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A primary care doctor delves into the opioid epidemic

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February 20, 2017

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Comments

Dionysia
March 25, 2017

THANK YOU FOR YOUR COMMITMENT AND INSTRUCTIVE READINGS.
DOES WHAT YOU DESCRIBE FOR OPIOID ADDICTIONS APPLY ALSO TO MARIJUANA ADDICTS AND ABUSERS?

Deborah Grossi
March 25, 2017

While I am able to sympathize with some people’s unfortunate decisions I have lived every day of the last 20 years of my adult life in unrelenting Pain! Since medical care isn’t like the TV show House where the brilliant doctors come in and make it all better without the opiates I am unable to do more than sit in pain 24 hours a dayear wishing I didn’t chose to have children so I could have chosen to end my suffering! Then one day I was sent to a different doctor because my regular doctor had an emergency and he didn’t feel that I should be left to suffer though life. He put me on a very high dosage of opiates and I am able to move now, able to make healthier lifestyle choices and lose nearly 100 pounds over the years. I don’t know if I am “addicted ” to my pain relieving drugs and frankly I don’t care because now I am not thinking about killing myself everyday! So I’m very sorry for the people who choose to abuse drugs and alcohol but those of us who have no life with out them deserve to have a life! Maybe we should work towards better mental health care services and to be more sympathetic towards those who have dependency problemso and stop insisting that I have to pay for a monthly doctor fee for the MEDICINE that allows me to have a life as well!

No Victim
March 29, 2017

The despicable greed of the Pharmaceutical Companies behind this crime is staggering. I have seen them send out paid “patient advocates” like this who post this garbage even on childrens obituary pages who have died of overdoses.
There is a great corporate crime behind this epidemic. The truth needs to be told.

JHR
March 24, 2017

When I first met my doctor, in 2008, it was during the time that doctors took responsibility to help their patients who are suffering from chronic pain.

At my first appointment, I told my doctor I wanted assisted suicide. She told me I didn’t qualify because I wasn’t terminally ill. I knew that, but that didn’t change the fact that I wanted it as the only way I knew not to hurt anymore.

I was sent to the pain clinic, where they joined her and trying to convince me to take the opiate pain medication. I absolutely did not want to do that.

Finally, I did begin taking it. I started out with oxycodone and later switched to short acting morphine as that helped me more. Due to the tolerance issues all of these medications unfortunately have, they do not help me as much as they used to due to the tolerance issues all of these medications unfortunately have, they do not help me as much as they used to. But they still do help me, and I need all the help I can get I also use medical marijuana which helps me the most, but I cannot drive while using that so without the medications I would have nothing for my pain to drive and probably just wouldn’t, being unable to afford to go visit my son or go to doctor appointments This is what convinced my doctor to let me continue to take the same dose I have taken for years with never one incident of problems with the medication.

She tells me she has seen this addiction problems, but acknowledges that it is the exception rather than the rule among the patients who take these medicines

I also use guided imagery and hypnotherapy which helps, but not enough, Thought this is all doctors think you should have – mindfulness, cognitive behavioral therapy, etc.

I would like to see them wake up without a nine pain level every morning like I do and get by with their cognitive behavioral therapy.

There is a lot of drug abuse of these medications, outside of the medical establishment especially, but this has nothing to do with the poor suffering pain patients such as myself, just try to get by day by day and have some kind of a life and help their families.

My guess is a lot of the suicide is because people just can’t stand the pain anymore. I think about it all the time and wish it wasn’t so frightening thing to do Every night when I go to bed I pray not to wake up, but unfortunately I do, to another day of this. I also pray for a very quick terminal disease so that I could qualify for assisted suicide Life is not fair that young people who want to live their lives, with their whole lives ahead of them, have to die from these diseases when I would give anything to take me out to take that disease from them and have it myself.

It is too bad the buttons that the doctors were with stamp out pain or gone. It is too bad the buttons that the doctors were with stamp out pain are gone. I have gone through the whole change and I just wish that the Doctor Who wrote this and all the rest of them could spend just five minutes living with this pain-wracked body of mine. Five minutes is all it would take and all I would wish on anyone.

I hardly ever respond to these things, but I just had to this time. To all those who suffer every day like I do, I am very sorry. I had 57 years of wonderful health followed by the past 11 years of horrible pain I know what life is supposed to feel like and this torture I go through every day isn’t it

I wish you all the best day you can possibly have.

And I wish for the doctors to be able to look into their souls and reclaim their compassion.

