The prescription opioid epidemic that began in the mid-1990s, and that continues today, has spawned a new and very serious heroin epidemic. Forty years ago the typical American heroin addict was a young, poor, urban, minority male with a criminal record. Today’s heroin addicts are demographically and geographically very different. They are young to middle age, white, often female, and residents of urban suburbs, small cities, towns, and rural areas. Many, but by no means all, are poor. What they have in common is an addiction to opioids—a potentially lifelong, and fatal, health problem. Few of these newer opioid addicts use only opioids; most also have problems with alcohol and other drugs.
Many, perhaps most, of these patients come to addiction after they are prescribed an opioid for pain, with escalating doses. Many of the prescribing physicians clearly wanted to help their patients deal with pain. For more than a decade, increasing the dose of opioids has been considered reasonable medical practice in good pain management.
Concurrently, for more than a decade, a small number of unscrupulous physicians have prescribed quantities of opioids in storefronts or clinics now recognized as “pill mills,” in which they saw a steady stream of patients for whom they wrote prescriptions after asking few questions, kept few records, and required no follow-up. These patients originally may have become addicted when treated for pain, or they may have been drug-seeking all along, looking for a high when they first passed through the door. The patients who frequented the pill mills were not really patients; they were the doctors’ customers, and they got what they paid for, until they no longer could afford it. Now the pill mills are being closed by a crackdown by the federal Drug Enforcement Administration (DEA), and the pill mills have left their customers addicted and desperate.
For both types of people, the pain patients and the pill mill customers, a new option has entered the scene. Mexican black tar heroin now is a cheap alternative to prescribed opioids, no longer marketed by shady dealers in dark alleys and dangerous parts of inner cities, but through a system that has been likened to a pizza delivery—just an easy cell phone call away.
How can the caring physician navigate this minefield? How can real pain be adequately treated, how can dependence on pain medication be handled? What are the signs of drug-seeking and dishonesty? Some patients who had no intention of becoming dependent find they like the feelings produced by prescribed opioids, feelings that have nothing to do with the relief of physical pain. They escalate their doses of opioids to high levels. They often have prior histories of alcohol or drug abuse. At some point they may recognize that their opioid use is excessive and that their physicians would be concerned about their opioid use if they told the truth. These “good” patients then begin to lie to their physicians about their opioid use and usually about their alcohol and other drug use. If their physicians become reluctant to prescribe, these patients may find other physicians who will. Or, they may reach the point where they turn to heroin, which is readily available and cheap. In general, opioid pain patients who become heroin addicts do not exercise the option of honest discussion with their physician and the option of addiction treatment.
How can physicians prescribing opioids identify patients who are drug addicts? While there are important clues, the simple answer is that physicians cannot reliably make this distinction—at least not all the time. Patients who are at higher risk for problems and require more attention include any patient with a history of alcohol or drug abuse, one who requires very high doses of controlled substances for long periods of time, and one who shows signs of intoxication or other cognitive deficits. Asking all patients about all of their drug and alcohol use, especially those receiving high doses of controlled substances, is wise. It is also often useful to drug test patients for both alcohol and other drugs. Finally, it can also be useful to speak with family members about the patient’s use of the medicine and the use of alcohol and other drugs. Does the family see the patient as being intoxicated and dependent of the medication beyond a reasonable alleviation of pain? These methods often are useful in distinguishing between dependence on an opioid for pain management and addiction, as defined in the DSM-V as a substance use disorder (SUD).
The two fundamental characteristics of an SUD are continued drug use, despite multiple serious problems caused by the drug use, and dishonesty. If these characteristics are present, treatment for SUD may be indicated, preferably including long-term participation in the 12-Step fellowships of Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The physician–patient relationship should be maintained during treatment and after completion. Controlled substances should no longer be prescribed. Physicians should encourage and support recovery—abstinence from the use of alcohol and other drugs.
For patients in pain who are physically dependent, the treatment in the absence of addiction may be gradual dose reduction and alternative measures to treat pain such as physical therapy. However, pain is not trivial; patients who are clearly suffering from true pain need to be treated respectfully with good pain management practices including opioids. Dependence on opioids is not in and of itself a bad thing.
Every patient for whom controlled substances, particularly opioids, are prescribed at substantial doses over long periods of time should be evaluated for addiction. Over-confidence by physicians in being able to distinguish the patient-addict from the patient who is physically dependent is not just arrogance but it puts patients at risk.