Medical Minute – What Could be Worse than COVID?

By: Dr. James Lee

The opioid crisis is as ubiquitous as covid.  Not only have we become fatigued from hearing about it, but the overall death rate from overdose exceeds that of covid.  A recent study out of British Columbia found that not only did the mortality due to overdose increased during covid, but it also exceeded the death rate due to covid.

Opioids are a class of drug that include natural or synthetic drugs that are derived from the opium poppy.  Commonly used opioids include hydrocodone (Vicodin, Lortab, Norco), oxycodone (Percocet, Oxycontin), codeine (Tylenol 3), morphine, heroin, fentanyl, methadone, and opium.  Opioids attach to receptors in the spinal cord, limbic system of the brain, and brainstem. The action of opioids on the spinal cord receptors decreases the feeling of pain, even to serious injury.  The effect on the limbic system, which control our emotions, creates feelings of euphoria—pleasure contentment, and relaxation.  This is why opioids are addictive.  The action of opiates on the brainstem, which controls things we do automatically, specifically breathing, are why these drugs are dangerous and cause death. 

Long term use of opioids creates a condition called tolerance.  This means that more amount of drug is needed to produce the same desired effect be it pain relief or euphoria.  For those who develop tolerance and those who become addicted, there is a significant number that will transition from oxycodone to heroin, either due to tolerance, availability, or search for a better euphoric state.  The effect of these increased doses and increased potency on the brainstem receptors makes it more likely that overdose and death will occur.

There has been increased awareness of addiction and crackdown on prescriptions for opioids and other restricted medications by state and federal agencies that have arisen out of the Opioid Crisis.  This has forced people with chronic pain to seek other options and unintentionally resulted in an increase in illegal drug use.  The restrictions have cut down on the number of opioids available through legitimate pharmacies and have resulted in a rise in counterfeit pills.  Cartels have produced look alike medications down to the color, shape, and pill identifier codes.  There is no regulation of the dose, or which opiate ingredient and its potency is in these pills.  There has been a rise in Fentanyl, a very potent synthetic opiate that can be created in a lab.  Fentanyl is 50 times more potent than heroin and a hundred time more potent than morphine.  Just 2 milligrams of fentanyl can be lethal.  Fentanyl is on the rise in our state and community and is often added to heroin or counterfeit pills.  Another synthetic opiate Carfentanil is 100 times more potent than Fentanyl.  For those who choose to get their pain medications illegally, it is quite literally a game of Russian roulette.

There has been a lot of discussion about how we got here, blaming physicians and big pharmacy companies.   While there certainly has been overprescribing by well-intentioned physicians, “pill mills” by not so well-intentioned physicians, and inaccurate statements regarding the safety and risk of addiction by pharmaceutical companies perhaps driven by the bottom line, there is one culprit that has not been widely discussed: the federal government. 

In 1996, the American Pain Society instituted the use of pain as the 5th vital sign.  Vital signs include temperature, pulse, blood pressure, and respiration rate.  They are a way of rapidly assessing physical health, help diagnose possible disease, and show progress in treatment.  Shortly after the institution of this policy, Centers for Medicare and Medicaid Services (CMS) through patient satisfaction surveys of all patients admitted to hospitals across the U.S., began linking hospital reimbursement to patient satisfaction with how well their pain was managed.  Questions like “How often did the hospital or provider do everything in their power to control your pain?” and “During this hospital stay, how often was your pain well controlled?”  Setting aside the fact that those patients who had a negative experience are more likely to complete a survey than those who had a positive experience (think Yelp reviews), by CMS decreasing reimbursement to those hospitals that got bad surveys and bonuses to those hospitals where patients said their pain was always controlled, it is easy to see how this resulted in the overprescribing opiate pain medications.  Many small hospitals keep their doors open through reimbursement by CMS.  Anything but the top response from a patient, counts against the hospital. Of note, CMS continued to use these questions up until 2017, well into the opioid crisis, and it has directly contributed to the prescribed opioid epidemic.

Next week we will look into the numbers, what is being done, and what you can do to help.

Dr. James Lee serves as the Coroner of Winn Parish. He is a General Surgeon and Surgical Oncologist who has been practicing in Winnfield for over ten years. Dr. Lee attended the University of Colorado for his medical degree. He completed his residency in Surgery at the University of Oklahoma before completing a fellowship in Surgical Oncology and Endoscopy at Roswell Park Cancer Institute in Buffalo, NY. Dr. Lee and his wife Scarlett live in Winnfield with their son and are active in the community.