Does It Have to be an Opiate?

There are other ways to manage pain. Ask Heidi Klingbeil of the VA Medical System in the Bronx, New York. A runner, Dr. Klingbeil, who is Chief of Physical Medicine and Rehabilitation at her center, advocates a good diagnosis as a starting point.  Problems that need surgery, get surgery.  But following that, she uses a range of holistic medicine approaches to manage pain.  These include acupuncture, exercise, chiropracty and Reiki. These methods take more work and more “buy-in” on the part of both doctor and patient, but lead, says Dr. Klingbeil, to an improved quality of life.  (Heath Druzin, Stars and Stripes, April 1, 2015)

Doctors are conditioned to relieve pain and opiates offer a quick solution to chronic and acute pain. But patients can habituate to an opiate and require increasingly high dosages. When the pills get too expensive, or the doctor worries about the amount of drugs he’s prescribing and cuts the patient off, the Law of Unintended Consequences applies. We are increasingly aware that the “gateway” to heroin is often through addiction to opiate pain medication. The figures now seem to indicate that 80% of heroin users started with opiate pain medication.

There are other ways to treat chronic pain, but they all take effort and “buy-in,” things that may not be so attractive in this “I want it, and I want it now” society.  When there is an App (or a pill) for everything, who is willing to go to physical therapy several times a week? Or do the work at home between physical therapy appointments?

Rather than jumping immediately to pain medication, there are other avenues to treat chronic pain, including acupuncture, biofeedback, hypnosis, relaxation therapy, massage, and physical therapy. Changes in diet or exercise patterns can be helpful. Therapy for depression (because pain can be correlated with depression)  may prove helpful for some people.

Being fully aware of the possible long-term effects of opiates is a good first step. Discuss the use of opiates with your doctor and tell him if you have a history of addictive behavior.  Ask good questions, and ask the doctor for recommendations that avoid prescription medication. Doctors are increasingly aware of their part in the opiate epidemic and should be willing to take the time to discuss it fully before giving you a prescription.

Does Profit Trump Lives?

As a Behavior Analyst, I always told my supervisees not to listen to what people said, but to watch what they did. I find myself amazed about what is being done, or not being done, about the steep rise in the price of Naloxone since the beginning of the year.

Estimates are that there is one Opioid-related death every half-hour [in the United States]. The World Health Organization says that increasing the availability of Naloxone could prevent more than 20,000 deaths in the United States annually. Naloxone is a "lifesaving antidote" to opioid overdoses and increasingly, first responders, including the police, are carrying Naloxone kits and are being trained to administer it to people who, without it, would die of a overdose. "Everyone" agrees that this is an important measure in the State's fight against the growing opioid addiction problem, which includes the surprising and troubling rise of heroin addiction and overdose deaths. But guess what! What appears to be an excellent solution to a pressing problem is being hampered by a sharp increase in the cost of the life-saving drug.

The Baltimore Business Journal (1/30/15) reported that the cost of Naloxone doubled in the past year. The cost of a kit needed to administer the medication rose 111%, from $19.56 to $41.95 in a six-month period, meaning that the grant monies used to purchase the kits, which would have purchased 3,600 kits, can now only purchase 2,000. 

According to Dr. Leana Wen, Baltimore's Health Commissioner, cited in July, 2015, since the spring, the price of a 10-dose kit needed to administer the medication, went from $97 to $370.

If the price of a life-saving medication is allowed to rise with market forces, ought we to enquire whether we think profit trumps lives? Should we be writing our legislators, urging them to increase the grant funding for this medication? Would that reinforce the price rise by giving in to Big Pharma’s demands for more money?

It’s easy to say it’s all greed, and that is certainly something that can be hypothesized. The easily-administered nasal spray dose that is being used to train non-EMTs uses a much higher dose of the Naloxone than the injectable dose. Nasal Naloxone from the one company that makes it, uses 1-mg/ml in each dose, compared to 0.4/ml for the injectable dose (MedPage Today, The Gupta Guide, Psychiatry, 11/26/14).  However, I do have difficulty understanding how an increase of 0.6 mg of a generic drug that has been around for many years can account for a doubling of the price of the medication depending on the delivery system. There are issues with the drug in its injectable form, mostly having to do with the delivery system. Because of issues with needles, blood transfer with patients who may have HIV/AIDS, and liability, the relatively risk-free nasal delivery is preferred.

The nasal form of the drug and its delivery system are made by one company; when one source controls the market, prices tend to rise. Recently, a self-injectable form of the medication was given the go-ahead by the FDA. Evzio works much like an EpiPen used by allergy sufferers.  The delivery system appears quite complex and the prices on-line, even with a “manufacturer’s coupon” range from $594.85 to $636.41 for a two-dose pack.

If this is a “commodity” needed to save lives, oughtn’t there be some regulation? People may not be too excited about saving the lives of heroin addicts (“after all, they brought it on themselves”), but this could be your grandmother, who took an overdose of pain medication because she didn’t remember when she took her last dose. It could be the new-born, to whom it was administered to counteract the effects of narcotic pain medication given to the mother during labor. If we say that this is important, ought we not to ensure that it is available in quantities necessary to save more than 20,000 lives in the United States every year?

How Much is Too Much?

In 2013, there were 434 opioid-related deaths in Maryland. In a state with a population of 5,939,000, that represents approximately .00008% of the population. Is it worth it, then, to spend millions of dollars to combat a problem that "really doesn't touch us?" The fact is, it does touch us. It is no longer a problem of the inner city, or minorities, or "poor people," which, by the way, were not good reasons for ignoring the problem either.

A recent CDC News Release (July 7, 2015), which many of you may have read, or heard on the news casts, clearly indicates that the face of the heroin/opioid user is changing, and the new face is "us."

The use of Heroin among white, non-Hispanic women has increased by 100% from 2004 to 2013. Males making over $50,000/year are using Heroin at a rate 60% higher than they were ten years ago. Sixty-three percent of those abusing heroin have private health insurance. We are no longer talking about "the others," people who don't live in our neighborhoods or go to our children's schools. To cite one of my favorite philosophers, Walt Kelly, "We have met the enemy and he is us." (Pogo, Earth Day, 1971).