Andrew Whyman, M.D.
March 24, 2017

The good doctor has it mostly right. Treatment involves doing what works for the patient. Detox, MAT, NA, AA, group and family counseling all have their place. Each works for some, not for others. Every addict deserves a competent, caring, knowledgable clinician.
But this is also a public health crisis, and there is enough blame to go around a large circle. Including groups like politicians, district attorneys, crusading law enforcement and all those who readily characterize illegal drug possession as a crime deserving punishment. Criminalizing drug use contributes to countless deaths, under treatment, mistreatment, and failure to seek treatment, to name just a few outcomes.
Heroin Assisted Treatment(HAT) is offered in several European countries with positive results. Not in America. Medically supervised injection facilities are offered in some countries. At present in its earliest stages of adoption in some U.S. jurisdictions.
We need many more competent clinicians in this field and we need to change the drug laws. One without the other is a band-aid on an open wound.

Valentine Chuk
March 3, 2017

I must say thank you for the courage and passion to make a move in this deadly trend of substance abuse. Just like you, I witnessed a death of a relative. In his case, he was just unstoppable and what made matter worse was that his edginess and depression was intense with increased blood pressure. Later we noticed he had increased breathing with varicose veins. Of course, we could not understand the connection with venous disease. I was close to him and because someone had told me about http://www.varicoseveinremovals.com/, I referred him to the site. Before we could understand what was happening to him, (and perhaps because people had begun talking about it – stigmatisation), he went into seclusion and refused any form of interaction. It wasn’t long before he surrendered. Of course, I can understand when you fear stigmatisation that may come with treating anyone who indulges in substance. I think government can do more with awareness campaign to help those already in a maze and prevent others from taking a hold of the substance. I just want to say kudos to your courage and passion and to say keep it up.

Emily
February 27, 2017

This is definitely a problem, but for those with pain that needs to be managed, what are they truly to do? They are addicted to opioids because it is the only thing that really helps them feel SOME relief, but at the same time they still don’t fully feel better. Pain management and treating chronic pain must change for the better otherwise the situation will only get worse.

Monique Tello, MD, MPH
March 7, 2017

There is a time and place for narcotics. I prescribe short courses of narcotics for my patients for pain control in various clinical situations, and I also have several patients on chronic narcotics, low doses and low numbers of pills, for as-needed use. Most of those patients are elderly and with multiple other medical problems such that they cannot have surgery nor take anti-inflammatory meds for their horrible spinal stenosis/ hip arthritis/ cervical disc disease et cetera. We have safe prescribing practices and guidelines for this, and we use them. Research shows us that for most chronic pain, particularly back pain, narcotics are no more effective than other safer modalities. (See upcoming posts on treatment of back pain. And new pain treatment guidelines for physicians: http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice)

Robin
February 27, 2017

I have a designating spine. I am 62 years old. I have had 3 spine surgerys but do not want to do anymore. I was taking a maximum of 3 Vicodin a day (10 mg) since my last surgery for 4 years. I never lost an Rx or escalated my dose. Having moments without pain allowed me to be active and kept me healthy. Now nobody will prescribe, so I live in pain and am unable to do the things I want.

I see an osteopath, go to PT once a week and get massages regularly as well as do yoga nightly.

Not everyone who drinks becomes an alcoholic and not everyone who uses pain pills appropriately becomes an addict. The current war on pain killers is inhumane.

Monique Tello, MD, MPH
March 7, 2017

Not sure if you can see my reply above, so I will paste it here:
There is a time and place for narcotics. I prescribe short courses of narcotics for my patients for pain control in various clinical situations, and I also have several patients on chronic narcotics, low doses and low numbers of pills, for as-needed use. Most of those patients are elderly and with multiple other medical problems such that they cannot have surgery nor take anti-inflammatory meds for their horrible spinal stenosis/ hip arthritis/ cervical disc disease et cetera. We have safe prescribing practices and guidelines for this, and we use them. Research shows us that for most chronic pain, particularly back pain, narcotics are no more effective than other safer modalities. (See upcoming posts on treatment of back pain. And new pain treatment guidelines for physicians: http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice)

juliette
February 27, 2017

It is impossible for me to believe when Mass. changed the opiate prescription rules for doctors that they didn’t have the foresight to see what would come next.

Mass is now trying to say there are more ods now because there is fentanyl on the streets. This is true but what they completely miss is that droves of addicts who were turned away from legal medications are now using street drugs.

I’m a recovering heroin addict, and believe me I have my finger on the pulse of what’s up around here (Plymouth County).
There are more people using ILLEGAL opiates now.

I’d love to hear your thoughts – basically do you really think that those new regulations were made without them seeing the fallout (a new breed of illegal drug users). Also, people who are just starting out with illegal/street opiates can’t decipher the correct amount to do, yet another reason for more od’s.
Dumbest thing ever, throwing people off of their medications so that they experience withdrawal. They are driven to the street. If these ‘rulemakers’ knew how bad it was to be sick from withdrawal, they would make better choices. I know a woman in her 80’s who is looking for suboxone on the street, it’s obsurd.

