Articles by JCS

The Quiet Epidemic

       

                                                                                                                                          

Word count: 3209

The Quiet Epidemic

A recent newspaper headline on Nov. 2, 2015, caught my eye warning that “Something Startling Is Happening to Middle-Aged White Americans.” This article reviewed a study co-authored by a 2015 Nobel Prize winner who spoke of a “lost generation” of Americans whose future is less bright than those who preceded them. Not only is their future less bright, it is more deadly.

In fact, these lost souls were “baby boomers” having mid-life crisis spurred by opioid abuse! This generation has the highest mortality rate increase over the past 15 years of any demographic group compared to non-white Americans or to middle-aged Europeans.[1]

Dr. Angus Deaton, a professor of economics at Princeton University and Senior Scientist at Gallup conducted the research with his wife, Anne Case, PhD, also professor of Economics and Public Affairs at Princeton. He was recently awarded the 2015 Nobel Prize in Economics.

Their paper, “Rising Morbidity And Mortality In Midlife Among White Non-Hispanic Americans In The 21st Century,” documents a shocking trend of drugs, despair, alcohol and suicide that unexpectedly has killed half a million middle-aged white Americans, an overlooked “quiet epidemicwith deaths comparable to the number of Americans who unnecessarily died of AIDS.

This trend marked an increase in the all-cause mortality of middle-aged white men and women in the United States between 1999 and 2013. This change reversed decades of progress in declining rates of mortality and was unique to the United States; no other advanced country saw a similar increase.

Screen Shot 2015-11-05 at 7.53.11 PMThese two Princeton researchers analyzed health and mortality data from the Centers for Disease Control and Prevention and concluded that rising annual death rate among this American baby boomer group is driven not by the customary killers like heart disease and diabetes, but by a “quiet epidemic” of afflictions stemming from the economic recession, depression, substance abuse leading to alcoholic liver disease, and suicides attributed to overdoses of heroin and prescription opioids.

“That could be just a volatile mix that could set off something like this,” says Deaton, who mentions, “After the productivity slowdown in the early 1970s, and with widening income inequality, many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents.[2]

The Deaton-Case study suggests 488,500 deaths would have been avoided in the period 1999 2013. “Only HIV/AIDS in contemporary times has done anything like this,” according to Dr. Deaton.

“Pretty quickly we started falling off our chairs because of what we found…you look around the room and peoples’ mouths are just hanging open,” says Deaton. He then offered this understatement: “We need to think hard about controlling the prescriptions of opioid painkillers.” [3]

Indeed, it’s hard to control opioids when the standard medical treatment for many conditions of the musculoskeletal system are treated indiscriminately with opiates; consequently we now have a public dependent upon opiates for pain control as well as creating a segment of patients who became addicted and now abuse opioids.

To remind you of the enormity of this Hillbilly Heroin epidemic, a 2014 study, “Opioid Painkiller Prescribing,[4] by the CDC found MDs prescribed 259 million prescriptions for opioids, equivalent to one for every American adult. Each day, 46 people die from prescription painkillers in the U.S.[5]

In 2012, there were 41,502 deaths due to drug poisoning in the United States, of which 16,007 involved opioid analgesics and 5,925 involved heroin.[6]

As well, 22 vets commit suicide daily in this country, many of who undoubtedly suffer from chronic back pain, depression, neglect and unemployment—all the contributing factors of this “quiet epidemic.” Chiropractors could help many of these suffering warriors if the VA was not so intransigent despite being legally included in the VA system, patients must jump through hoops and often wait months before chiropractic care is approved. 

Other researchers admit the abuse of opioid painkillers also has become a gateway to heroin. More than half of those who use heroin were addicted to prescription opioid painkillers and more than 90% of heroin users also use at least one other drug.

This increasing mortality was in conjunction with increasing reports of pain.  One in three white middle-aged Americans reported chronic joint pain, taking the years 2011, 2012 and 2013 together, and one in seven reported sciatica. Social Security Administration records also show increased disability associated with musculoskeletal problems and mental health issues.[7]

“With regards to the increase in mental illness, I think it is part and parcel of all of this bad stuff going on,” Dr. Deaton said. “But if people are drinking and drugging too much, or thinking about killing themselves, it is not so surprising they will report rising mental illness.”

