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Part One: Personal Pain

by Emil Kraepelin, with a personal story from Alexa Smiley

I readied myself for work on a late January morning. January 21st, 2014, to be exact. As I put myself together, I received a text message from a childhood friend, which said simply: “Steven is dead. He died of an overdose last night.” I sat down at the top of my staircase—processing the message—and quietly cried in the darkness of the winter dawn.

I had known Steven all my life. His story stands out as I consider him to be my first love; he was a special man and I think of him every day. But he is not the only one I have lost. Fourteen of my childhood friends have had their last breaths stolen by opioids.

These fourteen, however, are only a small fraction of those who die of overdoses every year. Over 47,000 individuals died from opioids in 2017, with a 12% increase in the rate of such deaths compared to 2016.1 Non-Hispanic whites accounted for 78% of all opioid overdose deaths; at a rate of 19.4 deaths per 100,000 people, whites are affected more than any other race or ethnic group in the United States.

The opioid epidemic isn’t relegated to the hills of West Virginia nor does it discriminate between the rich or the poor. Steven was the youngest of three boys born into a very well-off Catholic family. His father was a respected businessman in the community and his mother retired from nursing to raise her sons. They had a beautiful home and took exotic vacations; like so many of us who grew up in that area, money was never an issue for Steven’s parents. Steven was like any other kid; he played sports, was interested in music, and did well in school.

Steven and I began dating in high school. We spent long periods together, followed by intervals of separation. In 2008, we reunited and our love was soon rekindled. On an early morning in mid-December, I received a frantic call from Steven’s mother: he had left my apartment the night before and, on his way home, he was struck by a drunk driver. His hip and left leg were shattered. To help with the pain, he was prescribed OxyContin®, a long-acting version of the opioid oxycodone.

Steven and I separated again soon after his accident. After several months with no contact, he called me, asking if he could come over. When he arrived, I knew something was terribly wrong; standing at 6’3” and formerly weighing 235 lb, he now weighed, at most, 170 lb. He pulled out a cellophane bag and asked, “Can we do these here? It’s some Oxys, muscle relaxers, and Klonopins.” I hesitantly invited him in. We moved to the living room, where I sat in shock as he crushed an 80 mg OxyContin® tablet and snorted it off of a DVD case. He leaned back on the couch, his muscles relaxed and eyes struggling to stay open.

After some time, he started to come down and became more alert. I asked him why he was snorting the high-dose oxycodone. The pain medication he was getting from his doctor just wasn’t enough, he explained; snorting delivered it into his system faster, and it was the only thing keeping him sane. He insisted he wasn’t addicted.

I moved on with my life, focusing on my education and career. Steven continued with the drugs. In a period of three years, he accumulated more than 57 criminal charges in four districts. He was sent to prison in 2012, and released in 2013. We reconnected on Facebook after his release; he was clean and sober, had a job, and was engaged to a nice girl. We had our final brief, yet pleasant, exchange on December 29th, 2013. Less than a month later, he was dead.

A well-trod path

Like Steven’s, every story of addiction and overdose is, of course, unique. The interplay of genetics, environment, and psychology is complex. But strip away the particulars, and a common path is exposed.

First, we must understand what addiction is, and what addiction is not.  The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) is the standard handbook of diagnostics used in psychiatry in the United States. Published in 2013, the latest edition of the DSM created a new category for addictions: “substance use disorders.” The new classification combined two previously separate diagnoses, substance “abuse” and substance “dependence.”2 The criteria for substance use disorders (SUD) are mostly the same for each drug. Figure 1 provides a summary of DSM-5 opioid use disorder (OUD) criteria.3

Figure 1. Diagnostic criteria for opioid use disorder, also known as opioid addiction.

A substance use disorder—an addiction—is not simply a physical dependence or tolerance to a drug. An individual may be prescribed opioids and, if a dose is missed, experience withdrawal symptoms. But if they do not display any of the other criteria, the individual would not have an opioid use disorder.

The etiology and course of substance use disorders, as noted above, are a tangled web of biology and circumstance; however, some common elements stand out.

Risk and protective factors contribute to whether an individual develops an addiction.4 Family history of addiction, gender, and various other biological factors account for approximately 50 percent of an individual’s risk for developing a substance use disorder. A chaotic home life, including abuse, neglect, and parental drug use; poor social skills and academic performance; and availability of drugs and early experimentation represent common environmental risk factors.

Protective factors lie at the opposite end of the spectrum; self-control, parental supervision, community resources, positive relationships, and good academic achievement all reduce one’s risk of developing an addiction.4

Steven was from a wealthy family in a stable household. He was smart, but his school performance in adolescence began to decline. He formed relationships with others abusing substances; he started using at an early age. For Steven, the risks soon overtook any protective factors he maintained.

