That Fifth Vital Sign

The week that started on Sunday, August 21, 2016 was probably significant in that it highlighted the extent of the opioid epidemic in the US.
On Tuesday and Wednesday of that week, there were over 60 overdose cases in Cincinnati alone. In 2 counties in southern Indiana, there were 14 overdose cases between Tuesday night and Wednesday morning. In Mount Sterling in Kentucky, a city of about 7000, there were 12 overdoses on Wednesday alone!
Drug overdoses are up significantly in the US and 60% of them are due to opioids. It is estimated that there are about 16 000 opioid overdose cases a year now. So how did we get here? How did the US come to occupy the non-enviable position of the world’s largest consumer of opioids and opioid deaths?
To understand that, one has to understand what opioids are.

These are natural occurring drugs derived from opium, like morphine, that work on the opioid receptors in the body to relieve pain or synthetic ones like oxycontin and fentanyl that do the same. Now another kind of opioid, heroin, derived from morphine, has been used purely for recreation for a while but it’s recently become the replacement drug for addicts who cannot get their hands on the synthetic ones like oxycontin. More about that later.
Before the 1990s, doctors used opioids rather sparingly. One can say that pain was undertreated. Narcotics were mainly given to cancer patients. Then in 1980, Hershel Jick published a study claiming that the use of narcotics in 11,882 in-patients led to only 4 cases of addiction. Six years later, Portenoy published his study looking at the use narcotics in non-cancer patients. He claimed that there were no adverse effects. He studied 38 patients! He based his claims on 38 patients!
Even though both studies were highly flawed, they dramatically changed medical thinking and then practice. Portenoy formed the American Pain Society and preached that the risk for opioid addiction was less than 1% – a number he would later confess that he grabbed out of thin air!
The society came up with “Pain as a 5th vital sign” slogan and it caught on.

Into this fray, jumped Purdue Pharma. It launched Oxycontin in 1996. With aggressive marketing, the company promoted this new drug and got all on board.
The Joint Commission got behind the “Pain is the 5th vital sign” movement and the 0 to 10 pain scale with smiley and “wincey” faces was born. By 2004, doctors who undertreated pain faced sanctions. Opioids were being prescribed to all, even outpatients. Later Endo Pharma and Johnson & Johnson would join the opioid party with their own portfolio of synthetic opioids.
Purdue Pharma claimed that oxycontin was a slow-release formulation and would never lead to addiction. Well, we know better now. They had to pay $635 million in fines in 2007 for misbranding and reformulate the dug but by then it was too late.
By 2012, sales of opioids were more than $9 billion a year and in 2013, opioid overdose surpassed car accidents as the number one cause of accidental death.
To combat the indiscriminate prescription of opioids, several states like Kentucky, have enacted laws in the last 2 years that have made prescription of these drugs more onerous. Overnight, all the pill mills which churned out prescriptions for opioids vanished. The poor addicted patients had to find the next best replacement.

Enter heroin!
To make things worse, dealers are now lacing the heroin with illegal fentanyl that is formulated with raw materials from China.
To get how dangerous this combination is, follow me here. The standard opioid for comparison is morphine. Let’s give that a potency of 1. Heroin is about 4-times as potent and Fentanyl 75 – 125-times as potent. Now combine heroin and fentanyl!
So the intricate web of opioids and addiction was woven by Big Pharma and the medical profession around the issue of pain. Pain. Let’s define it:
“A distressing feeling caused by intense or damaging stimuli”, like cutting yourself with a knife or breaking an ankle. It was designed by the body to tell us something is wrong and to find a fix.
Pain is further broken down into acute and chronic pain.
Acute pain is what I described earlier. It comes on fast and is usually from an injury. it is treatable and goes away in days or even in a few months.
Chronic pain is a different animal. It is it’s own disease state because there is really no one reason for it. It is intractable pain that exists for three or more months and does not resolve in response to treatment. It is affected by physical, environmental and even psychological factors. Now acute pain can turn chronic if not treated well.
Opioids should classically be used to treat really bad acute pain like surgical pain, burns and trauma. It should be tapered off and other modalities of pain management used. Opioids should not be used for chronic pain, where there is no end in sight. The only group of patients with chronic pain who should be on long-term opioids should be cancer patients. That unfortunately did not happen and we are in this mess.

A way out might be the use of marijuana. In 2014, Bachhuber et al published a study in JAMA that showed a drop of 25% in opioid deaths in the 3 states where marijuana use is legal. Another paper by Powell’s group supported this. It showed that medical marijuana dispensaries were associated with a 16 percent (and possibly as high as a 31 percent) decrease in opioid overdose deaths. Lastly a study from this past July shows that doctors in states with medical marijuana laws wrote fewer opioid prescriptions.
The use of marijuana for pain might be due to it’s effect of cannabinoid receptors in the brain that modulate pain perception and it’s effect on sodium channels that play a role in pain genesis.

Like the needle-exchange program that was initially frowned on by many, it might be the only way out of this opioid quagmire.
Hopefully we as physicians will learn from this to base clinical decision-making on sound science and resist the aggressive marketing of the pharma industry.