Monique Tello, MD, MPH
March 7, 2017

Agreed, we need to move away from the idea that narcotics are effective for long-term treatment of pain, because they are not, and they cause many more problems than they solve. I also agree with you that we desperately need more providers willing to prescribe Suboxone so people do not have to go to the street for it.

Nick C
February 23, 2017

Narcotics Anonymous and Alcoholics Anonymous are great… For some people. Unlike NA or AA, this writer is reporting on Hard Science that shows the relapse rates of people that use Medication-Assisted-Treatment.
NA and AA have no data, but I am familiar, and I would hazard a guess that far more than 15pct of people that first walk into a meeting relapse at some point, or perhaps leave a fellowship altogether. I think anyone that is familiar with these fellowships would agree.
Again, they are great for some people. But I believe they should alter their stance on MAT and try to be a bit more progressive, given the amount of data available.
If science says MAT is better, and the treatment industry has been 12 step based for 60 years, it might even be safe to say that the treatment industry has failed millions of people.

Monique Tello, MD, MPH
March 7, 2017

Thank you for your observations and comments, which make alot of sense.

someone with in pain.
February 22, 2017

So let me get this straight so now you’re against treating people with pain with opioids. its almost as if the medical community are so willing to leave those in pain and tell them an addict I mean it does not matter right. You have pretty much no real risk if you screw someone up for life as I was done by one of your fellow doctors leaving me disabled unable to work. I get the double hit with more medical cost lower income and no hope. whale I agree that those with drug problems need help not at the expense of my treatment of my condition. I am just wondering if we are all on board to tell those with pain to shut up and suck it up. are you guys going to help us out and provide a way to end our life if your not going to treat the pain.

Monique Tello, MD, MPH
March 7, 2017

I’m pasting this reply again here for you:
There is a time and place for narcotics. I prescribe short courses of narcotics for my patients for pain control in various clinical situations, and I also have several patients on chronic narcotics, low doses and low numbers of pills, for as-needed use. Most of those patients are elderly and with multiple other medical problems such that they cannot have surgery nor take anti-inflammatory meds for their horrible spinal stenosis/ hip arthritis/ cervical disc disease et cetera. We have safe prescribing practices and guidelines for this, and we use them. Research shows us that for most chronic pain, particularly back pain, narcotics are no more effective than other safer modalities. (See upcoming posts on treatment of back pain. And new pain treatment guidelines for physicians: http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice)

Neil Vincent MD
February 22, 2017

“First Do No Harm”. Putting addicts on replacement opiates will tether them to perhaps something worse than their original addiction. In fact, addicts continue to use while being prescribed Suboxone, often selling their sub in order to obtain funds to use heroin. They cleverly will then restart sub just in time for it to show up on their urine tests. The answer is not to substitute one addiction for another. Ask any addict who has suffered through it, coming off suboxone is more brutal than dope sickness. The answer is Vivitrol, for extended periods, probably continuing therapy for 2 years or longer to get them past the cravings experienced during Post Acute Withdrawal Syndrome. Of course, Vivitrol isn’t going to work unless the addict is highly motivated and continues to “work” hard on recovery. Read this study results carefully. There were NO OVERDOSE DEATHS in the treatment group.
http://www.nejm.org/doi/full/10.1056/NEJMoa1505409?query=featured_home&#t=articleTop

Pennie Embry
February 23, 2017

“Putting addicts on replacement opiates will tether them to perhaps something worse than their original addiction.” This cannot be stressed enough. Our 30 year old daughter, now clean 3 years, was addicted to prescription painkillers. Started at the hospital after an accident, continued by doctors, but she owns it. Two years on methadone and then suboxon, she was sicker than ever. Less able to work. She claims to this day that when a doctor prescribes methadone, the addict may as well pour gasoline on herself and set herself on fire. She has talked with me for hours about this. She got clean at our house, with help from providers at a FQHC (I sit on the board of that FQHC) and trips to AA. She was deathly ill for months. They did NOT do pain management, they found & treated the source of her addiction. It has been hard and horrible work but successful. I am looking for more info that I can use to help me in my crusade to get more addicts and their families access to the sort of treatment my daughter had instead of “replacement opiates.” Any “pointing in the right direction” you can offer would be appreciated on a level no words can describe.

Monique Tello, MD, MPH
March 7, 2017

Vivitrol is a wonderful option, for some people. AA and NA alone are wonderful options, for some people. Suboxone and Methadone are wonderful options, for some people. The reality is that every person and patient is different, and some may require any or all of the above.

Sherman
February 21, 2017

As an occupational medicine physician having to manage patients with pain symptoms, I have been for some times now concerned with overuse of opioids for general pain.
Only about ten years earlier, I remember I was criticized by senior staffs for not aggressively prescribing opioids. Just a few years back, it was routine to give opioids to almost any patients who have pain complaints. The main reason, clinicians are pressured to be aggressive and not be accused of “under treating” pain. Fast forward a decade in time, clinicians now are pressured to do the opposite, avoid being accused of “over treating” and over prescribing opioids.
My observation is that in the recent past, opioids were aggressively overused, but the current trend and potential negative is that pain could be under treated due to the
180-degree swing in pain management policy and state mandatory monitoring oversight.