Compelling evidence has been available for sometime suggesting that the epidemic of back pain is the #1 disabling condition in the nation, military, workplace, and world. Back pain is the leading indication for opioids and now appears to be also the leading cause of suicides due to opioid poisoning.

Opioids for Kids and Teens, Too

While we hear the growing calls for opioid reform from scientists like Deaton, recently President Obama also announced reducing prescription drug and heroin abuse by allocating additional funding to states with prescription drug monitoring programs (PDMPs), and expanding and improving treatment for addicts.

On the other hand, little has been said or done by the AMA, Big Pharma or the Federal Drug Administration to contain this deadly epidemic of opioids. Certainly economics trump concern for patient safety by the medical-pharmaceutical industry to change tracks. Prescription painkillers for back pain brought in $17.8 billion and opioids alone made $3 billion in 2010.[8] Undoubtedly in 2015 it’s much more.

Making opioid access even more available, inexplicably the FDA recently approved OxyContin for kids. Just as neighborhood drug dealers get kids hooked on drugs at an early age, now we see the same with problem with the FDA! If the present baby boomer generation is lost in mid-life from opioid poisoning, imagine what their kids and grandkids will experience after growing up on opioids.

“While some kids are in awful, terminal pain, and can clearly benefit from it,” Deaton said, “the scope for abuse is there, especially if pharmaceutical companies misbehave, as they have done in the past.”

Sports Illustrated (June 22, 2015) revealed this problem of adolescent opioid abuse in an exposé, “Smack Epidemic,” concerning the sordid situation in high school sports where opioids are killing young athletes.

“Anyone who is giving a kid an opioid prescription without serious oversight and supervision is out of their mind,” says Joe Schrank, a New York City–based drug counselor and former USC offensive lineman. “That stuff is like kryptonite.”[9]

Once the “kryptonite” source ends, these kids turn to the street for cheaper heroin. The SI writers report while opioid painkillers cost up to $30 per pill on the black market, heroin cost $5 a bag and gives a more potent high.

Jack Riley, the DEA’s chief of operations, recognized that high school athletes were becoming “unwitting customers of the cartels,” which target people susceptible to prescription-drug abuse. “In the athletic arena, if anything can be likened to a weapon of mass destruction, it’s heroin,” Riley says. “It is that pervasive now.[10]

Heroin use among adults 18 to 25 has more than doubled in the past decade and the number of overdose deaths quadrupled between 2002 and 2013, according to the Centers for Disease Control and Prevention.[11] More than 8,200 people—one in every 50 addicts—died in 2013.

Not only are opiates pervasive in our society, a new discovery will soon make it easier to obtain by manufacturing it yourself. UC Berkeley bioengineer John Dueber and a team of scientists discovered the final step in modifying common yeast cells to manufacture opiates.[12]

This discovery could have a huge payoff because it’s not just a cheaper, purer source of medical morphine, but also has potential anti-cancer properties. The downside could be just as significant — potentially spawning an industry of DIY (do it yourself) enthusiasts who, instead of brewing beer, are making heroin.

Devious Drug Marketing

Thomas Frieden, MD, director of the Centers for Disease Control (CDC), admitted in 2011 that physicians had essentially supplanted street corner drug pushers as the most important suppliers of illicit narcotics.[13] Ironically, by using an MD instead of a pusher, this deal is perfectly legal and paid by insurance.

Although the Princeton research team mentioned the increased availability of opioids in the late ’90s as a potential cause, they failed to point out the devious method Big Pharma used to con prudent MDs into becoming drug pushers.

Twenty years ago Big Pharma and its well-paid “thought-leaders” like Drs. Russell Portenoy, a New York City pain specialist, and Kathleen Foley chided wary MDs who resisted the use of opioids for chronic pain cases, accusing them as suffering from “opioid-phobia.”

In 1986, these two doctors with vested economic interests published a paper, Chronic use of opioid analgesics in non-malignant pain: report of 38 cases,”[14] allegedly to determine the indications, course, safety and efficacy of opioid therapy and found no problems:

“We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.”

