friends turned to an old wives tale method to revive him—they put him in a bathtub and turned on the shower with cold water. When he didn’t wake up, they moved him to his bed and left the apartment. Like Jimi Hendrix, he vomited, aspirated and died.
I made the notification to the family. Unfortunately, we didn’t determine whether his son’s path to heroin had begun with a legitimate prescription to pain medication. At the time, heroin overdoses were not on the national agenda.
We interviewed the young man’s friends, including the one’s he had been partying with. They were afraid to call 911 for fear of getting themselves, or the victim, in trouble. There were no “‘Good Samaritan” statutes at the time, like there are now here in Missouri, that would have alleviated their fear of legal trouble when calling for help. We were able to identify the heroin dealer and notified our narcotics division who were able to extract some justice.
It was around this time, as a result of aggressive marketing by the pharmaceutical industry, opioid prescriptions skyrocketed. The marketing fostered a trend in the medical community to view opioid prescriptions as a viable and low risk method to manage patients with pain. The stigma of addiction and related adverse health conditions were glossed over by the advertising strategies of the pharmaceutical industry.
A historical construct of the Purdue Pharmaceutical marketing scheme for OxyContin that seems to have spawned the opioid problem, can be found in an October 2017 article in the New Yorker magazine:
“Purdue launched OxyContin with a marketing campaign that attempted to counter this attitude and change the prescribing habits of doctors. The company funded research and paid doctors to make the case that concerns about opioid addiction were overblown, and that OxyContin could safely treat an ever-wider range of malaises. Sales representatives marketed OxyContin as a product “to start with and to stay with.” Millions of patients found the drug to be a vital salve for excruciating pain. But many others grew so hooked on it that, between doses, they experienced debilitating withdrawal.” 
The current crisis may have certainly begun with the over prescription of opioid painkillers; however, the increase in the number of overdose deaths that grab headlines are from synthetic opioids, such as Fentanyl. 
Fentanyl can be 50-100 X more potent than morphine and may be added to heroin or used in the manufacture of fraudulent prescription pills sold illegally. A minute amount of this crystalline powder can kill the unsuspecting drug user.
A recent article in the American Journal of Public Health recommends a change to the Centers for Disease Control and Prevention (CDC) method used for quantifying prescription overdose deaths. They propose a method that removes deaths as a result of illicitly manufactured fentanyl (IMF).This change would improve data accuracy on reporting the number of overdose deaths directly related to a prescription opioid. 
These are clearly challenging times. Heroin prices are at an all-time low. The availability of IMF from China and Mexico is increasing while there is a call to reduce the number of opioid prescriptions written by providers. Restricting or denying access to opioids for legitimate chronic pain patients could force them to obtain relief with illicit drugs purchased from street drug dealers. The increase in the deaths from illicit drugs may be an unintended consequence of this restriction.
Solving the current opioid problem requires multi-factorial strategies. Educating providers in the appropriate use of opioid prescriptions is necessary, especially if they are managing chronic pain patients. Non-medical options including acupuncture, massage and chiropractic can offer relief for some patients.
Some commercial insurance companies have taken proactive approaches to address this issue. These include collaboration between the business units that manage their member’s pharmacy benefit, mental health professionals and the Special Investigations Unit charged with investigating health care fraud, waste and abuse.
They search claims data for members who appear at-risk for prescription fraud, such as patients who go to multiple doctors for pain medication prescriptions. They also identify providers who may be involved in aberrant prescriptive practices.
Strategies include limiting a member, suspected of prescription drug abuse, to a single pharmacy or prescribing doctor. Members may be referred to behavioral health staff where they can receive counseling and possibly medicated assisted treatment for addiction disorders.
Providers suspected of over-prescribing pain medication or other abusive or potentially criminal behavior undergo additional scrutiny by the SIU investigators which may result in notification to law enforcement and regulatory boards. These interventions are showing positive results in the reduction of opioid prescriptions and patients receiving behavioral health assistance.
Programs like this will not solve the opioid (IMF/Heroin) crisis, but they are steps in the right direction to avoid the unintended consequences of more overdose deaths.
 Puja Seth, Rose A. Rudd, Rita K. Noonan, Tamara M. Haegerich, “Quantifying the Epidemic of Prescription Opioid Overdose Deaths”, American Journal of Public Health 108, no. 4 (April 1, 2018): pp. 500-502.