Monique Tello, MD, MPH
March 7, 2017

I do think that we have historically turned to narcotics for treatment of pain too quickly and used them for too long, creating alot of problems. The reality is that there are many modalities and medications for the treatment of pain, and we need to consider all of them, choosing what is most appropriate and safe. Narcotics should be prescribed where appropriate and safe.

Noah S Heftler MD
February 21, 2017

Nobody seemed to care when it was just Appalachia. Well, the chickens have come home to roost. It is time for us to get angry and to get mobilized. There is a great crime behind this opiate epidemic. It is a corporate crime which rivals “big tobacco” and it needs to be exposed. The perpetrators of this crime, The Sackler Family behind Perdue Pharmaceutical and others, need to be fully disgorged of their blood money and the funds should be set up to aid those in recovery, to support educational efforts and to aid the families and communities so devastated. It is time to report on the role the “philanthropic” Sackler Family has played in this epidemic which is now responsible for the deaths of over 40,000 young people per year.
“Behind every great fortune there is a great crime”-Balzac
Sincerely,
Noah S Heftler MD

http://www.latimes.com/projects/oxycontin-part1/
https://www.statnews.com/…/09/22/abbott-oxycontin-crusade/
http://www.forbes.com/forbes/welcome/?toURL=http://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxycontin-clan-the-14-billion-newcomer-to-forbes-2015-list-of-richest-u-s-families/&refURL=https://www.google.com/&referrer=https://www.google.com/
https://www.thefix.com/content/oxycontin-cartel-billionaire-family-16th-richest-us-according-forbes
http://www.latimes.com/projects/la-me-oxycontin-part3/

Neil Vincent MD
February 22, 2017

Here is the link to the STAT News article. STAT has done a solid job of reporting on the greed behind this public health crisis.
https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade/

Robert
February 21, 2017

This well-worn narrative of an innocent/accidental addict starting on prescribed opioids and naturally/inevitably progressing to heroin use is not supported by the evidence. The vast majority of people who use a prescription opioid non-medically never go on to initiate heroin use. Here it is from the source: “However, the vast majority of NMPR users have not progressed to heroin use. Only 3.6 percent of NMPR initiates had initiated heroin use within the 5-year period following first NMPR use.” And of the 3.6 % that initiated heroin use, most of those do not become addicted, in the same way that people who used illicit alcohol during Prohibition became alcoholics. It is time to start moving toward legal regulation of ‘narcotics’ such that a patient can obtain drugs without having to go to a physician for permission (see globalcommissionondrugs.org).

https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm

Monique Tello, MD, MPH
March 7, 2017

Thanks for your input, we welcome all views.

Joseph McManus
February 20, 2017

Citation from National Institute of Drug Addiction (NIDA)

The Science of Drug Abuse and Addiction: The Basics

What is drug addiction?

“Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes can be long lasting and can lead to many harmful, often self-destructive, behaviors. ”

Thank you for an excellent summary of your personal and professional knowledge of our American opioid crisis. As I reviewed your journey in learning about treatment options I think that you may be underestmating the danger of relapse, the greatest recovery risk of all. As you know the variable medication compliance track record for mental health medications is well documented. Opioid use disorder is a chronic, relapsing brain disease frequently assaosisted with mental illness comorbidities. There is a serious risk of sudden death at relapsing events. Recently the CDC reported that in the year 2015 over 33,000 Americans were killed by opioid overdoses. Is there evidenve of how many were relapsing events? While I agree that medication treatment may be life saving initally I hope that you recognize that harm reduction requires long term adherence to not only medication treatment but also strong compliance to family and therapeutic communities. This long term harm reduction point seems to be missing in your otherwise excellent presentation.

Monique Tello, MD, MPH
March 7, 2017

Thank you for your thoughts, and appreciate your readership.

Carl B.
February 20, 2017

My name is Carl, and I am a recovered alcoholic and drug abuser. There is one thing that is a thread throughout all addictions, and that is, the substance is only a symptom. There are people, non addicts, who many develop a dependence on opioids, however, they can detox and go on with their lives. The ‘real addict’ cannot do that. Narcotics Anonymous, as with Alcoholics Anonymous, treats the cause of the addiction or alcoholism. They treat the reasons behind the symptoms. There is not another treatment anywhere that says, if you follow the suggestions, you will recover from ‘a seemingly hopeless state of mind and body’.

Monique Tello, MD, MPH
March 7, 2017

Thanks for sharing your experience.

Commenting has been closed for this post.

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