BY SABINA REBIS, M.D. AND JOSEPH P. SHAW
Most know the game of “Telephone:” Children sit in a circle, one whispers a phrase into another’s ear, then that person whispers it to the next, and so on. The phrase travels around the circle, a hand cupped over one ear at a time.
Then the phrase returns to the first child, who usually disintegrates into giggles at the nonsense of a recycled sentence mangled by misinterpretation.
But what happens when that game of “Telephone” becomes metaphorical — in the context of marketing and medicine?
America’s most recent public health crisis — the 20-plus-year opioid epidemic — arguably began with a seemingly benign five-sentence letter published in a prestigious medical journal in 1980. The writers concluded: “Despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”
It was a small spark that started an inferno.
Local medical professionals acknowledge that today’s opioid crisis is rooted in choices made a decade or more ago, often with a patient’s best interests in mind, but with faulty information about how addictive painkillers can be. Not surprisingly, money was another root cause, with choices driven by changes in the way doctors and hospitals were reimbursed by insurers.
The result was an unintended consequence, but a devastating one: Addictive opioids were made widely available by doctors, sowing the seeds of the current crisis.
“Early on, I remember doctors and nurses saying, ‘We don’t want to give this stuff to people; they’re going to get hooked.’ But the newer drugs supposedly were not addictive in the same way,” said Robert Chaloner, who has been a hospital administrator for 35 years, currently at Stony Brook Southampton Hospital. “As an industry, it was, like, ‘What’s the harm? Give them the stuff. Because the stuff isn’t really that bad — this is the new thing. We’re not giving them morphine.’ ”
Today, Mr. Chaloner sees the fallout in his own East End community — young and old, locals and celebrities, rich and poor. “It’s everywhere,” he said. “I mean, it’s to the point where I never used to think to worry about it. But I find myself telling my kids over and over again, ‘Don’t touch this stuff. Don’t touch this stuff.’
“Everybody is susceptible to it,” he added. “I really believe that. It’s every spectrum of society right now.”
A Breakdown In The System
The letter in the medical journal spawned a series of subsequent scholarly articles that cited its conclusions and expanded them to argue that patients are “literally at no risk for addiction,” that “properly administered opioid therapy rarely if ever results in ‘accidental addiction’ or ‘opioid abuse’ ” and that “medical opioid addiction is very rare.”
In June 2017, The New England Journal of Medicine published another letter, from a group of four doctors in Toronto. They reported that subsequent research had cited the 1980 letter 608 times, often using its conclusions “heavily and uncritically” to sell the idea that opioids were generally non-addictive.
More startlingly, the researchers wrote, there was a “sizable increase” in the number of citations after the 1996 introduction of OxyContin — a long-acting opioid that, a little more than a decade later, would be the subject of federal criminal charges, with its makers admitting to misleading the medical community and patients about how addictive it is.
The Canadian doctors concluded that the short 1980 letter, and its subsequent citations, “contributed to the North American opioid crisis by helping to shape a narrative that allayed prescribers’ concerns about the risk of addiction associated with long-term opioid therapy.”
On Manhattan’s Upper East Side, a 31-year-old doctor named Russell Portenoy, based at Memorial Sloan Kettering, witnessed the agony of cancer patients — and the improvement in their quality of life when pain was closely controlled. He extrapolated that those with other types of chronic pain might also benefit.
Studies were done in 1986 on 38 subjects. Only two of the subjects had difficulty with medication management, both of whom also had a problem with prior drug addiction. What followed was a case of opportunism. Like ransom letters, sentences from scientific publications were chopped up, glued together and contorted into mass marketing campaigns by pharmaceutical companies peddling pain medications.
“It is a very well-known fact that patients with advanced cancer have significant pain,” said Dr. Natalie Moryl, an internist who specializes in treating pain in terminal patients and who oversees the palliative care unit at Memorial Sloan Kettering.
“Appropriate pain management is really, really important for the terminal patient’s quality of life. In the cancer community, we use opioids for somatic pain and neuropathic pain, and they work well,” Dr. Moryl said.
But pain in a general sense is highly individual. The brain’s interpretation of pain is illusive: Although pain is clearly the result of stimuli of nerve fibers in the body, due to trauma or damage to tissue, it differs in its interpretation based on each patient’s unpleasant emotional experiences, coping styles and genetic makeup.
Opioids block the pain pathway to specific brain regions and activate the reward system — flooding the circuit with dopamine, which brings on feelings of pleasure. The overstimulation of this system is habit-forming. Dopamine imprints this stimulation in memory and teaches the patient to do something again and again without thinking about it.
