There are no guidelines on how to differentiate iatrogenic opioid abuse triggered by treatment for legitimate pain from illicit use. And yet, theories abound.
The recent death of the actor Philip Seymour Hoffman from an apparent heroin overdose has increased awareness of a reported resurgence in the use of this drug. What especially caught my attention in a number of the stories on this unfortunate event were comments by some drug abuse experts tying the resurgence to prescription opioid abuse.
According to these experts, the growing concern about prescription opioid abuse has resulted in a shortage of the drugs and an associated increase in their cost on the street; the higher cost of opioids, it is believed, leads users to turn to less expensive heroin. Some experts even speculated that many of the heroin users had been prescription opioid users and that the problem of abuse of both largely originated from physicians being overly aggressive in the treatment of pain.
I don't specialize in the treatment of drug abuse but during my medical career I have received a fair amount of training in it and have often addressed the issue in patients with pain who are abusing prescription drugs, especially opioids and benzodiazepines. I believe that many of those who commented with apparent certainty on the issue of prescription opioid abuse after the Hoffman death were actually stating things unsupported by our current knowledge.
Of course there are drug abusers who were previously using prescription opioids and switched to heroin because of price considerations. (There is no indication that Hoffman was one of these people. Most of the reports on his life indicate that he began abusing alcohol and illicit drugs at a young age and before he began using prescription ones. And, as he was a well-paid actor, price wouldn't appear to have been a major factor in electing his drug of choice.) However, no one has any firm idea how many prescription-opioid-users-turned-heroin users had originally taken opioids for legitimate pain complaints.
Furthermore, there is nothing to indicate that the large number of physicians who were previously prescribing opioids in what they felt was an appropriate and legal manner have suddenly decided to stop doing so, thereby “forcing” these patients to seek drugs from illegal sources.
There are, unfortunately, also doctors who knowingly write prescription for opioids for people whom they know have no pain complaints. The same week as Hoffman's death, federal authorities brought charges against a clinic in New York City where doctors allegedly wrote prescriptions for opioids, primarily oxycodone, in return for $300 a prescription. The indictment alleges that over a 3-year period, the clinic wrote 31,500 prescriptions for 5.5 million oxycodone tablets which had a street value of up to $550 million. (It was estimated that in New York City a single 30 mg oxycodone tablet sold for $30 to $40 and as high as $100 in the rest of the country.)2
Nowhere in the article was there any mention that OxyContin would have been an inappropriate choice for any form of acute pain including dental surgery as the drug, like all long-acting opioids, takes several days to attain its maximum analgesic effect. If the dentist wasn't aware of this, he or she shouldn't have been prescribing it.
There are, unfortunately, also doctors who knowingly write prescription for opioids for people whom they know have no pain complaints. The same week as Hoffman's death, federal authorities brought charges against a clinic in New York City where doctors allegedly wrote prescriptions for opioids, primarily oxycodone, in return for $300 per prescription. The indictment alleges that over a 3-year period, the clinic wrote 31,500 prescriptions for 5.5 million oxycodone tablets which had a street value of up to $550 million. (It was estimated that in New York City a single 30 mg oxycodone tablet sold for $30 to $40 and as high as $100 in the rest of the country.)2
It was also reported that access to the clinic was controlled by a drug ring that recruited those who were to receive the prescriptions and denied access to anyone not working for the ring.
Clearly, if the charges are true, the physicians at this clinic have a very different view of what constitutes the legitimate practice of medicine from that of physicians who seek to provide care for those patients they believe have legitimate pain and may benefit from opioids.
Few patients whom I have treated for pain and opioid abuse (these are patients who were prescribed opioids for legitimate pain complaints although in a number of cases other medications or therapies may have been more appropriate choices) have turned to heroin or have even purchased opioids from illicit sources as there was usually no need to do so.
Most of the patients referred to me who have pain and have already begun to abuse medications received opioids from physicians who felt they were prescribing them appropriately and failed to recognize the problem until it had become severe.
Other patients I have seen received opioid prescriptions from multiple sources without informing their various caregivers of this. The growing number of states that have instituted prescription monitoring programs that allow health care professionals to access what controlled substances their fellow practitioners are prescribing should have a substantial impact on this.
One major problem that makes it very difficult to make any comment about the issue of opioid abuse among patients with legitimate pain complaints is that there is very little research differentiating them from illicit users who never took opioids for any medically indicated reason. Both groups are usually lumped together. I believe that this is primarily due to the fact that most substance abuse experts don't have any experience in pain management and are unaware that these two groups might be very different with regard to what causes the abuse and what treatments are best for it.
As far as I am aware none of the currently available diagnostic systems that address drug abuse offer guidance on how to differentiate iatrogenic abuse resulting from treatment of a legitimate medical complaint from illicit use. I tried to have such a category included in both the 4th and 5th editions of the American Psychiatric Association' Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-5) but was unsuccessful.
I still believe that until we can specifically identify the problem of iatrogenic abuse we can only speculate on what it involves and any statements on it should be acknowledged as such.
1. Sontag D. Small-town toll and mother's grief reflect spread of heroin addiction. New York Times. Feb. 10, 2014.
2. Weiser B. Doctors charged in drug scheme at clinic controlled by traffickers, authorities say. New York Times. Feb. 6, 2014.