With Narcotics Abuse, Don't Just Blame Doctors

Dr. Richard Friedman certainly makes his point. But unfortunately, he fails to make a very important one, so in this instance public health was not completely well served.

In a recent New York Times op-ed, entitled "How Doctors Helped Drive the Addiction Crisis," he blames doctors for creating the soaring narcotic addiction problem in the United States. There is no doubt that there's some truth to this, but it's what Friedman doesn't say that's most interesting.

Recently we've written about a substantial increase in the deaths of middled-aged white men. While there was no single culprit, alcohol, drug abuse and suicides were mentioned as primary factors. But in Dr. Friedman's opinion piece, it's drug abuse primarily hydrocodone (Vicodin) and oxycodone (Percocet) that he focuses upon, saying "it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality." Later, he added that in "2013 alone, opioids were involved in 37 percent of all fatal drug overdoses."

This is the first problem. What Dr. Friedman, a professor of clinical psychiatry and the director of the psychopharmacology clinic at the Weill Cornell Medical College, didn't note is that the narcotic is often not to blame.

According to Dr. Sharon Hertz, the FDA's Deputy Director for the Division of Anesthesia, Analgesia and Addiction Products, Center for Drug Evaluation, "acetaminophen was responsible for at least 40 percent of [liver failure], and as many as one third of the deaths. The acetaminophen overdoses associated with these cases were more commonly unintentional than intentional. That's clearly a problem."

So, the OD numbers are inflated by one-third something that Dr. Friedman did not mention. In fact, he says, "What the public and physicians should know is that there is strong evidence that nonsteroidal anti-inflammatory drugs (Nsaids), like Motrin, and other analgesics like Tylenol are actually safer and more effective for many painful conditions than opioid painkillers."

I have written recently that Tylenol is not nearly as safe as people think. The difference between a therapeutic dose and a toxic dose is small. And, given the fact that many companies now make cough syrups with added decongestants and Tylenol (which is not easy to spot on the label), it is not far-fetched that someone would take twice the daily recommended dose enough to cause irreversible liver damage.

Friedman suggests that Tylenol combined with an NSAID (Advil, Aleve, etc) could be a good alternative to narcotic use (which is possible). But long-term NSAID use is very likely to screw up your stomach, and encourage bleeding, so this is not a slam dunk either.

But Friedman also gets quite a bit right:

• "The pitch to doctors [in the 1990s] seemed sensible and seductive: Be proactive with pain and treat it aggressively."
• "Well, doctors clearly got the message: The medical use of these drugs grew tenfold in just 20 years."
• "They are highly addictive and can produce significant depressive and anxiety states. And the annual direct healthcare costs of opioid users has been estimated to be more than eight times that of nonusers."

We clearly have a very serious narcotic addiction problem in the U.S. But, I worry that a heavy-handed approach could end up penalizing patients who have legitimate needs (this is already happening), while at the same time driving addicts to heroin. That is not only worse, but it involves needle-sharing, which is already spreading HIV and hepatitis C infection.

The whole thing is a mess. No good solutions exist only less-bad ones. But the worst of them is cruelly denying these strong, but very imperfect drugs, to terminal cancer patients and others who must deal with crippling pain.