Some Thoughts about Drug Testing

While the use and abuse of opioids (prescribed and illicit) in this country is not new, the magnitude of the current opioid crisis still is very significant. Many people have tried to explain it and the one thing they share in common is their oversimplification. The motivation for the explanations are clear; a desire to bring order out of chaos. The problem is that simple answers to complex problems are almost always wrong.
The historical use of opioids is not new. The first written mention of opiates is believed to have come from Mesopotamia in 3400 BCE, when people had discovered that drying the poppy plant’s extracted fluid created a highly powerful drug which be-come known as the “joy plant,” and later “opium” (PBS, 1998). Following that, different factors served to expedite the use and abuse of opioids:
  The hypodermic needle was introduced in 1853 (Bellis, 2017).
  The common use of morphine as a painkiller during the Civil War resulted in such a large number of soldiers who became ad-dicted to the opiates given to them for battle injuries that the postwar morphine addiction prevalent among them came to be known as “Soldier’s Disease” (Lewy, 2014).
  A community group in the US, the Saint James Society, began a campaign to supply free samples of heroin through the mail to morphine addicts who were trying to give up their habits in the early 1900s (“From the,” 2002).
This history alone would not account for today’s opioid crisis. Other, more recent factors have contributed to where we are today. These include:
  A cultural belief that we should not be uncomfortable, and if we are, there is some immediate medicinal fix for it
  Direct-to-consumer advertising of both OTC and prescription medications, permitted only in two countries, the US and New Zealand (Every-Palmer, 2014)
  The consensus statement from the American Pain Society and the American Academy of Pain Medicine in 1997 which stated that there was little risk of addiction and overdose in pain patients, which they claimed as less than 1 percent, now known to be up to 50 percent in nonmalignant chronic pain patients (Højsted & Sjøgren, 2007)
  The huge amounts of money spent by pharmaceutical companies marketing to physicians (Zezima, 2017)
  Legislation passed by Congress weakening the DEA’s ability to stem opioid sales (Whitaker, 2017)
  The message that pain is “the fifth vital sign” (Keyes, Cerdá, Brady, Havens, & Galea, 2014)
  Physician overprescribing
  The introduction of illicitly manufactured fentanyl
  Treatment and reimbursement of addiction treatment as if it is an acute illness
As you can determine from this list, there is no single cause for today’s opioid epidemic, but a series of different, yet relat-ed, synergistic circumstances. Let us look more closely at some of these.

An Increase in Prescribing Opioids by Physicians
The federal government began tracking how physicians treated pain, and if doctors and hospitals were not deemed to be giving patients appropriate (i.e., “enough”) pain medication, they did not receive full funding or payment. At this time, pain be-came the “fifth vital sign” in addition to blood pressure, temperature, pulse rate, and respiration rate (Keyes et al., 2014). Also, pain was determined subjectively by patients using a zero to ten pain scale, but at that time the inclusion of “function” was not used to determine the effects of the chronic pain. Physicians were encouraged to prescribe more narcotics. To give you an indication of prescribing practices, “approximately 80 percent of the global opioid supply is consumed in the United States” and “There was [sic] about 300 million pain prescriptions written in 2015” globally (Gusovsky, 2016).
More than 259 million opioid prescriptions were written in 2012 (National Safety Council, 2016). This increase was fueled in part by aggressive marketing and payments to physicians. According to an article in The Washington Post last year, “Research-ers at Boston Medical Center found that from 2013 to 2015, 68,177 doctors received more than $46 million in payments from drug companies pushing powerful painkillers” (Zezima, 2017). One contributing factor is limited and/or absent insurance re-imbursement for non-drug-treatment for chronic pain.
An unintended consequence of these attempts to control the overprescription of opioids has resulted in the movement to heroin, which is less expensive and more available. These control efforts include no refills on controlled substance prescrip-tions; limiting the number of pills in a prescription; opioid prescriptions having to be written and physically handed to pharma-cies (no electronic transmission), with patients showing ID when dropping off and picking up; limiting opioid prescriptions to seven days; the replacement of short-acting for long-acting formulations; prescription drug monitoring programs (PDMPs); and physician and pharmacist training. Another factor adding to the movement from prescription opioids to heroin was that drug-makers in recent years have stepped up efforts to make painkillers difficult to abuse, developing tamper-resistant pills that cannot be crushed, liquefied, or injected (Volkow, 2015).
Forty or fifty years ago people addicted to heroin were overwhelmingly male, disproportionately black, and very young (e.g., the average age of first use was sixteen). Most came from poor inner-city neighborhoods. These days, more than half are women, and 90 percent are white. The drug has crept into the suburbs and the middle classes, and although users are still mainly young, the age of initiation has risen: most first-timers are in their mid-twenties (Cicero, Ellis, Surratt, & Kurtz, 2014).