Dr. Portenoy claimed that the risk of addiction to opioids use to treat chronic pain was less than 1%; this figure was based on virtually no scientific evidence according to The Wall Street Journal.[15] That paper “opened the door to much broader prescribing of the drugs for more common complaints such as nerve or back pain.”

Dr. Portenoy and other pain doctors who promoted the drugs now admit they overstated the drugs’ benefits and glossed over the risks. Dr. Portenoy said in an interview with WSJ, “Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I did. We didn’t know then what we know now.”

 “I gave innumerable lectures in the late 1980s and ’90s about addiction that weren’t true,” Dr. Portenoy said in a 2010 videotaped interview with a fellow doctor. Dr. Portenoy said it was “quite scary” to think how the growth in opioid prescribing driven by people like him had contributed to soaring rates of addiction and overdose deaths.[16]

He was also paid handsomely for his misinformation. The WSJ revealed Dr. Portenoy has “disclosed relationships with more than a dozen companies, most of which produce opioid painkillers.” Dr Portenoy curiously denied that these financial relationships biased any of his lectures or publications despite the common knowledge of pervasive medical payola by Big Pharma to bribe researchers and physicians.

The consensus now confirms there is little, if any, evidence that opioids provide safe and effective treatment for chronic non-cancer pain, and that side effects such as opioid-induced hyperalgesia and narcotic bowel syndrome can complicate long-term treatment.

Medical Train Wreck

The Deaton-Case paper can easily make the case that Big Pharma’s attempt to expand the market for these heroin-like drugs has become a national disaster with very few positive features (except for post-surgical or intractable cancer patients) although it has been a bonanza for drug manufacturers.

Today, Big Pharma’s quest to cash in on opioids has become a national nightmare on small towns across America. While Big Pharma and Big Medicine are making billions, local communities are left to pay the bills for prosecution, incarceration, and hospitalization of these drug addicts.

Moreover, millions of families are left destroyed as President Obama said at a panel discussion on opioid drug abuse. "This crisis is taking lives; it's destroying families and shattering communities all across the country. That's the thing about substance abuse; it doesn't discriminate. It touches everybody."

Complicit with Big Pharma in this opioid pandemic are thousands of “pain management” clinics, spine interventionalists, primary care physicians, and pharmacists who all knowingly dispense opioids instead of referring patients for non-drug treatments, primarily chiropractic spinal manipulation for neck and back pain.

Doctors of chiropractic have seen this “quiet epidemic” for years in a typical scenario: the patient suffers a severe neck or back attack, goes to pain management clinics or family PCP where they are prescribed opioid painkillers like Halloween candy. When the drugs fail to correct the underlying mechanical spinal problem, the acute flare-up becomes a chronic pain problem.

Then the patient begins the inevitable medical railroad ride to stronger drugs, epidural shots, MRIs detecting “incidentalomas,” all leading to the final destination of spine surgery based on the debunked ‘bad disc’ diagnosis, chiropractic is rarely recommended by MDs as the published guidelines recommend.

Within two weeks the patient may become addicted to the opioids, their pain and hopelessness increases, and ultimately falling prey to the surgeon’s knife for a quick-fix that rarely happens.

With only a 24 percent chance of recovery for disc fusion [17], little does the unsuspecting patient realize there is a 76 percent chance of permanent disability and continued unemployment. Of course, allthewhile the patient’s psychology worsens, drug dependency increases often with alcohol consumption. Sooner or later, this is the “volatile mix that could set off something” as Dr. Deaton mentioned.

And this sad situation began because the patient was not referred to a chiropractor first for non-drug treatments for their MSDs. In this era of evidence-based healthcare, data from insurance payors show the most efficient spine treatment destination typically begins with a patient consulting a chiropractor first as the Optum study [18] concluded:

This path tends to lead to interventions that are more closely aligned with recommended treatment guidelines and ultimately more favorable solutions at more reasonable costs.