Pain relief via euphoria was not the goal of the pain management movement at first. “Clearly, there was a breakdown in the system,” Dr. Moryl said. “Physicians tried to apply the same principles of pain management to patients with non-cancer-related pain.”
The ‘Pain-Free Patient’
When it comes to healing, doctors often face pressure for a quick fix: “You’re a doctor — do something!” But for the longest time, Mr. Chaloner noted, pain management was not the same as pain elimination.
“Historically, pain was always seen as just something that happens as part of the healing process,” he said. “The notion [was] that you just have to kind of see your way through it.”
But 15 years ago, he said, a sea change occurred: “Suddenly, for whatever reason, the notion was that … people don’t need to be suffering.”
The change was driven, not surprisingly, by financial considerations.
Health care facilities began administering a survey, Hospital Consumer Assessment of Healthcare Providers and Systems, to measure patients’ evaluations of the care they received. At a time when “value-based” health care was seen as a way to improve quality, the patient survey results were connected to reimbursements that hospitals and doctors received.
Mr. Chaloner noted one question that was included on the survey: “Did the staff adequately address your pain?”
“We were rating people’s pain,” he said — the survey used the familiar smiley faces to simplify the ratings system, and hospitals were often penalized financially if a patient chose anything but “most satisfied.”
At the same time, OxyContin — a slow-release form of the opioid oxycodone — came on the market, claiming (falsely, it turned out) to be an effective opioid pain reliever that carried virtually no risk of addiction. The aforementioned studies at the time were suggesting that the risk of opioid addiction was widely overblown.
The result, Mr. Chaloner acknowledged, was that medical professionals began “very liberally prescribing” pain medication, both in the hospital and upon discharge. “Someone would go home with a hundred oxycodone,” he said. “At the end of that bottle, they’re hooked.”
“For the providers, it wasn’t malicious,” Mr. Chaloner added.
That era of the “pain-free patient” can be traced to the last decade of the 20th century. By comparison, the Core Principles of Pain Management, stated by the American Pain Society in the mid-1990s were almost militaristic in their doctrine.
But in 1999, the society drafted a new statement: Patients had the right to management of pain and “the patient’s self-report of pain was the single most reliable indicator of pain” and physicians needed “to accept and respect this self-report, absent clear reasons for doubt.”
A Fifth Vital Sign
Dr. Daniel Van Arsdale, director of both palliative care and the family medicine program at Stony Brook Southampton Hospital, recalls the time when “you gave stronger and stronger pain medication to get patients out of pain.”
Doctors were writing the prescriptions “very freely,” said Dr. Shawn Cannon, an internist in Amagansett who specializes in treating opioid addiction. “Vicodin, or hydrocodone, was a lesser controlled substance at that point … The Vicodin was flying like candy, because it did not need, necessarily, a physician’s signature.”
Coincidentally or not, in 1996 Purdue Pharma developed OxyContin. “The push in education at that point was fewer pills in the community,” Dr. Cannon said. “So we thought we were doing something good — because now instead of giving 240 pills a month, you gave 60, so that, theoretically, put fewer pills in the community. It’s not what happened.”
According to a study published in 2009 by Dr. Art Van Zee, between 1996 and 2001, pharmaceutical companies conducted all-expenses-paid conferences at resorts, recruiting health care professionals to train as national speakers to promote their products. Compiling prescriber profiles based on prescriber habits, drug reps targeted these doctors with stuffed toys, hats and dinners.
Purdue Pharma, the maker of OxyContin, paid more than $40 million in incentive bonuses to drug representatives who increased sales.
The company also started a coupon program (“Get in the Swing With OxyContin”) that provided patients with a free limited-time prescription for a seven- to 30-day supply. A total of 34,000 coupons were redeemed by 2001.
Financially, it paid off: The heir to the Purdue empire just purchased a $22 million mansion. But for patients and doctors, it backfired. Opioids will likely kill more than 50,000 Americans this year.
Part of the fallout was that the pain control movement failed to distinguish pain from human suffering.
Trainees were taught not to question a patient’s subjective idea of pain; at the same time, addressing mental health or addiction openly was not the norm either.
“In the 1990s, there was more reported chronic pain,” said Dr. Richard Rosenthal, a psychiatrist and addiction specialist at Stony Brook University Hospital, citing factors including musculoskeletal problems resulting from increasing rates of obesity and the growth of the aging population. This was coupled with a buildup in expectations for pain relief — due at least partially to effective marketing.