Beyond the other risk factors he possessed, Steven had one factor that has been particularly prevalent the current opioid crisis: Easy access to the abused substance. Steven was one of the 35% who obtained the misused opioids legally from a doctor.5 Nationally, another 40% were given the prescription opioid from a friend or relative for free. Steven was prescribed opioids for chronic pain, which accounts for a 300% increase in prescription opioid sales in the United States over the last twenty years.6 Nearly half of all individuals seeking treatment for opioid use disorder were first exposed to the narcotic from a prescription for pain.7

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducts a national survey on drug use and mental health for individuals aged 12 years and older. Of those who misused opioids in the past year, 62.3% reported doing so to relieve physical pain.5 A combined 23.7% misused opioids to feel good, get high, or to relax or relieve tension. Approximately 4% wanted to help feelings or emotions, and 3% were seeking better sleep.

The evidence reveals a population suffering from physical pain, and an obliging medical establishment ready to treat the aches and agony. With a torrent of pain pills permeating all levels of society—particularly among whites—rates of addiction exploded. And thus exposed is the Trifecta of Death: Pain, opioid prescribing, and addiction are connected to one another, and each alone is linked to greater loss of life.

The Trifecta of Death constitutes the nexus of the catastrophic epidemic of opioid overdoses and suicides.8 Pain itself increases vulnerability to opioid overdose and suicide. Increased prescribing of opioids for chronic pain—both expanded use throughout the population and higher doses per individual patient—also elevates the risk for overdose and suicide. Liberal dispensing of prescription opioids caused an increase in the rates of opioid use disorder—opioid addiction—again raising the rates of overdose and suicide.

And thus the well-trod path: pain to prescription, pills to problems, problems to poison.

Prescription blizzard

The current opioid crisis is not a product of the ineluctable forces of nature. Individuals, corporations, health care systems, and governments all actively constructed the framework from which this disaster grew.

One clear driver of the crisis was the Sackler family’s Purdue Pharma. Purdue Pharma’s blockbuster OxyContin®, a long-acting form of the opioid oxycodone, was first released in the 1990s. At a launch party, Richard Sackler, Senior Vice President of Sales, declared, “The prescription blizzard will be so deep, dense, and white…”9 The OxyContin® blizzard did indeed blanket the nation, especially the white population; from 1999-2017, nearly 400,000 Americans died from opioid overdoses, many of them victims of oxycodone.1

To paraphrase an oft-quoted remark: one opioid death is a tragedy, 400,000 is a statistic. Steven’s death was a tragedy for his family and friends. His story humanizes the scourge of opioids infecting our society. Indeed, the present installment of this series is meant to expose the human suffering and death engendered by the explosion in opioid prescribing. Part Two of this series will explore more fully the etiology of the opioid epidemic previewed above, including the Sackler family, Purdue Pharma, and the rise of illicit heroin and fentanyl.

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References

1.         Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;67. doi:10.15585/mmwr.mm6751521e1

2.         Hasin DS, O’Brien CP, Auriacombe M, et al. DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale. Am J Psychiatry. 2013;170(8):834-851. doi:10.1176/appi.ajp.2013.12060782

3.         Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Publishing; 2013.

4.         NIDA. Drugs, Brains, and Behavior: The Science of Addiction. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction. July 20, 2018. Accessed January 22, 2019.

5.         Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Rockville, MD: SAMHSA Publications; 2017.

6.         Madras BK. The Surge of Opioid Use, Addiction, and Overdoses: Responsibility and Response of the US Health Care System. JAMA Psychiatry. 2017;74(5):441-442. doi:10.1001/jamapsychiatry.2017.0163

7.         Cicero TJ, Ellis MS, Kasper ZA. Psychoactive substance use prior to the development of iatrogenic opioid abuse: A descriptive analysis of treatment-seeking opioid abusers. Addict Behav. 2017;65:242-244. doi:10.1016/j.addbeh.2016.08.024

8.         Bohnert ASB, Ilgen MA. Understanding Links among Opioid Use, Overdose, and Suicide. N Engl J Med. 2019;380(1):71-79. doi:10.1056/NEJMra1802148

9.         Massachusetts Attorney General Implicates Family Behind Purdue Pharma In Opioid Deaths. NPR.org. https://www.npr.org/sections/health-shots/2019/01/16/685692474/massachusetts-attorney-general-implicates-family-behind-purdue-pharma-in-opioid-. Accessed January 22, 2019.

by Emil Kraepelin

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