What do hospice nurses and teenage heroin addicts have in common?

What do hospice nurses and teenage heroin addicts have in common? One may be an unintended consequence of the other.

A pair of articles published recently in two prestigious medical journals help make the case.

The Lancet reported that 47 million of the 58 million deaths occurring annually worldwide take place in developing countries, and that of these, fully 27 million die without having received proper palliative care. The article attributes this dismal performance to the overly restrictive regulation of narcotic pain relievers in an effort to help combat drug trafficking; morphine is unavailable in more than 150 of these countries. The regulatory burdens are so great that most pharmacies are reluctant to even order it. The strongest analgesic available to many cancer patients in developing countries is aspirin. Of 1 million cancer patients requiring pain medication in India in 2008, only 40,000 received morphine.

Such grisly data can’t help but make one grateful to be living in the developed world, where—in no small part thanks to Leo Tolstoy, whose short story The Death of Ivan Ilyitch greatly increased public awareness of the need for palliative care—the situation is much different. Cancer patients in the United States have widespread access to hospice programs—modern day Mercy Queens—and narcotic pain relievers. But we may be victims of our own success. The movement to relieve pain and suffering at the end-of-life has morphed into an effort to relieve pain and suffering in the general population, with extended-release, long-acting opioids the agents of choice. An editorial in The New England Journal of Medicine discusses the consequences.

There are approximately 1 million prescribers of controlled substances registered with the Drug Enforcement Administration and about 4 million patients receiving long-acting opioids annually. Deaths from unintentional drug overdoses are now the second leading cause of accidental death in the United States, with 27,658 such deaths in 2007. 41% of these—11,499—were due to synthetic opioids. Emergency room visits for opioid abuse more than doubled from 2004 to 2008, and admissions to chemical dependency treatment programs rose by 400% from 1998 to 2008, with prescription narcotics second only to marijuana as the cause of addiction. Since 1990, the medical use of opioids has increased ten-fold. Drugs such as Oxycontin “are essentially legal heroin.”

The proliferation of these drugs has put them in the medicine cabinets of citizens—and parents—all across the country. So much so that it is just as easy for a thrill-seeking 14-year-old to filch some Oxycontin from the medicine cabinet as it is to siphon some Jack Daniels from the liquor cabinet. But Oxycontin is highly addicting—and expensive. Teenagers who develop an addiction to it—whether taken from the medicine cabinet of their parents or that of their friends’ parents—soon have trouble scoring enough to maintain them. They quickly discover a much more affordable and readily available alternative: heroin, which when smoked is dirt cheap compared to Oxycontin. A two-hour exposé on local TV in San Diego this week referred to the problem of teen use of Oxycontin with subsequent migration to heroin as “epidemic.”

So there you have it: from genuine Mercy Queens to teenage heroin fiends, the rise of opioid use in America.

We should perhaps not be so quick to condemn our developing world counterparts for their reluctance to embrace our more permissive use of prescription narcotics.

Richard Barager is a nephrologist who blogs at his self-titled site, Richard Barager.

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