Social Losses Add to the Crisis
New studies strengthen ties between loss, pain, and drug use such as stagnating wages and fraying ties among people. Ac-cording to an article in Scientific American, “for every 1 percent increase in unemployment in the US, opioid overdose death rates rose by nearly 4 percent” (Szalavitz, 2017a). The counties with the lowest rates of social capital—including people’s trust in one another and participation in civic matters such as voting—had the highest rates of overdose deaths (Keyes et al., 2014; Szalavitz, 2017b). From 1999 to 2014, research “showed counties with the highest social capital were 83 percent less likely to be among those with high levels of overdose” (Szalavitz, 2017a). Additionally, an article in The Guardian states, “Indeed, this is seen as so important that researchers now see it as a subset of social capital they have labeled ‘recovery capital,’ and study what types of organizations and interventions are most conducive to growing it” (Szalavitz, 2017b).

The Role of Pharmaceutical Companies and Distributors
Spending on Oxycontin marketing went from $11,000 in 1996 (the first full year it was on the market) to $2 million in 2002. While there are doctors who overprescribe pain medication, the distributors (i.e., the link between the pharmaceutical com-panies and the retail pharmacies) know exactly how many pills go to every drug store they supply. And they are required un-der the Controlled Substances Act to report and stop what the DEA calls “suspicious orders” such as unusually large or fre-quent shipments of opioids. But DEA investigators say many distributors ignored that requirement. 60 Minutes reported that “a pharmacy in Kermit, West Virginia, a town of just 392 people, ordered nine million hydrocodone pills over two years” (Whita-ker, 2017). Additionally,
In 2008, the DEA slapped McKesson, the country’s largest drug distributor, with a $13.2 million dollar fine. That same year, Cardinal Health paid a
$34 million fine. Both companies were penalized by the DEA for filling hundreds of suspicious orders—millions of pills. Over the last seven years, distributors’ fines have totaled more than $341 million. The companies cried foul and complained to Congress that DEA regulations were vague and the agency was treating them like a foreign drug cartel (Whitaker, 2017).

Legislation Weakening the DEAís Ability to Stem Opioid Sales
The Washington Post reported the following:
In April 2016, at the height of the deadliest drug epidemic in US history, Congress effectively stripped the Drug Enforcement Administration (DEA) of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets.
. . . A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, the “Ensuring Patient Access and Effective Drug Enforcement Act,” which undermined efforts to staunch the flow of pain pills, according to an investigation by The Washington Post and 60 Minutes. The DEA had opposed the effort for years.
. . . The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican (Higham & Bern-stein, 2017).
Rep. Marino was President Trump’s nominee to be drug czar, a nomination later withdrawn when it was revealed that Rep. Marino received donations from the pharmaceutical industry of almost $100,000 (Higham & Bernstein, 2017).

