Death is relative unless of course, it affects someone close to you. How we measure deaths and over what period of time matters in how the public perceives these deaths. Here a few figures about deaths related to opioids, and we’ve changed the way they’re presented. Rather than spreading them out over time, we’ve aggregated them. They make for pretty shocking figures.

Opioid-related data demonstrated an almost fourfold increase in overdose deaths from 1999 to 2008, according to a 2018 review published in NCBI.

By 2016, deaths had risen to over 42,000 for that calendar year. Keep in mind these are deaths directly caused by overdose or abuse of the drug. Many deaths aren’t shown as such, so this figure is conservative. People die in drug-related crimes, violence, and suicide, directly linked to their addiction lifestyle. Opioids pulled the trigger, but arent recorded as the primary cause of death.

Opioid overdoses related to illegally manufactured fentanyl (the most powerful of the opioids) represented the greatest contribution to the increasing numbers, accounting for 20,000 of the 42,000 deaths. As a result, on October 16, 2017, the US Government declared the opioid epidemic a public health emergency.

The medical community, and particularly pain medicine practitioners, had been active participants and fully aware of the development of the current state. Prescription drug monitoring programs (PDMPs) and the National All Schedules Prescription Electronic Reporting Act (NASPER) have effectively contributed to the reduction in opioid prescriptions by 8%, but on the ground, these initiatives have not translated into saved lives. In fact, quite the opposite.

Fast forward to 2021. From emerging figures, it becomes evident that we are losing this battle, and spectacularly so. In 2019, nearly 50,000 people in the United States died from opioid-involved overdoses.

From 1999 to 2019, nearly 841,000 Americans died from a drug overdose.³ Over 70% of overdose deaths involved an opioid-like prescription, opioids, heroin, or synthetic opioids (like fentanyl). If you add in figures from 2019 to now, 2021 you can safely assume we are over a million deaths, of which more than 700 000 are related to opioid addiction.

How did we get here?

Opioids and cocaine were widely prescribed in the late 19th century for anything from toothache to diarrhea. No regulation existed and only when street addition became evident was regulation enforced. The Harrison Narcotic Control Act of 1914, passed in response to the sudden emergence of street heroin abuse as well as iatrogenic morphine dependence, influenced both physicians and patients alike to avoid opiates.

It would take nearly eighty years for opioids to come back into vogue as one of the most effective treatments we have to manage pain, particularly extreme and chronic pain. The concept was a simple one. If cancer patients could benefit from opioid use to manage pain, why not extend the benefit to chronic pain sufferers too? The flaw in this concept, evident even to a layman, lies in the fact that the two types of pain differ significantly, cancer pain and chronic, non-cancer pain, and ignores the etiologies of malignant and non-malignant pain

This dangerous conflation disregarded the complex biopsychosocial phenomena that is chronic pain, and despite many cautions to this effect, opioids grew into the primary modality of chronic non-cancer pain treatment we know today in the USA¹.

It can therefore be argued that pressure from within Pharma and the decision to widely ignore the cautionary voices raised across the industry are directly responsible for the opioid scourge that now blights American Healthcare. This is worth noting as we look to assign responsibility for the opioid pandemic.

To explain the depth of complicity, consider this. In 2000 the Federation of State Medical Boards and the Drug Enforcement Agency issued statements promising less regulatory scrutiny over opioid prescribers, thereby assuaging physician reluctance to prescribe more liberal amounts of opioid analgesics.²

Provider abetted addiction in modern-day American Healthcare had just been given the official green light.

How opioids work

All opioids are chemically related and interact with opioid receptors on nerve cells in the body and brain. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use — even as prescribed by a doctor — can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose incidents, and deaths.

Exactly how addictive are opioids? That depends on a number of factors and varies from patient to patient. It should take a couple of weeks to become physically dependent on an opioid, but that varies. If you take an opioid for a day or two, it should not be a problem and, generally, you will not become addicted. However, some studies show even the first dose of an opioid can have physiological effects.

There is no exact data and by ingesting an opioid, you are in effect playing a pharmacological version of Russian roulette. If you suffer from cancer-related pain, then you are in a category where the risk is justified by the pain you are experiencing. It is important to understand that you can be physically dependent on a substance but you don’t necessarily have problematic use. A cancer patient with chronic pain may be physically dependent but not addicted.

Opioids are one of the most addictive medications prescribed. Even doctors can become caught up in this dependency cycle, popping a few pills over the course of a few days for sorting out a nagging pain. Ingesting an opioid exposes you to the risk of addiction.