Societal factors like poverty and substandard living and working conditions also led to a generalized sense of what was perceived as “pain.” This is reflected in the statistics: “Regions with the lowest levels of social capital have the highest opioid overdose rates,” Dr. Rosenthal noted.
The unspoken truth was that pain pills silently doubled as happy pills — a deceiving solution to the ache of life.
“The thing that completely got missed, unfortunately, is that more than 10 percent of the U.S. population has some kind of addiction,” Dr. Moryl said. “This had been invisible for a long, long time.”
There is still a stigma in talking about mental health. In retrospect, those pointing to a frown on the chart of facial expressions before their first opioid prescription may have been seeking help — but didn’t know for what.
Pushed To The Streets
Prescription monitoring programs mandated by most states have made it harder to obtain legal prescriptions for opioids, pushing many opioid abusers to seek treatment. But others find themselves in the grip of addiction — and seeking relief on the streets.
“I don’t believe any legitimate doctors are giving out the prescriptions the way they used to,” Mr. Chaloner said.
He noted that doctors and hospitals now use I-STOP, an internet-based prescription monitoring program that provides a database of pain medication requests by patients, to identify those who might be feeding an addiction by “doctor-shopping,” or visiting various providers to try and obtain a prescription by pleading, cajoling or threats.
“Probably in the last 12 years or so is when you started to see it,” Mr. Chaloner said. “All of a sudden, you hear doctors and nurses saying, ‘They’re a pain medicine seeker. They’re a drug seeker.’ You see it all the time. You hear it all the time.”
Those who can’t afford treatment or can’t afford to buy opioids on the street with the new regulations in place are turning to heroin and other synthetic opioids. According to Dr. Rosenthal, fentanyl, a powerful synthetic, is even cheaper to manufacture than heroin. And because fentanyl is used as a filler in the illegal drug, by default, heroin is now cheaper, too.
“It has become much easier to get hold of heroin,” he said. “A pure gram, which was $3,200 in 1981, went down to less than $500 in 2013.”
But these man-made street drugs have deadly consequences. “People are going after fentanyl because they hear it’s so powerful. A lot of people don’t know what they’re taking, which is why you end up with so many fatal overdoses,” Dr. Rosenthal said.
It is these street combinations that have led to the increase in overdoses, which in New York State are responsible for more than 80 percent of overdose fatalities, according to Dr. Rosenthal.
Meanwhile, insurance coverage is shortsighted. “We’re using data right now from 1958 alcoholism studies,” says Dr. Cannon. “We don’t have enough studies on heroin — they’re ongoing.”
The maximum amount of coverage insurance companies will agree to for a substance abuse disorder is 30 days of inpatient rehabilitation, but both Dr. Cannon and Dr. Rosenthal agree that recovery is really a six-month process at a minimum.
“We fight for treatment for people,” Mr. Chaloner said. “If you’re an addict and you’re not really too organized in your thinking anyway — all your focus is on drugs — fighting a managed care company to get 30 days of treatment is not going to happen. So people just keep spiraling down. It’s just horrible.”
He said understanding and recognizing addiction, and its symptoms, should become as ubiquitous as knowing the five signs of a stroke.
“We have a tendency to demonize — it’s a disease, it really is,” Mr. Chaloner said. “Some people are more inclined to become addicted. And then once they are, you’ve got to treat them like they’re sick. I don’t think jailing addicts is the way to go.”
According to Dr. Cannon, it’s not just a medical disease. “This is a very complex disease,” he said, “and if we want to be successful, we have to make sure the patients are engaged in their treatment and doing the work, not just showing up in an office visit and, here is a prescription, go get it filled.”
Although maintenance medication like buprenorphine, mostly known as Suboxone, can be key to treatment, it’s not really as simple as popping a pill. “It would benefit every public health department in every county of New York to have people trained in addiction,” Dr. Van Arsdale maintains.
“As a medication, buprenorphine is a lifesaver,” states Dr. Rosenthal. “If used alone, it is a pretty safe medication.”
The problem surfaces when it ends up misused. “If mixed with alcohol or benzodiazepines [anti-anxiety medication], you may get enough of an additive effect to make a serious respiratory depression,” he said.
With caution thrown to the wind, history has a nasty habit of repeating itself, Dr. Cannon said: “We’re going to end up with the same problem we did with opiates — people are going to be taking them like candy.”
Sabina Rebis, M.D. is a family medicine physician. She writes on health and wellness for regional and national publications. Joseph P. Shaw is executive editor of The Press News Group. Stony Brook University interns Dorothy Mai and Elizabeth Pulver contributed research to this story.