Hero in Our Midst Part 1, Prescription Opiate Epidemic Revealed

Debra L. Glasser, M.D.

PHOTO BY GLORIA TOWNE

Attachments

A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned

Opioids for chronic noncancer pain A position paper of the American Academy of Neurology

Opioid Dosing Trends and Mortality in Washington State Workers’ Compensation, 1996–2002

I had the recent privilege to interview a local hero who uncovered the origins and causes of the national prescription opiate crisis. He did this right here in Olympia in the WA State Department of Labor and Industries (L&I).  

His story, our story, is stranger and more horrific than any fictional mystery thriller because it is both tragic and true.  It is a story that needs to be told.

The prescription Opiate Epidemic is one of the worst manmade epidemics in history.

Since the late 1990s, more than 200,000 people in the United States have died from unintentional opiate overdose, a number that far exceeds the number of US military casualties in the Vietnam War (58,000).  This is much more than an epidemic of deaths. This is an epidemic of dependence, addiction, and disability that has impacted (i.e. ruined) hundreds of thousands of lives (mostly men’s) in the prime of life. They and their families are still suffering and our institutions (our taxes) are still supporting them. This nightmare has quite likely touched your life in some way as it has mine both professionally and personally.

Even when actively involved in medicine and working with patients prescribed and addicted to opiates for chronic pain at the Veterans Administration Woman’s Health Clinic at American Lake from 2012-2017, I did not understand what was going on. How and why did doctors get these patients hooked?  Even while mandated by VA policy to get these patients off opiates (no easy task), those of us working in primary care were clueless about its cause.  

Enter neurologist and public health physician Gary Franklin, M.D.

He joined our department of L&I because of his commitment to public health, specifically that of injured workers. He is the hero along with his collaborating pharmacist manager, Jaymie Mai, Pharm.D. Together and painstakingly in COLLABORATION with multiple WA State departments, they uncovered the truth of this epidemic. Their landmark and policy-changing research was published in 2005 (reference below).

In the late ‘90s, Dr. Mai noticed an unusual number of claims for benefits being submitted by surviving spouses of injured workers. Together with Dr. Franklin and the department, they conducted an in-depth investigation of these claims and the injured workers’ deaths. They found that these patients had been prescribed long-term and unusually high-dose opiates.

These deaths were a mystery.

The injured and disabled workers were not found unconscious in a back alley as one might find a heroin addict.  They were found dead in their beds by their spouses. Only now do we know that they likely died of respiratory arrest (i.e. they stopped breathing) caused by their prescribed medications (i.e. opiates alone or combined with other medications).

Our hero’s case research involved the study of death certificates, toxicology reports, and pharmacy prescriptions for each person who died while receiving state disability benefits between 1996-2002. The research required them to develop a definition for ‘probable and possible death’ from opiates vs. from other causes. Their definitions became the standard for researchers of this crisis nationwide.

They discovered that during this time period, the average daily morphine equivalent dose (MED) used in injured workers increased from 80 to 140 mg/day. For context, you might be prescribed 30 to 60 mg/day for a few days after major surgery.   Between 1997 and 2002, 32 injured workers were found to have died from opiates, most of them men between the ages of 32 and 54. By 2004 the state’s overall annual prescription opioid-caused worker’s comp deaths had increased to 351, and by 2010 that number had risen to 512.

Man holding pills and about to take them with a glass of water.

Innocent people were dying.

How did this happen?

Until the latter part of the 1990s, the use of long-term opioids (oxycodone in the form of Oxycontin, long-acting morphine, and methadone) for chronic (i.e. long-standing) non-cancer pain was prohibited in most states. For physicians trained before 1999, you simply did not prescribe opiates to people with headaches, low back pain, arthritis, and other ongoing pain conditions. If you did, you risked losing your prescribing privileges and potentially your medical license. State laws at that time reflected prevailing evidence that this practice was neither helpful nor safe.

In the late 1990s, five critical developments unfolded that allowed this all to change.