Examining the types of opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.

Brand names (generic names)

• Abstral (fentanyl),
• Actiq (fentanyl),
• Avinza (morphine sulfate extended-release capsules),
• Butrans (buprenorphine transdermal system),
• Demerol (meperidine [also known as isonipecaine or pethidine]),
• Dilaudid (hydromorphone [also known as dihydromorphinone])
• Dolophine (methadone hydrochloride tablets)
• Duragesic (fentanyl transdermal system)
• Fentora (fentanyl)
• Hysingla (hydrocodone)
• Methadose (methadone)
• Morphabond (morphine)
• Nucynta ER (tapentadol extended-release oral tablets)
• Onsolis (fentanyl)
• Oramorph (morphine)
• Oxaydo (oxycodone)
• Roxanol-T (morphine)
• Sublimaze (fentanyl)
• Xtampza ER (oxycodone)
• Zohydro ER (hydrocodone)

Street Names

Captain Cody, Cody, Schoolboy, Doors & Fours, Pancakes & Syrup, Loads, M, Miss Emma, Monkey, White Stuff, Demmies, Pain killer, Apache, China girl, Dance fever, Goodfella, Murder 8, Tango and Cash, China white, Friend, Jackpot, TNT, Oxy 80, Oxycat, Hillbilly heroin, Percs, Perks, Juice, Dillies.

Opioids listed by strength

Opioids are not all created equally and are available in varying strengths, with carfentanil and fentanyl widely recognized as the most potent. This list, provided with thanks by the Dana Point Rehab Campus lists the typical opioids by strength.

1. Carfentanil — Carfentanil is an extremely dangerous opioid that is 10,000 times more potent than morphine and 100 times more potent than fentanyl. Carfentanil is used to tranquilize elephants and other large animals and is not intended for use in humans. Drug dealers may mix carfentanil into their drug supplies to provide their customers with a more potent, addictive high.

2. Fentanyl — Fentanyl is 50 to 100 times more potent than morphine and has been the main contributor to the rise in overdose deaths in recent years. The majority of fentanyl-related deaths involve synthetic fentanyl that is manufactured overseas and mixed with other illicit drugs including heroin, cocaine, and methamphetamine.

It is sold under brand names including Sublimaze, Duragesic, and Actiq. It also has many street names including China Death, TNT, Murder 8, Jackpot, Goodfella, Dance Fever, Apache, and China Girl.

3. Buprenorphine (Butrans) — Buprenorphine is an FDA-approved medication for the treatment of opioid use disorder. It is about 25 to 100 times more potent than morphine, but it does not provide a euphoric high like other opioids. Buprenorphine is used in drug detox to relieve and reduce opioid withdrawal symptoms.

4. Oxymorphone — Oxymorphone is sold under brand names such as Opana and Numorphone. It is an extended-release opioid that has many street names including O Bomb, Stop Signs, Biscuits, and Blues. Oxymorphone is used to relieve moderate to severe pain in patients who are unable to reduce or control pain with other medications. Oxymorphone is 3 times stronger than morphine when taken in tablet form, and 10 times stronger than morphine when received as an intravenous injection.

5. Hydromorphone — Hydromorphone is used to relieve moderate to severe pain and is about two to eight times more potent than morphine, reports the DEA. It is available as an injection, tablet, liquid, and rectal suppository.

6. Heroin — Heroin is an illicit drug classified as a Schedule I substance with a high potential for abuse. Heroin is usually two to five times stronger than morphine and commonly mixed with other potent substances such as fentanyl or carfentanil. In 2018, heroin was involved in 14,996 overdose deaths in the U.S.

7. Methadone (Dolophine, Methadose) — Methadone is another FDA-approved medication for the treatment of opioid addiction and is about three times stronger than morphine. Methadone is often used for long-term maintenance in people in recovery from opioid addiction, and can only be dispensed at an outpatient clinic under direct medical supervision.

8. OxyContin — OxyContin is a brand name for Oxycodone, a well-known extended-release opioid. Oxycodone is prescribed to treat moderate to severe pain and is about 50% stronger than morphine. The CDC reports that oxycodone is one of the most common drugs involved in prescription opioid overdose deaths. In 2018, prescription opioids like oxycodone contributed to 14,975 overdose deaths in the U.S.

It is usually sold as a tablet that is meant to last an entire day, which is often bypassed by drug abusers to quicken the release time. Street names include O.C., Oxy, Oxycet, Oxycotton, and Hillbilly Heroin.