The Overdose Crisis
The most notable aspect of the opioid crisis is the number of overdoses and resulting deaths: 20,101 from prescription opi-oids and 12,990 from heroin in 2015 (Rudd, Seth, David, & Scholl, 2016). This rate of overdose has increased because of the increasing availability of illicitly produced fentanyl, which is one hundred times more powerful than morphine.
Overdose reversal is accomplished by the administration of naloxone, an opioid antagonist. Naloxone prevents opioid re-ceptors from binding with any further opiates present so that a person who ingested too much of the substance will not expe-rience overdose from toxicity. The drug also completely counteracts the effects of an opioid overdose. In most cases the effect is immediate (within thirty to forty seconds), blocking the effects of the overdose and allowing the person to breathe again. Sometimes multiple doses are required and it is possible that even repeated administrations will not reverse a fentanyl over-dose. While available in a number of delivery systems, the most common is the nasal spray Narcan.
Narcan must be considered as a tourniquet only, and reversal will often result in the person continuing to use and possibly overdosing again. As valuable as is our ability to frequently reverse overdose, this is only the beginning (e.g., think of detoxifi-cation alone with no treatment follow-up). It is also important for first responders to know that, while fentanyl has a short dura-tion of action (thirty to ninety minutes), it can stay in fat deposits for hours, and patients should be monitored for up to twelve hours after resuscitation.
Medication-Assisted Treatment (MAT)/Pharmacotherapy for Addictive Disorders
There are now evidence-based treatments for opioid dependence, which include methadone (an agonist); buprenorphine, usually combined with naloxone as Suboxone (a partial agonist); and extended release, injectable naltrexone, Vivitrol (an an-tagonist). These medications should be administered in the context of behavioral counseling and psychosocial supports to im-prove outcomes and reduce relapse. Two comprehensive Cochrane reviews related to agonists—one analyzing data from eleven randomized clinical trials that compared the effectiveness of methadone to placebo, and another analyzing data from thirty-one trials comparing buprenorphine or methadone treatment to placebo—found that agonist treatment is a safe and effective treatment for drug dependence (Mattick et al., 2003). Methadone and buprenorphine are equally effective and Suboxone and Vivitrol are as well, but there is a problem with induction as Vivitrol requires ten to fourteen days of abstinence from an opioid before it can be administered.
Unfortunately, medications approved for the treatment of opioid abuse are underutilized and often not delivered in an ev-idence-based manner. Fewer than half of private-sector treatment programs offer these medications; and of patients in those programs who might benefit, only a third actually receive it (Knudsen, Abraham, & Roman, 2011).

Recommendations
Recent recommendations to physicians are that opioids be used only for short-term surgical pain and malignant pain, not for chronic pain. One concern is opioid-induced hyperalgesia (OIH), which “is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli” (Lee, Silverman, Hansen, Patel, & Manchikanti, 2011). This could result in increasing use to control the pain. According to an article in The New England Journal of Medicine, “prescribing opioids long-term for their analgesic effects will typically require increasingly higher doses in order to maintain the initial level of analgesia—up to ten times the original dose (Volkow & McLellan, 2016).
States and now the federal government have declared the opioid epidemic a public health emergency. States like Maryland have “tightened practices for those prescribing opioids and received a waiver to allow Medicaid to pay for residential drug treatment” (Allen, 2017). Additionally, funding has been made available to purchase Narcan, but there is still insufficient treatment capacity with resultant long waiting lists for treatment and MAT. One solution is to provide buprenorphine for those on wait lists in the interim until they can enter treatment.
One attempt to address the opioid crisis in some areas is that after overdose medication is given, the individual is brought to the hospital emergency room for stabilization, where a peer recovery specialist immediately contacts the addict and/or the addict’s family and discusses various available treatments including detoxification, MAT, and the range of psychosocial treat-ment options. If needed, the peer recovery specialist will drive the patient to the selected, available treatment. The goal is to intervene in the likelihood that the individual will immediately return to use. The combination of MAT, psychosocial treatment of sufficient duration, and case management or recovery support services appears to provide the best opportunity for a posi-tive outcome. Once again, there needs to be sufficient treatment resources for this to work effectively. c

About the Author
Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.

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