It turns out that this man-made epidemic involved COLLABORATION between groups of professionals in power, business, and government whom we are meant and need to TRUST. 

Purdue Pharmaceuticals, the developers of MS Contin (long-acting morphine used to treat cancer pain and suffering at the end of life) developed Oxycontin (long-acting oxycodone) in 1996. The epidemic creators saw ‘opportunities’ for this new drug and collaborated to disseminate a series of unsubstantiated assertions to promote its use:

1. Clinical leaders with one powerful neurologist leading saw a ‘market’ for the use of this new Oxycontin in chronic pain. They had the support of a published letter-to-the editor in The New England Journal of Medicine, one of the country’s most highly respected medical publications. This letter suggested that opioids weren’t as addictive as physicians had been taught.
2. They were further able to declare several scientifically unsubstantiated ‘facts’: 1) if a patient became tolerant to a prescribed opiate dose, the solution to overcome it was to increase the dose, 2)  there was no harmful dosage ceiling for opiates and 3)  long-term opioids were appropriate, safe, and offered sustained benefits to chronic pain patients.
3. The Federation of State Medical Boards, supported by financing from Purdue Pharmaceuticals and other opioid manufacturers, published model opiate policies (not based on scientific research) and with these lobbied more than 20 states to liberalize opioid prescribing laws and regulations.
4. The University of Wisconsin Pain and Policy Group further assisted in this effort by successfully lobbying the World Health Organization (WHO) and state Medical Boards to influence their legislatures to repeal their current opiate dosing laws. At the time most states prohibited physicians from prescribing opiate doses >80 MED. They succeeded in changing most states’ laws to unlimited prescribing rights without risk of prosecution.
5. The American Pain Society and other forces were then successful in convincing the Joint Commission on Accreditation of Health Care Organizations (JCAHO) to make pain the 5^th vital sign and connected patient satisfaction to these scores that were tied to Medicare funding.

Voila!  

Americans (and the international public) were caught in a lethal, life-destroying set of policies set forth by those to whom they trusted their health and medical treatment. A few powerful leaders in pharmaceutical companies, government, and medicine were able to convince well-meaning primary care physicians to prescribe dangerous and addictive long-acting opiates to hundreds of thousands of our citizens suffering from chronic pain.  

The rise of unintentional poisoning from prescription opioids discovered and first reported by our hero, Dr. Franklin and his group began within two years of the liberalization of the laws in 1999. Subsequent studies documented a national epidemic of unintentional deaths associated with prescription opioids. A strong relationship between mortality (deaths) and specific prescription opioids (oxycodone and methadone in particular) was shown. By 2005 these deaths exceeded those from firearms and motor vehicle accidents in persons aged 35-54.  In Washington, opioid prescribing increased by 500% from 1997 to 2006.

We were in the midst of an evolving nightmare.

This horror could not be solved until it was discovered and understood.

 These are the forces that led us to the facts:

• The scientific curiosity, courage, and drive of Dr. Franklin and his colleagues at L&I
• The funding of government agencies and their dedicated workers who create policy and collect important data for the public good
• The COLLABORATION of multiple state agencies who worked together to bring this crisis to light (and continue to do so to reverse the trends – stay tuned)
• The courage of Dr. Franklin to publish his work and whistle blow in the face of collaborative forces of power and money that led to the loss of so many lives

Since this discovery, Dr. Franklin and his team have been on an unstoppable mission to change this injustice. But that is Part 2, my next column on June 13.  

References:

A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and
Lessons Learned, Published online ahead of print January 20, 2015 | American Journal of Public Health

Opioids for chronic noncancer pain, A position paper of the American Academy of Neurology, Published  2014 by the American Academy of Neurology. 

Opioid Dosing Trends and Mortality in Washington State Workers’ Compensation, 1996–2002, published by  AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 48:91–99 (2005)

Debra L. Glasser, M.D., is a retired internal medicine physician who lives in Olympia. Got a question for her? Write drdebra@theJOLTnews.com

Editors note: This column was edited on 6/6/2023 to reflect more accurate information with input from Dr. Franklin.