Nichole Marie Case unwittingly became dependent on opioid pain drugs. SheÕs 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 worldÕs 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 even health care providers taking a closer look at the way doctors prescribe Schedule II pain drugs.
Even pharmaceutical companies are taking notice.
Last week, Highland Pharmaceuticals introduced a technology that allows opioids to be manufactured in a solid-dose oral tablets that cannot be crushed for inhalation or extracted for injection, methods drug abusers often use to consume them.
And this month, 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, oxymorphoneÊand 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 didnÕt experience a high.
ÒBut I didnÕt like taking them, because I couldnÕt drive or do much of anything,Ó she said. ÒI think I was pretty much in a state of screwed-up most of the time.Ó
Eight months after her back problems began, as she started feeling better, Case abruptly stopped taking her medications without telling her doctor.
Suddenly, she was in the throes of withdrawal, like heroin junkies go through on TV shows, she said. She was nauseated, sweating profusely and her nose ran constantly.
ÒMan, that was like hitting a brick wall,Ó she said. ÒIt felt like having the worst hangover of your life combined with the worst flu. It was miserable.Ó
It was a sign that sheÕd 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.
Rates of abuse in Missouri have increased at about the same rate as the rest of the country.
ÒAs thereÕs been more available and more people seeking it for illicit purposes, weÕve seen it grow,Ó said Scott Collier, spokesman for the St. Louis Division of the Drug Enforcement Administration. Oxycodone is the most popular drug of choice, he added.
ÒThereÕs no law that limits physicians in the amount or quantity of any drug that they prescribe,Ó Collier said. ÒThere has to be a valid doctor-patient relationship and a logical link between the patientÕs condition and the drug being prescribed.Ó
Dr. Howard L. Grattan, a pain specialist with A & A Pain Institute of St. Louis, said he believes Missouri laws are good enough and that anything stricter would be pointless.
ÒYouÕre dealing with people whoÕve gone to school for 11 to 12 years beyond high school where we learned how to treat patients and learned ethics,Ó he said.
In May, Gil Kerlikowske, the new director of the Office of National Drug Control Policy, called the abuse of prescription drugs Òour nationÕs fastest-growing drug problem,Ó 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, including Illinois, have passed legislation to do just that (though only 33 states have money to fund them). Missouri has not adopted such a law.
In June, Washington state passed legislation requiring doctors to refer patients to pain specialists when theyÕve been taking increasing doses of pain killers 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 & AÊPain 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. He also refers patients to acupuncture and counseling.
With Case, Grattan 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.
ÒI had to give a urine sample so they could make sure I wasnÕt abusing the drug,Ó Case said. ÒI was surprised how they monitored everything, which is good.Ó
Before prescribing opioids, Grattan has his patients sign an agreement stating that theyÕll only get the opioids from him and from only one pharmacy of their choosing.
ÒWeÕll call local pharmacies to see if theyÕve been getting those prescriptions from others,Ó he said. ÒItÕs a big task.Ó
Even though such agreements arenÕt legally binding, Collier, of the DEA, said such measures are common.
ÒItÕs a tool used by doctors to attempt to keep people using very potent narcotics under control,Ó he said.
Grattan weaned Case off the opioids slowly and painlessly after she told him of her withdrawal symptoms.
Today, she said, 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.
ÒThe body creates more pain receptors when youÕve been given pain medications for a long time so you have to keep increasing the dose,Ó Grattan said.
Michael Daly, assistant professor in pharmacy practice at St. Louis College of Pharmacy, thinks patient education is key.
Some patientsÕ pain becomes intractable, and they need lifelong narcotic treatment, Daly said. Others have pain thatÕs acute at first and requires potent narcotics, but as the body heals the pain subsides.
ÒThatÕs the critical area where you can get into dependence which often precedes addiction,Ó he said. ÒItÕs important in those instances for the physician and patient to have a plan where after a set amount of time, theyÕre going to ratchet down the dosage, and get the patient off of it.Ó
Daly is all for stricter legislation but thinks responsibility for preventing abuse and addiction lies equally with physicians, pharmacists and patients.
HeÕs 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.
ÒAnd theyÕre very specific about what they want,Ó Daly said. ÒThey say they want Demerol and sometimes they even know what doses they want. Some may be working the system.Ó
By Cynthia Billhartz Gregorian
St. Louis Post-Dispatch