        In fact, the Optum study certainly was not the first guideline to recommend chiropractic care initially as we saw over twenty years ago with the 1993 Manga Study and the 1994 AHCPR guideline #14 on acute low back pain in adults. The biggest problem is the chirophobic MD who ignores these evidence-based guidelines that recommend conservative care before medical spine care, dubbed the “poster child of inefficient care” by the editor of a leading international spine newsletter.[19]

 

 

 

Who’s Responsible?

In 1936 the propaganda movie, Reefer Madness, was produced to scare people about smoking weed. Perhaps today the government should produce a similar cautionary tale about this “opioid madness” brought to Americans by medical men they trust.

Although smoking pot may be deleterious to your lungs, unlike opioids, it has not killed nearly a half-million users. Nonetheless, opioid madness is a huge problem that doesn’t have a good solution in sight.

This opioid situation scenario sounds painfully similar to the oil rig accident in 2010 off the Gulf Coast when crude oil polluted our coastlines and British Petroleum was forced to pay billions to repair the mess to the environment and local economy.

It is also painfully similar to Big Tobacco poisoning smokers. As you know, this led to lawsuits by consumers and government agencies to pay for the expenses caused by tobacco-related illness. It also led to regulations to ban advertisements for tobacco products, especially the “Joe Camel” iconic figure aimed at teenagers.

This begs the question: why hasn’t the federal government fined the AMA and Big Pharma for financial restitution to combat the very Hillbilly Heroin epidemic they created and have profited by so dearly?

Okay, stop laughing because we know every legislator on Capitol Hill is in the pockets of Big Pharma. According to author and TIME columnist, Steven Brill, the medical-industrial complex spends four times as much on lobbying as the No. 2 Beltway spender, the much feared military-industrial complex.[20] Certainly these medical special interests have persuaded Congress to look the other way instead of placing blame where it is due at Big Pharma and its medical pushers.

Perhaps a grass roots movement by the chiropractic profession or the F4CP should make this an PR issue and have every DC and their patients call their Congressman and Senators and ask why has Big Pharma and the AMA wreaked havoc and gotten away with it?

Final Verdict

I wish there were a happy ending to this opioid tragedy, but I have no reason to mislead you. Only a few MDs have sporadically been prosecuted for egregious criminal behavior. On occasion Big Pharma has been sued such as the case of Purdue Pharmaceuticals in a civil lawsuit with the state of Kentucky concerning the Hillbilly Heroin epidemic caused by the injudicious use and consequences of OxyContin.[21]

But overall, opioids give patients an outrageous inebriation that is perfectly legal, too many Americans like the quick-fix to mask pain these painkillers offer, and too many physicians are happy to accommodate them just to keep them out of the chiropractors’ offices.

An interesting article,Opioid Prescribing: Navigating the Ethical Battlefield,”[22] discusses the concerns regarding opioid overdose, misuse, and abuse, laws and guidelines regulating the prescribing of painkillers to patients.

 “Whether we are speaking in clinical, moral, ethical, or legal terms, the fundamental question remains: What is best for my patient?” said Stephen J. Ziegler, PhD, JD, associate professor in the Department of Public Policy at Indiana State University.

Jennifer Bolen, JD, is a former US District Attorney and expert on medico-legal issues related to pain management. “In many ways it comes down to how well equipped the physician is to perform patient assessment and screening for abuse; how well the physician understands and how easily the physician can access integrated care, including behavioral health support; and how much of the physician's focus is money oriented vs. patient centered.”

She hit the nail on the head with her last comment whether the “focus is money oriented vs. patient centered.” This was the case in a recent trial in Los Angeles. Prescribers of narcotics are faced with more than just ethical dilemmas when making the decision to treat a patient with opiates; they are also being challenged on the legal front.

In October, 2015, a Los Angeles-area doctor was convicted of murder in a landmark case for killing three patients who overdosed on what a prosecutor called "crazy, outrageous amounts" of painkillers she prescribed.

In the Associated Press article, the second-degree murder convictions of Dr. Hsiu-Ying "Lisa" Tseng were the first against a U.S. doctor for recklessly prescribing drugs. "You can't hide behind a white lab coat and commit crimes," said Deputy District Attorney John Niedermann who told jurors Tseng repeatedly ignored warning signs even after several patients died as she built a new medical clinic and earning $5 million in a three-year period.[23]

Defense lawyer Tracy Green said, "I don't think it bodes well for doctors in America."