9. Percocet — This drug is a combination of oxycodone and acetaminophen. It comes in tablet, liquid oral solution, and capsule form. Some of the street names for the drug include Percs and Hillbilly Heroin since it also contains oxycodone.

10. Hydrocodone — The next in the list of opioids strongest to weakest is hydrocodone, which is sold under many different brand names such as Norco, Vicodin, and Zohydro. It is usually sold as a way to manage pain after surgery, chronic pain, or pain from an injury. It comes in both syrup and tablet form. Street names for hydrocodone include names such as Watson-387 and Vike.

Hydrocodone has about the same strength as morphine and is commonly combined with other pain relievers such as ibuprofen and acetaminophen.

11. Morphine — The drug that was known as the “soldier’s disease” due to addictions it caused during war times, is the next in our list of opiates. Brand names include MS Contin and Duramorph among others. It is often used as a pain-management solution for cancer patients. It is available in tablet, capsule, suppository, and injectable form. It has street names such as White Stuff, Monkey, and Miss Emma.

12. Tramadol (Ultram) — Tramadol is used to relieve moderate to moderately severe pain and has about one-tenth the potency of morphine. This drug is the only opioid categorized as a Schedule IV substance on the Controlled Substances Act.

13. Demerol (Meperidine) — The brand name opioid, Demerol, is most frequently used to treat moderate to severe pain, and is about 7 to 10 times less potent than morphine. It may also be used as anesthesia due to its potency. The drug comes in a variety of forms including an injectable solution, tablet, and liquid oral solution. Common street names include Pain Killer and Demmies.

Though meperidine is less potent than many other opioids, it is classified as a Schedule II narcotic along with oxycodone and fentanyl.

14. Codeine — This opioid is a relatively short-acting opiate. It is commonly prescribed along with aspirin and acetaminophen. Tablet, capsule, and liquid forms of the drug are sold. Some of the names that Codeine goes by when sold illegally include Purple Drank, Lean, Cody, and Sizzurp.

Overcoming opioid addiction

It will probably come as no surprise that pharma has been beavering away to create treatments it can sell you to counter opioid addition. Ironic and possibly the most glaring indictment of an industry bereft of ethics or patient-focused motives. Weaning a patient off opioids is a lengthy, expensive and demanding process, for both provider and patient and is often met with failure.

Methadone, when administered properly, is included in treatment with counseling and is always provided in a clinical setting. It helps to block the effects of opioids and to reduce cravings.

The medicine buprenorphine also helps opioid cravings without giving the same high as other opioid drugs. Prescribed by many physicians, this is typically a daily dose placed under the tongue and can also be delivered as a once-a-month injection or through thin tubes placed under the skin every six months.

These medicines both activate opioid receptors in the body that suppress cravings, and are effective and similar in safety and side effects, and typically used for maintenance treatment. They can be used as a taper agent as well but some patients relapse. Patients who are highly motivated and have good social support have a tendency to do better.

Naltrexone

This medicine is very different and doesn’t activate the opioid receptor the way that buprenorphine and methadone do, but instead blocks the euphoric/sedative effects of opioids. Your system must be completely free of all opioids before beginning naltrexone. It can be taken orally or as a once-a-month injection.

References

1. Opioid treatment of chronic nonmalignant pain. Stein C Anesth Analg. 1997 Apr; 84(4):912–4. [PubMed] [Ref list]
2. Pain management, controlled substances, and state medical board policy: a decade of change. Joranson DE, Gilson AM, Dahl JL, Haddox JD J Pain Symptom Manage. 2002 Feb; 23(2):138–47. [PubMed] [Ref list]
3. America’s Drug Overdose Epidemic. [CDC]

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It’s a tip of the hat to faith healers, shamans, and witch doctors. It is also a shameful marketing ploy by medically trained professionals that should know better and it is a seriously dangerous red flashing light for the profession and its credibility.

Drugs have become our fallback for almost everything. Practitioners in general are massively guilty of doling them out as a panacea for socially compromised adults. Adults that possess no life skills or coping mechanisms are simply drugged into oblivion. You don’t need to worry about handling life if you’re too stoned to notice it. Forget therapy or actually trying to provide the necessary life skills. Too time-consuming and really, why cure when you create a lifetime of dependence? 

Medicine is slipping, quitely, intentionally and unnoticed, into a new sideline.

It is becoming the traveling quack show we so despise, prescribing drugs to treat conditions that mostly don’t exist, conditions some practitioners are unqualified to recognize, let alone prescribe for, and unfortunately, when it comes to those who are trained, the fallback (and sometimes go-to)treatment is the ever lucrative cocktail of mind-altering concoctions we now have at our disposal.

