You’ve heard Brian Mendell’s story — or one just like it — before.
In the early 2000s, after sustaining an injury while playing football at Joel Barlow High School in Redding, Brian was prescribed an opioid. Later he became addicted to these prescription pills, and then he started using heroin. Brian took his own life in 2011 at the age of 25.
Though the dangers of prescription opioids are well-documented today, there are still problems with the way they are routinely prescribed, says Brian’s father, Gary Mendell, who founded Shatterproof, a nonprofit dedicated to the fight against addiction, after Brian’s death.
“People are becoming addicted every single day in this country because a doctor legally prescribed two to three to four weeks of a prescription opioid that’s not necessary,” Mendell says.
As many as “1 in 4 people who receive prescription opioids long term for non-cancer pain in primary care settings struggles with addiction,” according to the Centers for Disease Control and Prevention. This has helped fuel the heroin epidemic, as one study in the 2000s found 80 percent of heroin users took prescription opioids prior to heroin.
In 2016 the CDC issued new guidelines detailing 12 measures for prescribing opioids for chronic pain. The first measure advises clinicians that “nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.”
Ever since the new guidelines were published, Mendell’s nonprofit has worked to publicize them to health care professionals, as prescription opioids are still regularly prescribed outside the recommended guidelines.
According to the CDC, in Connecticut in 2016, the most recent year for which data is available, 55.9 opioid prescriptions were dispensed per 100 persons, which is below the national average of 66.5 per 100 persons. This number is also down from a high of 69.3 in 2012. The state has seen a steady decline in opioid prescriptions between 2013 and 2016, culminating in an 18.4 percent decrease in the number of prescriptions, according to statistics provided by the Connecticut State Medical Society.
Doctors in the state are optimistic that trend will continue to improve.
Dr. Mark Kraus, co-chair of the Connecticut State Medical Society Opioid Task Force and internist and addiction medicine specialist with Franklin Medical Group and St. Mary’s Hospital in Waterbury, says doctors need to continue studying how to best treat pain patients. “It’s very much an ongoing education. Pain is not well taught in medical school and is poorly taught in residency. We’ve also learned that a pain patient can also be an addiction patient, so that’s a new cohort.”
Dr. Gregory Shangold, who is also co-chair of the opioid task force and specializes in emergency medicine and works at Windham Hospital, notes that 80 percent of emergency department visits are for pain, and doctors and patients have to change their expectations when it comes to pain relief. “[Patients] should not expect to be pain free, but to have your pain controlled so you can be functional,” he says. When prescription opioids are given, he adds, they need to be done so with caution. “It’s giving smaller amounts, not giving 50 or 60 Vicodin for every broken bone, but giving a smaller amount and then reassessing the patient to see if they really need that medicine.”
Until the 1990s, use of opioid prescriptions outside of hospitals was rare. The prescribing culture shifted dramatically that decade thanks in part to a massive marketing campaign by pharmaceutical companies including Stamford-based Purdue Pharma, makers of OxyContin, which was released in 1996. The pro-opioid marketing initially included faulty claims that the risk of addiction for patients given prescription opioids was low.
The mistakes of this ad campaign and the addiction potential of prescription opioids were clear, or should have been clear, early on. In 2003 Barry Meier, a New York Times journalist, released the book Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death, which details the then-little-known issues with how opioid medications were marketed and their potential for abuse. Even with the knowledge of potential risks for at least a decade and a half, the medical community has been slow to put the opioid-prescription genie back in the bottle. Watching this over the years has been heartbreaking to Mendell.
“It’s extremely tragic that we know what to do as a country, as a health care system, to prevent many of our loved ones from ever becoming addicted to prescription opioids, and our health care system is not adapting at a rate commensurate with the number of lives that are being lost unnecessarily,” he says.
Shortly after OxyContin was released, abusers of the drug learned that its signature time-release formula could be overridden by crushing the tablets, providing an intense high. In 2010 the company released its first abuse-deterrent version of the drug, which couldn’t be crushed. But the benefits of reformulated opioids are debatable, according to Dr. Jane Ballantyne, a professor of anesthesiology and pain medicine at the University of Washington School of Medicine.
“Abuse-deterrent formulations don’t stop people from becoming addicted, they only stop people from tampering with these medications,” she says. “The old party line was that as long as the medications are taken as prescribed, they are safe and effective. We now know that is not true, partly because people simply do not take any medications exactly as prescribed, which leads to problems, especially with risky drugs. Moreover, there is little evidence that long-term opioids are either safe or effective.”
In February, Purdue announced that it would stop promoting OxyContin directly to doctors and that it was cutting its sales force by more than half, down to 200. The company will shift marketing focus away from the blockbuster drug which earned $1.8 billion last year, according to data compiled by Symphony Health Solutions. Instead the company is focused on other products including Symproic, a drug for treating opioid-induced constipation. In an email, Bob Josephson, executive director of communications for Purdue Pharma, says, “In light of the opioid crisis, Purdue stopped its speakers programs, as well as direct promotion to prescribers. During the past years, Purdue has also launched multiple initiatives to help address the opioid crisis — including partnering with law enforcement to distribute naloxone, directing prescribers to the CDC Guideline for Prescribing Opioids for Chronic Pain and funding prescription drug-monitoring programs. We recognize that more needs to be done and that’s why we continue to pursue a range of solutions that will have a meaningful impact to help turn the tide of this national public health crisis.”
The move comes as the company, along with other opioid manufacturers, is facing an onslaught of lawsuits filed on behalf of towns and states across the country, including several in Connecticut.
James E. Hartley Jr., of the Waterbury law firm Drubner Hartley & Hellman, believes these moves by Purdue Pharma are too little too late.
“The pharmaceutical industry’s continued position is, ‘Oh, we’re doing whatever we can to help,’ ” Hartley says. “They want you to infer that it’s not really their fault, this just happened. [They] still cling to the false premise that these opioids prescribed under a doctor’s care don’t lead to addiction. That’s not true. Not everyone gets addicted, but clearly enough people do.”
In separate cases, Hartley is representing Waterbury and a dozen other Connecticut municipalities, including Hartford, Newtown, Bridgeport, Beacon Falls, Seymour and Naugatuck, in lawsuits against Purdue Pharma and other leading opioid manufacturers.
Connecticut is not among the states that have sued major opioid manufacturers, but Attorney General George Jepsen’s office is a leader in a multistate investigation looking at the practices of both manufacturers and distributors of opioid drugs.
“When I came into office in 2011 there was around 300 opioid-related overdose deaths a year. Five years later in 2017 we broke through 1,100,” Jepsen says. “The number of deaths due to prescription opioids has remained pretty constant but the growth has been [from] the access to cheap heroin and, in the last few years, fentanyl. We’re trying to get our arms around the real causes of this and what’s the best route to deal with it.”