Apparently if medical ethics, industry regulation, and federal legislation cannot stop this prescription drug abuse, the only other way to stop this opioid epidemic is via the courts. Perhaps the possibility of jail time will give pause to MDs who ignore the guidelines and refuse to refer to DCs, preferring instead to fuel the opioid addiction epidemic that has led to this “quiet epidemic” of deaths among mid-life Americans.

But, like driving 55 MPH on the highway, such law-abiding on opioids will only occur when there’s a cop in sight. Currently there are too many MDs, too few cops, too much money, too few ethics and too much greed to do the right thing.

 



[1] Tristan Gerrard, Death Rates Rise for Middle-Aged Whites, The Herald, Nov. 2, 2015

[3] Tristan Gerrard, Death Rates Rise for Middle-Aged Whites, The Herald, Nov. 2, 2015

[4] National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, www.cdc.gov/vitalsigns/, July 2014.

[6] Margaret Warner, Ph.D., Division of Vital Statistics; and Holly Hedegaard, M.D., M.S.P.H., and Li-Hui Chen, M.S., Ph.D., Trends in Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 1999–2012 by Office of Analysis and Epidemiology. CDC 2014

[7] Tristan Gerrard, Death Rates Rise for Middle-Aged Whites, The Herald, Nov. 2, 2015

[8] Rafia S. Rasu, BPharm, MPharm, MBA, PhD; Kiengkham Vouthy, PharmD; Ashley N. Crowl, PharmD; Anne E. Stegeman, PharmD; Bithia Fikru, PharmD, MPA; Walter Agbor Bawa, MS, PharmD; and Maureen E. Knell, PharmD, BCACP, “Cost of Pain Medication to Treat Adult Patients with Nonmalignant Chronic Pain in the United States,” Vol. 20, No. 9 September 2014 JMCP Journal of Managed Care & Specialty Pharmacy

[9] L. Jon Wertheim and Ken Rodriguez, “Smack Epidemic,” Sports Illustrated, June 22, 2015.

[10] L. Jon Wertheim and Ken Rodriguez, “Smack Epidemic,” Sports Illustrated, June 22, 2015.

[11] Today’s Heroin Epidemic, CDC, www.cdc.gov/vitalsigns/heroin

[12] William C DeLoache, et al., An enzyme-coupled biosensor enables (S)-reticuline production in yeast from glucose, Nature Chemical Biology 11, 465–471 (2015) doi:10.1038/nchembio.1816

[13] Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008; 2011: www.cdc.gov/media/releases/2011/t1101_presecription_pain_relievers.html.

[14] Portenoy RK, Foley KM, “Chronic use of opioid analgesics in non-malignant pain: report of 38 cases,” Pain. 1986 May;25(2):171-86

[15] Thomas Catan and Evan Perez, A Pain-Drug Champion Has Second Thoughts, WSJ, Dec. 17, 2012

[17] Anderson, Joshua T. BS; Haas, Arnold R. BS, BA; Percy, Rick PhD; Woods, Stephen T. MD; Ahn, Uri M. MD; Ahn, Nicholas U. MD, Single-Level Lumbar Fusion for Degenerative Disc Disease Is Associated With Worse Outcomes Compared With Fusion for Spondylolisthesis in a Workers' Compensation Setting, Spine: 01 March 2015 - Volume 40 - Issue 5 - p 323–331

[18] Optum. Conservative Care: Ensuring the Right Provider for the Right Treatment, 2012, pp. 6.

[19] The BACKPage editorial vol. 27, No. 11, November 2012.

[20] Steven Brill, What I Learned From My $190,000 Surgery, TIME, Jan. 8, 2015

[21] “Drug Maker Warns That OxyContin Suit Could Be 'Crippling'” By David Armstrong, Bloomberg News, Oct 20, 2014

[22] Opioid Prescribing: Navigating the Ethical Battlefield, MPR, September 11, 2015

[23] Brian Melley, California doctor convicted in overdose deaths of 3 patients, AP, October 30, 2015


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