Tennessee Doctors: No One Knew Painkillers were so Deadly
My cousin come up from Knoxville
And he taught me a thing or two
Now I'm headed nowhere but downhill
With the OxyContin blues
— Steve Earle, "OxyContin Blues"
You can trace the history of Tennesseans' problems with substance abuse by listening to their music.
In 1957, Robert Mitchum was roaring out on Thunder Road singing about "moonshine, moonshine to quench the devil's thirst."
By the 1980s, Steve Earle was back from Vietnam and warning the sheriff to stay away from his marijuana plants on Copperhead Road.
In 2007, Old Crow Medicine Show's drug of choice was methamphetamine.
And the following year, Earle had the OxyContin Blues.
"We seem to have a cultural predilection for outlaw status," said Dr. John "Rett" Blake, a pain specialist in Chattanooga and a member of the state task force that wrote the rules for how doctors should prescribe painkillers. "After Prohibition, we moved on to the next thing, and now it is illicit opioids."
The problem of painkiller abuse is not limited to Tennessee — it's a nationwide issue, one that is intertwined with heroin and counterfeit drugs.
But Tennesseans love their painkillers.
At their peak, doctors in the Volunteer State were writing 143 prescriptions for every 100 Tennesseans, tied with Alabama as the most in the U.S.
That's more than twice the rate as in California or New York.
Part of the reason may be that Tennesseans are sicker than people in most other states.
"Patients are older than they used to be, you have more people with more back and knee surgeries, and we have higher rates of obesity," Blake said. "Combine all of those things and you have more chronic pain, and you have more people wanting treatment."
For a while, painkillers, particularly OxyContin and hydrocodone, seemed like a panacea.
"People like simple solutions. Nothing is simpler than giving a tablet," said Dr. Peter Martin, an addiction psychologist and professor at Vanderbilt University School of Medicine.
"We want quick and easy fixes that don't involve going to the gym and exercising and eating properly," Blake said.
But what seemed at the time like a miracle cure, turned out to have a nasty side effect: the easy availability of the inexpensive pills fueled a new wave of drug addiction that pushed deaths from overdoses to an all-time high. Fatalities from prescription opioids, a class of painkillers that includes methadone, oxycodone (OxyContin), and hydrocodone (Vicodin), quadrupled since 1999, to more than 14,000 in 2014.
How did what seemed like a medical breakthrough in the treatment of pain turn into a nightmare of drug abuse?
Doctors in Tennessee say a drug company should take part of the blame. But they also point to a misguided effort to do more to help pain sufferers that resulted in overprescribing of painkillers. And they say physicians themselves are also at fault, for failing to question claims about new drugs that were just too good to be true.
Drugs made from the poppy plant have been used to alleviate pain since ancient times. Five thousand years ago, the Sumerians referred to it as the "plant of joy," and some historians claim Homer was referring to opium when he described the potion Helen of Troy poured into a jug of wine "to lull all pain and anger, and bring forgetfulness of every sorrow."
In the Civil War, morphine, an opium derivative, was a staple for doctors performing surgery in the field, and after the war, morphine addiction even had a nickname — the Soldier's Disease. Morphine was commonly prescribed for a variety of ailments until the early 20th century.
But that began to change shortly before World War I. The establishment of the Food and Drug Administration meant companies peddling miracle potions had to tell consumers what was in them — often narcotics. The Harrison Narcotics Tax Act of 1914 dramatically slowed sales of opiates, and heroin and morphine became synonymous with drug addiction.
That image began to change again in the 1990s.
In 1995, the American Pain Society, a nonprofit group of doctors and researchers, recommended that pain be treated as one of five vital signs doctors should consider when evaluating a patient, along with blood pressure, heart rate, respiratory rate, and temperature. That's the origin of the smiley-face cards many doctors and nurses use that ask patients to rank their pain on a sliding scale.
That effort to make pain a part of any diagnosis got a boost in 2001, when The Joint Commission, the powerful organization that accredits health care organizations in the U.S., published standards "in response to the national outcry about the widespread problem of under-treatment of pain." Doctors were urged to reconsider their efforts to treat pain, and for many, that included re-evaluating their reluctance to prescribe narcotics.
There was a laudable moral principle behind the push — "Our job is to treat pain and suffering," Blake said.
There was also a business incentive. Insurance companies were paying more attention to the quality of treatment in hospitals, and began asking patients about how well their doctors had managed their pain. "Patient satisfaction is one of the issues being assessed in terms of getting insurance companies to pay for hospital bills," said Dr. Daniel Sumrok, director of the University of Tennessee College of Medicine's Center for Addiction Science. "If the patient said it was unsatisfactory, hospitals pressured doctors to be more aware of the issue of pain management."
That meant doctors had to learn about narcotics, Sumrok said. The state medical association sent out guidelines for prescribing the powerful opioids. First, doctors needed to have a substantiated diagnosis that the pain was real.
"They should have some evidence from laboratories and X-rays, and it would help if they had letters from specialists saying that they had tried other things such as physical therapy," he said.
The idea was that physicians would pay close attention to the cause of the pain and carefully monitor the results.
"For a lot of doctors, and for me, too, that's a tough thing to do," Sumrok said. "That balance is tough to maintain with every visit, especially if you are pushed for time."
If doctors point to a villain in the saga of painkiller abuse, it is likely to be Purdue Pharma. Purdue won approval from the Food and Drug Administration in 1995 for a new opioid, OxyContin, to provide relief for moderate to severe pain that lasted more than a few days. The company launched a large-scale marketing campaign, meeting with medical leaders in Tennessee and elsewhere to tout the pill's promise.
According to a report by the U.S. Government Accountability Office, Purdue expanded its sales staff from 300 to 671 between 1996 and 2002, and added 300 more representatives through an agreement with Abbott Laboratories. Each sales rep had a list of between 105 and 140 doctors to call on, and was supposed to visit each one at least once a month.
During the first five years OxyContin was marketed, the company sponsored more than 40 pain management and speaker training conferences, generally in resort locations, according to the GAO report, and funded more than 20,000 pain-related educational programs through direct sponsorship of physicians or through grants that allowed them to earn required continuing education credits.
And the program was an unqualified success. By 2001, sales of OxyContin exceeded $1 billion — 90 percent of Purdue's total prescription sales.
Purdue marketed OxyContin as a safer pill than its predecessors because it released its painkiller over a period of several hours, instead of all at once. That would prevent abuse because users would not get an instant high. And there was no worry of addiction, the company claimed.
Many doctors were convinced.
"I'm not going to malign them," Martin said. "They felt they had created a compound that was less likely to be abused, so more patients could have the benefits of opioids."
The delayed release feature was a big deal, said Dr. Thomas Miller, a veteran pain management specialist and head of the Addiction Subcommittee for the Hamilton County Health Department. Older drugs lasted for only three hours, while OxyContin's effect might last for two or three days.
"It was a godsend," he said.
He also downplayed the idea that the drug company was somehow bribing doctors to use their product.
"They would take us to resorts," he said, "But we would have lectures and they were really good. There was nothing fun about it."
Besides OxyContin there was hydrocodone, a generic opiate that was easy to prescribe.
"A nurse could authorize it over the phone," Miller said. "There was a guy who lost his license finally after they found his nurse kept authorizing hydrocodone for a year and never saw the patient for a year. Somebody would just call in and say, 'I need a new prescription.'"