I would go so far as to say that 90% of the patients showing up cap in hand at your door aren’t suffering from any condition your medication could possibly treat, let alone cure. Forget management, if that’s where you’re going. That isn’t an out either. Someone who hasn’t been given the tools or strategies to cope with life doesn’t require medication, they need the school of life and real help to develop mechanisms many of us are already fortunate enough to possess. Medicating these patients is CRIMINAL. It is WRONG. It is UNETHICAL.

I would suggest to our modern-day mental health professionals and doctors alike, that unless you are really gullible or simply follow the flock, that you are aware of the failings in your treatment of these individuals. It’s an easy out, isn’t it? We’ve conditioned the patients to expect the pill. The miracle in the bottle, the panacea that will solve all of life’s problems.

Your patient doesn’t want any other form of help. They simply want the easy route and they’ll sit in front of you and bitch till you get out that pad and start writing. Part of you justifies it with a simplistic thought to ease your conscience. If you don’t prescribe, they’ll simply get it somewhere else. So you cave in. It’s quicker, it’s easier and at least, you think to yourself as you start writing, you can keep an eye on them.

WRONG. STOP. What you are doing is unethical. Is it in the patient’s best interest? Are you properly qualified to make that judgment? Do you understand that you are fundamentally changing the course of the person’s life sitting in front of you. Do you REALLY? Those quick, few lines on that script are potentially going to create a life of addiction and dependency. Was that why you joined the medical profession. For some doctors and many psychiatrists, it clearly seems to be.

Your flashing lights, new age mumbo jumbo, and cutting edge designer drugs are simply complex rituals you’ve designed to cover your snake oil shows. The best interests of the patient ceased being at issue years ago and the danger now, as even universities get involved in the medical mystery tour routine, is that people will start to perceive this as being real medicine. It isn’t and every effort must be made to ensure it never becomes that.

 It is a marketing farce, quackery, and pseudoscience wrapped up in what you assume to be a professional presentation to fool the public We see you. We see the lives you are destroying and you better believe we aren’t going to let it go.

It’s time to clean up your sad acts. Revert back to your core principles and HELP the patient, stop helping yourselves. Why Treat when you can Cure? By all means, assist your patients, but do so ethically. Treat them humanely and help them to address the shortcomings in their lives by providing them with lasting skills to cope with their existences. None of this involves any need to get your local pharmacist involved.

You’ll find the rewards from this difficult and lengthy process to be far more rewarding than all the time you currently spend arranging your mirrors and putting on the makeup. 

Where are your facts?

Oh, they’re coming. Don’t fret. This is simply a warning shot, fired across the bows, to encourage those with sense to pause, stop, and re-assess their current practices. Most will ignore it, but it may hopefully reach a few professionals. Medika will be publishing a few in-depth articles in the coming weeks on the disgraceful practices that are now becoming almost routine within the mental health community. Medication will feature strongly, as will the tendency to misdiagnose.

To push patients into neatly labeled boxes, each representing a different condition. Boxes that simplify everyone’s life. The patient considers his medication justified, even if the diagnosis of late-onset autism seems a little iffy. The care provider has only to continue handing out the medication and monitoring the patient. A lengthy and sometimes lifelong relationship that benefits no one, other than the practitioner.

Good doctors, ethical doctors, of whom there are many, whose sole purpose is to ensure the health of their patients, are also compromised as trust in the profession is eroded. Patients no longer view the profession with the dewy-eyed trust enjoyed by doctors fifty years ago. No one is more to blame for this than the quacks and charlatans from within the ranks of medicine itself.

That these quacks were, and are still able, in some instances, to pursue their chosen professions, speaks volumes to the lack of proper, swift, and merciless sanction from governing bodies. Lenient approaches from regulatory bodies within certain states encourage the problem and any potential solutions to eradicating this rot from the medical profession have to be undertaken with the full engagement of these bodies.

It must be eradicated. Medicine cannot afford further dilution of the trust it enjoys from the public. The consequences will be devastating, impacting vaccination rates, terminal care, and the inevitable escalating costs of trying to save those who have ventured away from traditional medicine to seek salvation in the hands of the natural healers and fraudsters that permeate the internet.

If we continue to dispense so easily, to medicate without sound reason, then we are in effect digging our own graves. You cannot magic away the problems of two generations of poorly parented adults with a pill. You see doctor, your patients aren’t ill, they are just ill-prepared.

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