HJNO Jul/Aug 2022

HEALTHCARE JOURNAL OF NEW ORLEANS I  JUL / AUG 2022 15 “Addiction as a brain disease revised: why it still matters, and the need for consilience” from theMay/June 2022 issue — it is obvious that addictive personality had a very impor- tant role in the development of the opioid epidemic. In medicine, we assess the seri- ousness of the pathology and how aggres- sively we need to react to treat it based on the degree of severity —mild, moderate, and severe. I used to tell my residents, “You do not want to kill a fly with a bazooka.” The DSM-5 stratifies current diagnostic catego- ries as such: risky substance use, substance use disorder, and, finally, the more compli- cated to treat and control, addiction. So, yes, we need a pathological behav- ior, and it can be in one of the three stages I mentioned above. But in concern of tak- ing a patient from risky substance use to severe, full-blown addiction ... that would need facilitators and enablers, and that is where money and greed play their roles. Once the aggressive marketing of Oxy- Contin started, and the prescriptions for opioids started to pile up, the demand grew, and one of the alternatives to make money (even to have access to other illicit drugs like cocaine, meth, crack, etc.), was diver- sion — selling the pills on the black market. Due to high demand and the convincing of doctors that the best way to treat pain was to increase the dosages, we went from only having OxyContin in 10, 20, and 40 milli- gram dosages to an off-the-charts dose of 80 mg! Since this opioid epidemic started, diver- sion of these drugs became a widespread practice, and it has been documented that the main source of opioid diversion in the United States is provider overprescribing for acute and postoperative pain. 9 This is the right time to share with you something that happened with one of my ex-patients that totally blew my mind and changed my decision making on how I was prescribing opioids. It is important to men- tion that this event took place in 2015. I entered one of the rooms of the clinic and found a man in his early 40s grimacing in pain and barely able to move, standing in one of the corners, resting his hand on the edge of the examination bed. I had read his medical history in the EMR, but this was the first time I saw him. The main diagnosis was chronic pain and lumbar spondylosis — in layman’s terms, arthritis of the lumbar spine. The patient looked in surprisingly decent shape, not the classic morbidly obese patient that meets the profile of someone suffering with chronic pain. That struck me as odd, but I gave him the benefit of the doubt. When I asked him what was wrong, he pointed at his lumbar area close to L3-4, beside the spinal processes. When I touched him, he almost fell to the floor grimacing and almost yelling in pain. He was on the verge of tears. We were prescribing oxyco- done with Tylenol 10/325 mg, three a day. He convinced me to give him a few extras due to the pain that, according to him, had started that morning after a weird move when he was leaving his bed. “It is unbear- able,” he said. I fell for it. I prescribed oxycodone with Tylenol 10/325 mg at 3 to 4 a day as needed for pain, and I gave him 105 pills — 15 more than the three a day, which would have been a total of 90. I told him that, usually, this kind of event subsides in about 72 hours (or three days), but on his next visit, we would try to wean him off because he was a young person in pretty good shape who would most likely do better if he could stick to a regular exercise program and get off the opioids. Well, fortune was on my side. I needed to renewmy medical license that day and had to go to my car to get my wallet to pay for it online. To my surprise, I sawmy “patient” jumping and goofing around with one of his friend’s, waving the prescription that I had signed a fewminutes earlier while they were crossing the street! The next day, without knowing that I saw him, he was at the front window demanding to see me because the pharmacist told him that I had canceled the prescription. I asked the receptionist to call me because I wanted to talk to him as soon as he showed up. It did not take long to get rid of him. When I mentioned the police, the guy practically vanished. Sadly, stories like mine, I am sure, happen every day all over the country, and we are not lucky enough to catch them all the time. More “prescription” opioids are being bought on the black market, often through social media or e-commerce websites. These pills are usually counterfeit, made in Mexico or China, and contain fentanyl and methamphetamine. 10 Another important point: The dosage and the number of tablets prescribed matters. Communities with higher opioid prescrib- ing rates experience higher drug overdose rates, even among individuals who are not prescribed opioids. 11 THE MEDICAL COMMUNITY DECIDES TO ACT Once the numbers started to resonate, it was imperative to use any resort at hand to control or at least mitigate the opioid epidemic. Numbers like 417,601 overdose deaths since January 2015; like in 2017, 75,000 Americans died for the same cause; over 93,000 overdose deaths in 2020, up by 30% from 2019 and the highest death rate ever recorded! 9 Deaths from the Vietnam War and AIDS pale in comparison to the statistics above. To be more specific, during the Vietnam War (1955-1975), a total of 58,220American service members died. The highest annual death rate attributed to AIDS was 43,000 in 1995; thankfully, by 2016, this death rate dropped to 6,721. 9 In the state of Louisiana, overdose deaths involving opioids are estimated to have increased by 67% from 2019 to 2020 accord- ing to LDH data from its Louisiana Opioid Data and Surveillance System, reaching nearly 1,000 in 2020. The total number of drug-related deaths in Louisiana in 2020 was 2,121, which means that opioid-related deaths accounted for nearly half. 12 As in most of the U.S., overdose deaths