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Spokane, Washington  Est. May 19, 1883

Painkiller addiction is growing problem with serious consequences

Cynthia Billhartz Gregorian St. Louis Post-Dispatch

Nichole Marie Case unwittingly became dependent on opioid pain drugs. She’s not alone.

The National Institute on Drug Abuse estimated in 2008 that 1.85 million people in the United States were dependent on or abusing prescription opioids, also known as Schedule II painkillers.

Americans make up 4.6 percent of the world’s population, but we use 80 percent of the global supply of opioids and 99 percent of the global supply of hydrocodone.

Deaths from prescription drug overdoses have become the second-leading cause of accidental deaths nationwide, behind car accidents, and the leading cause in some states, says the U.S. Centers for Disease Control and Prevention. They now take more lives than heroin and cocaine combined.

Such statistics have lawmakers, federal agencies and health care providers taking a closer look at the way doctors prescribe Schedule II pain drugs.

Even pharmaceutical companies are taking notice.

Highland Pharmaceuticals recently introduced a technology that allows opioids to be manufactured in a solid-dose oral tablet that cannot be crushed for inhalation or extracted for injection – methods drug abusers often use to consume them.

And the Food and Drug Administration approved monthly injections of Vivitrol, a drug used to treat alcoholism, to treat addiction to heroin and Schedule II painkillers.

Case, 48, of St. Peters, Mo., began taking hydrocodone, oxymorphone and tramadol in March 2009 when bulging discs pinched a nerve in her spine, causing excruciating pain in her back and numbness in her legs.

All three are opioids, which bind to receptors in the nervous system, decreasing perception of pain while increasing tolerance to it. In drug addicts, they can produce a high similar to their sister drugs, morphine and heroin.

Case took the drugs as her doctor prescribed and didn’t experience a high.

“But I didn’t like taking them, because I couldn’t drive or do much of anything,” she says. “I think I was pretty much in a state of screwed-up most of the time.”

Eight months after her back problems began, as she started feeling better, Case abruptly stopped taking her medications without telling her doctor.

Suddenly, she says, she was in the throes of withdrawal, like heroin junkies go through on TV shows. She was nauseated, sweating profusely and her nose ran constantly.

“Man, that was like hitting a brick wall,” she says. “It felt like having the worst hangover of your life combined with the worst flu. It was miserable.”

It was a sign that she’d become physically dependent on the drugs.

The leap in prescription opioid use began about a decade ago, after state medical boards began liberalizing laws that govern the prescribing of them.

In May, Gil Kerlikowske, the new director of the Office of National Drug Control Policy, called the abuse of prescription drugs “our nation’s fastest-growing drug problem” and vowed to make it a top priority.

He began pushing for more states to adopt databases in which doctors and pharmacists can log prescriptions for addictive drugs so law enforcement can track them.

Forty-three states have passed legislation to do just that, though only 33 states have money to fund them.

In June, Washington state passed legislation requiring doctors to refer patients to pain specialists when they’ve been taking increasing doses of painkillers with no decrease in pain.

It also calls for the formation of a panel of doctors, nurses and regulators to determine caps for prescribed dosages by next June.

In February 2009, the FDA announced that it will begin requiring manufacturers of opioids to increase their efforts to educate doctors and patients about the dangers of the drugs through medication guides, patient education sheets and continuing medical education courses.

But the plan does not require physicians to receive training or take opioid-related testing before prescribing the drugs.

Pain specialists like those at A & A Pain Institute of St. Louis, where Dr. Howard Grattan practices, approach pain management more conservatively than some doctors by using a variety of nondrug treatments, including injections of steroids and numbing agents into the spine, surgery to sever problematic nerve roots, lidocaine patches and physical therapy.

Grattan also refers patients to acupuncture and counseling.

With Case, he used spinal injections, muscle relaxers, lidocaine patches, physical therapy and, finally, nucleoplasty, a minimally invasive surgery that decompressed the herniated discs.

But he also prescribed the Schedule II pain drugs, because she was in excruciating pain. He monitored her use.

“I had to give a urine sample so they could make sure I wasn’t abusing the drug,” Case says. “I was surprised how they monitored everything, which is good.”

Before prescribing opioids, Grattan has his patients sign an agreement stating that they’ll only get the drugs from him and from only one pharmacy of their choosing.

“We’ll call local pharmacies to see if they’ve been getting those prescriptions from others,” he says. “It’s a big task.”

Even though such agreements aren’t legally binding, Collier, of the DEA, says such measures are common.

“It’s a tool used by doctors to attempt to keep people using very potent narcotics under control,” he says.

Grattan weaned Case off the opioids slowly and painlessly after she told him of her withdrawal symptoms.

Today, she says, her back rarely hurts and when it does, she pops a couple of ibuprofens.

Grattan and other experts question the effectiveness of pain medications after a certain amount of time.

A 2006 study in the Department of Medicine at Michigan State University found that patients who had legitimate pain, and had become dependent on oxycodone, reported higher levels of pain at the beginning of the study and significantly less as doses of the drug were decreased and as they became abstinent.

“The body creates more pain receptors when you’ve been given pain medications for a long time, so you have to keep increasing the dose,” Grattan explains.

Michael Daly, assistant professor in pharmacy practice at St. Louis College of Pharmacy, thinks patient education is key.

Some patients’ pain becomes intractable and they need lifelong narcotic treatment, Daly says. Others have pain that’s acute at first and requires potent narcotics, but as the body heals the pain subsides.

“That’s the critical area where you can get into dependence which often precedes addiction,” he says.

“It’s important in those instances for the physician and patient to have a plan where after a set amount of time, they’re going to ratchet down the dosage and get the patient off of it.”

Daly is all for stricter legislation but thinks responsibility for preventing abuse and addiction lies equally with physicians, pharmacists and patients.

He’s struck by the number of students at the college who go on rotations in the emergency rooms and report that patients come in wanting pain medications.

“And they’re very specific about what they want,” Daly says. “They say they want Demerol and sometimes they even know what doses they want. Some may be working the system.”