It strikes me that calling trends in opiate dependency and polypharmacy overdose deaths an “opiate epidemic” is a misnomer, akin to calling the Industrial Revolution an epidemic. While the term may effectively rivet pubic attention on the problem, characterizing the drug dependency and overdose crisis an “epidemic” undermines a deeper public understanding of it.

An epidemic is often sparked by a newly emerged infectious disease, usually a bacteria or virus. As such, mitigations are usually focused on the single agent that is placing communities at risk. Effective initial solutions may include the isolation of infected individuals, so they do not expose the general population to risk of infection. Or perhaps a vaccine to prevent infection or an antibiotic to treat those who are already infected. On the other hand, it is virtually impossible to isolate our populations from the knowledge of and exposure to pain relievers, and because drug dependency evolves over a lifetime, simple solutions are elusive.

The newly emerging threat in an epidemic is external to society. In contrast, like the Industrial Revolution, the drivers of drug dependency and overdoses are intrinsic to the evolving structure of society. The causes are complex and are, at least initially, deliberate. Research confirms that socioeconomic and educational disparity, unemployment, global policies, cultural incongruity and a health care system that is focused too much on profit have all been major contributors to the evolving problem over the past century.

This raises the question of timeline. As the years and decades pile up, it begins to become apparent that many of the trends we see have occurred before. Before your next breath, note that this is not cause – nor call for – despair. But it does remind us to learn from past experience and past mistakes, if not by our own generation then by earlier ones. From Prohibition in the 1920s, to the Rolling Stones Mothers Little Helper in the ‘60s, to crack cocaine in the urban U.S. in the ‘80s, to methamphetamine in the ‘90s, and now prescription and non-prescription pain relievers and opiates, the trend has been indolent and relentless over generations.

Because the drug dependency and overdose problem is imbedded in our social fabric, the solution is necessarily complex. To make criminal justice interventions the only solution to the drug dependency and overdose crisis would be like building a more robust fire department in response to climate change. Both strategies are destined to fail unless vigorously partnered with public health research and interventions that work upstream to limit the factors that incubate criminal behavior and modify human behaviors that contribute to climate change.

©April 2008

Perhaps the most important part of practicing medicine is to gain the capacity to see through your patient’s eyes.  To fully comprehend the experience of a patient as expressed in a chief complaint is often the most important clue to a diagnosis, no matter whether the goal is to understand the subtle characteristics of pain, to visualize a rash according to the patient’s description, to empathize with the distress of a spouse during a partner’s illness, or to anticipate the reluctance of a patient to take a medication as prescribed.  It is for this reason that the words of a patient are necessarily accepted, at least initially, as a basic truth.   But it is not often recognized how destructive it can be when a health care provider is deceived, either purposefully or inadvertently, about the best interests of the patient.  Perhaps the most serious example of the breakdown of the physician-patient relationship is the abuse of prescription drugs and the temptation to over-prescribe medications designed to relieve suffering.

First, it is important to emphasize that the recognition and treatment of pain is a critical responsibility of physicians and providers.  In 2001, California passed a law requiring all physicians to receive 12 hours of pain management education because of a perception that there was a gap in general knowledge of the subject.  However, since that time there has been a well-recognized increase in prescription drug abuse paralleled by an unprecedented increase in the prescribing of narcotics.

Pain is actually our friend.  It turns out that when the first protozoan recoiled from a hot object, the nervous system was born.  Responding to noxious stimuli only requires the memory of this event to inspire learning.  As memories of positive and negative experiences accumulate, the capacity to understand Shakespeare is only a few million years away.

A complex nervous system is designed not only to pull the strings that operate our machinery, but also to protect our bodies from injury.  Several disorders can cause individuals to lose the capacity to experience pain.  The end results of such conditions include joint destruction, bed sores, and infections, any of which can be life-threatening.  Indeed, there are many maladies that one should prefer to the loss of the ability to experience pain.

Prescription drug abuse is only encouraged by technological progress that has made it possible to both mass produce and market pharmaceuticals.  Every culture on earth has discovered substances that either relieve suffering or provide temporary pleasure.  If there is any doubt about the capacity of substances to place the brain on autopilot, simply observe a cat indulging in a patch of catnip.  In the past, pharmaceutical production was limited by the ability of farmers to grow and harvest poppies, plants and the like.  However, it is relatively recently that synthetic narcotics have become available in a wide array of doses, formulations and colors to pharmacies throughout virtually every corner of every community in the country.

Except for marijuana, tobacco and alcohol, prescription narcotics are now the most commonly abused drug in the local student population.  Most of these either come from prescriptions that have been diverted from the intended user, or are “extra” medications that were salvaged from previous prescriptions.

Tuolumne County had the second highest rate of drug-induced deaths in California during the period 2003 to 2005.  We simply must begin the process of re-educating ourselves and future generations to be comfortable with the idea of sometimes being uncomfortable.  While we must validate and treat pain when it is a part of illness, we must not substitute the illness of an anesthetized society for pain – both physical and mental anguish – that is serving a healthy purpose.