“I remember, the first pain pill they gave me, I felt really good. I actually felt very calm. I felt a sense of confidence that I never felt before. I knew it was going to be the start of something,” said a former high school football star to Soledad O’Brien on an episode of “Real Sports with Bryant Gumbel” called “Hooked” (HBO Sports), that originally aired in February of 2015.
During a routine drill, “Allieri” tore a ligament in his thumb. He went straight to the hospital, as he explained it and, following surgery, he began to take a lot of prescribed painkillers. After his doctor “cut him off,” Allieri said that he started buying painkillers “off the streets.” He had become addicted to opioids.
When feeding his addiction with painkillers became too expensive, Allieri began to use heroin. He was doing 50 to 100 bags of heroin each day at a cost of between $2 and $3 per bag. Painkillers, by comparison, would have cost about $35 for one pill. Heroin became his new passion.
The HBO Sports segment goes on to say that young, healthy athletes are the new targets for heroin dealers. They are more likely to be given opioid pills than their peers and are three times more likely to abuse them.
Dr. Andrew Kolodny, who was interviewed in the HBO segment, has views similar to those of many people who are critical of opioids, in that they want to focus the blame on the initial prescription without acknowledging that developing addiction requires more than just exposure to an opioid. It seems easy for him to blame prescription drugs for a problem like Allieri’s, and to be critical of doctors for prescribing the medication.
Drug Addiction Requires More Than a Prescription
What Kolodny doesn’t seem to understand is that opioids aren’t the real culprit, although “opioids are bad” makes for a convenient sound bite. The problem is that addiction is far too complex to be simply explained in a catchy phrase or headline.
Addiction is a genetic disease influenced by the environment. Admittedly, the problem cannot occur unless a person who is susceptible to addiction is exposed to a rewarding substance. But being introduced, and given access to a drug is only one leg of a three-legged stool. The individual also plays a role.
Kolodny implies that nearly every athlete becomes addicted when prescribed an opioid when, in fact, very few people who are exposed to an opioid ever abuse it or become addicted.
Nora Volkow, in a recent New England Journal of Medicine article, cites this statistic: about 8% of people on long-term opioid therapy develop addiction. In my estimation, that percentage is probably much lower for those who are prescribed opioids for short-term acute injuries.
Is Kolodny suggesting that all people with acute pain conditions be denied pain relief because someone may intentionally use drugs for non-medical purposes, and that will eventually lead to heroin use? Sounds like it!
Does Exposure to Opioids = Heroin Addiction? No.
Every person who chooses to use an opioid for non-medical purposes has agency — at least, initially. It’s the same as every person who drinks excessively or the person with obesity who eats compulsively. He or she has chosen a behavior that is self-destructive.
That doesn’t make the people who become addicted bad, nor does it mean they don’t have a serious disease once they become addicted. Quite the contrary: they have serious problems that deserve compassionate care. They should not be vilified any more than they should be lionized. We, as a society, tend to go to both extremes. But the truth is that people with addiction are neither villains nor heroes. They are people with a life-threatening disease.
Simply put, the fact that Allieri was prescribed painkillers was not the problem. The problem was that he used the drugs to get high. He liked the properties the opioids had beyond relieving pain.
That should be an alarm.
If exposure to opioids were all it took to get someone hooked on painkillers (and, perhaps, eventually on heroin), then to prevent all opioid addiction, we would have to ban all opioids for every person, under all circumstances, all the time. But that would leave millions in a big state of hurt.
None of us would accept that if it were our mother, our grandfather, or our child who needed the medication. We would not tolerate seeing someone we love hurting instead of being treated for pain.
There are more than 100 million surgeries per year, and almost every patient having a surgery will receive an opioid one or more times (for in-patient surgery statistics, see the CDC’s web site). Exposure to opioids is necessary for addiction to begin, but exposure by itself is insufficient for the disease of addiction to develop.
A vast majority of these Americans will never have a problem with opioids prescribed or administered for their acute pain. So should opioids never be prescribed or administered? How do we know for certain that opioids used by patients to get through surgery won’t trigger an addiction?
We don’t. Exposure to an opioid sometimes is the best option to relieve pain. Can it sometimes trigger addiction? Yes. Along with other factors, it can trigger addiction, in some cases. But, most of the time, people will take opioids to treat their pain, and they will not suffer from addiction to those opioids.
Addiction is a Complex Brain Disease
Addiction is a complex brain disease and should be treated as such.
It doesn’t do people with addiction –or society, for that matter — any good to direct all the blame to a single prescription for treating acute pain that is considered an acceptable standard of care for a vast majority of people with acute pain.
The message that “using opioids is always wrong under all circumstances,” is misguided and unhelpful. We need better information so that we can make better treatment decisions, so that we stop athletes, like Allieri, from facing decisions that will disrupt, or even destroy, his plans for leading a healthy and productive life.
Purchase my book The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us (available on Amazon) or read a free excerpt here.
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Copyright 2016, Lynn Webster, MD
Robert Brown says
April 18, 2016 at 5:06 pmBelow is where the oft quoted statistic that most heroin users start with prescription drugs come from. Note that “only” 3.6 percent of NMPR initiates end up initiating heroin use in the subsequent 5 years. In my view, this hysteria over opioids is a moral panic. And Dr. Kolodny? He has financial conflicts of interest. He is on the payroll of Phoenix House, the owners of the PROP program.* One might make the case that their political activity is rent-seeking behavior (get the government to declare a crisis, and throw over a billion dollars in business to your employer, Phoenix House). :
“Four out of five recent heroin initiates (79.5 percent) previously used NMPR whereas only 1.0 percent of recent NMPR initiates had prior use of heroin. However, the vast majority of NMPR users have not progressed to heroin use. Only 3.6 percent of NMPR initiates had initiated heroin use within the 5-year period following first NMPR use. The study contributes important new data to improve understanding of the role of prior NMPR use in initiation of heroin use in the U.S. general population.”
http://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm
*”PROP is a program of Phoenix House Foundation, Inc., a 501(c)(3) charitable organization. PROP’s education, advocacy and research are conducted without sponsorship from companies affected by those activities” (from the home page supportprop.org)