21st Century Scourge

The CDC recently put out a paper in their Morbidity and Mortality Weekly Report (MMWR) that studied the likelihood of long term opiate use after initial treatment with an opioid medication for acute pain.  The results, for me as a regular prescriber of opioid medications, were fairly shocking.  The study randomly reviewed 10% of patient records from the Lifelink database over the time period of 2006-2015.  If a patient was given a prescription for an opioid for longer than 10 days, there was a 1 in 5 chance that patient would be a regular opiate user one year later.  That's just staggering.

Few are unaware of the opioid epidemic sweeping through America.  In 2015, 52,000 Americans died from opioid overdoses.  That's more than the number of Americans who died during the peak of the AIDS epidemic.  And this scourge has been particularly problematic in predominantly rural, working class areas.  The mortality rate for white, middle aged Americans without a college degree has gone up a half a percent every year from 1999-2015.  This precipitous drop in life expectancy amongst a demographic cohort is unprecedented in an advanced western democracy--- the only comparable decline was seen in Russian males in the immediate aftermath of the fall of the Soviet Union.   Many epidemiologists attribute much of the startling rise in death rates of white middle aged Americans to opiate overdoses.  But it's far more complex than a simple x=y formulation.

The MMWR paper identified several risk factors for long term dependency: female sex, older ages, prior pain diagnosis before opioid initiation, and patients who were either publicly insured or had no health insurance.  In addition, the risk of long term opioid addiction in patients who receive short acting narcotics like Percocet or Vicodin (the ones I usually prescribe for post operative pain) is actually fairly low.  There seems to be a cumulative dose threshold of 700 mg morphine equivalents, after which the risk of long term use rises exponentially.  More powerful narcotics, especially dilaudid and fentanyl, will narrow that safety profile window.

One of the best books I've read in the last 10 years is Johann Hari's harrowing Chasing the Scream, a historical review of the "War on Drugs".   Substance abuse has long been understood by most Americans as either a manifestation of personal weakness or of illegal drugs getting their "chemical hooks" into your brain and never letting go.  This is a faulty and wrong and harmful way of thinking about substance abuse.  This blog post is not the place to dutifully review the complexities of Hari's book but I will give one example.  In the Vietnam War, over 20% of American troops-- marooned in a chaotic, sweltering jungle for opaque reasons, facing the threat of their own mortality day after day--- were using heroin on a regular basis.  But then when returned to the United States, over 85% of those users simply stopped using the drug.  Environment matters.  A sense of purpose matters.  Personal security matters.

The theme of Hari's opus is that addiction is a function of isolation and despair.  Whether it's Vietnam or a hard scrabble existence in a broken down rural Ohio town hollowed out by factory closures and shuttered businesses, when a man or woman faces uncertainty and existential dread, some will turn to alternative forms of escape.  Some regrettably will turn to drugs in order to cloud the mind.

In America, we turned our backs on the blue collar backbone of our nation.  We weakened unions and shipped jobs overseas and embraced all the ideals of a " new globalist century".  But we never thought about what would replace the old models.  We never constructed an adequate social safety net.  We let college tuition costs skyrocket to such an extent that even state schools are out of the range for the average American.  The exponential rise in health care costs was increasingly passed on to individual Americans in the form of high deductible plans and rising premiums.  Wages stagnated.  The imbalance in wealth distribution in this, the wealthiest nation in world history, reached banana republic proportions.  We stole the opportunity to make a good living, the ability to raise a family, from the millions of "slightly above average" Americans and passed on the proceeds to a tiny sliver of the super wealthy.  We asked too much of our Heartland to forego their own dignity in order to drive the inexorable upward rise in the Dow Jones.

And so no, as a surgeon, I take no responsibility for the opiate epidemic.  I will continue to prescribe Motrin 600 and 10-15 percocets for my post operative patients to ensure they have adequate pain management after elective surgery.  The cause of the opiate epidemic is not doctors or "pain as the fifth vital sign".  The cause of the opiate epidemic is economic stagnation, collective despair and the inability (or outright disinterest) of our government to do anything about it.

To paraphrase Hari:  The treatment for addiction is not criminalization.  The treatment for addiction is love, solidarity, expanding the idea of community.  To give back to the people the notion that life is not hopeless. To re-assert that the American Dream is not just a bygone myth.....