UNNATURAL CAUSES | SICK AND DYING IN SMALL-TOWN AMERICA: Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it.
Virtually all long-term users surveyed said that they were introduced to the drugs by a doctor’s prescription, not by friends or through illicit means. But more than 6 in 10 said doctors offered no advice on how or when to stop taking the drugs. And 1 in 5 said doctors provided insufficient information about the risk of side effects, including addiction.
The survey raises sharp questions about the responsibility of doctors for an epidemic of addiction and overdose that has claimed nearly 180,000 lives since 2000. Opioid deaths surged to more than 30,000 last year, according to new data from the U.S. Centers for Disease Control and Prevention, with deaths from heroin alone surpassing the toll from gun homicides.
Doctors have been widely blamed for sparking the crisis by overprescribing highly addictive opioids to treat everyday pain. The survey suggests that they are still doing too little to stop it.
“Why isn’t it 100 percent?” demanded Gary Mendell, founder of Shatterproof, a grass-roots group dedicated to reducing addiction in the United States, referring to the share who say doctors have counseled them on stopping the medication. “It’s unbelievable that it’s not 100 percent.”
Patrice A. Harris, chairwoman of the American Medical Association’s Board of Trustees and chair of its task force to reduce opioid abuse, acknowledged that doctors could do more to counsel patients on avoiding addiction.
“The doctors that I have talked to are discussing this with their patients,” Harris said. But, citing the survey, she added: “We could certainly do a better job.”
Despite the high rate of dependence, the poll finds that a majority of long-term opioid users say the drugs have dramatically improved their lives. Opioids relieve pain that is otherwise intractable, they said in follow-up interviews, allowing them to walk, work and pursue other activities. Fully two-thirds of users surveyed said relief is well worth the risk of addiction.
People living with opioid users tend to have a darker view of the drugs’ effects. While one-third of users say they are hooked, more than half of people living with them suspect addiction, the survey found. Family members are also far more likely to say the drugs have damaged the users’ physical and mental health, finances and personal relationships.
White women living in less-urban areas have seen a stark increase in death rates as much as 40 percent in some age groups.
Still, the survey’s findings highlight a fundamental conflict: While the drugs are a scourge for many, they are a godsend to others, especially the estimated 100 million Americans who live in chronic pain. Efforts by policymakers to restrict use have been met with outrage.
“We’re not saying that no one should ever be on these pills,” but most people would be “healthier and more functional if they were off them,” said CDC Director Tom Frieden, who this spring urged doctors to sharply limit the number of pills they prescribe.
“The bottom line here is that prescription opiates are as addictive as heroin. They’re dangerous drugs,” Frieden said. “You take a few pills, you can be addicted for life. You take a few too many and you can die.”
Opioid abuse — both prescription painkillers and their chemical cousins, heroin and fentanyl — is the main cause of rising death rates among middle-aged white Americans, particularly women in rural areas. It also has contributed to the first overall decline in U.S. life expectancy at birth in more than two decades, the government reported Thursday.
In 2014, U.S. doctors wrote 240 million prescriptions for opiates, enough for every adult to have their own bottle of pills. The CDC estimated that about 2.1 million Americans are addicted to legal narcotics.
In the first-ever guidelines on opioids for physicians, the CDC in March urged doctors to try nonnarcotic methods before offering patients pills containing oxycodone, hydrocodone and other opioids. The guidelines noted that there is little evidence that opioids are effective beyond 12 weeks.
“Three days or less will often be sufficient; more than seven days will rarely be needed,” the guidelines say.
But many people take the drugs much longer. In the past two years, about 5 percent of American adults have used prescription opioids for at least two months, the poll found; about half of those report taking the drugs for two years or more.
For the survey, one of the most comprehensive polls of long-term opioid users to date, The Post and Kaiser interviewed 622 people who said that they had taken narcotic painkillers for at least two months over the past two years. The survey also included 187 people who said they share a household with an opioid user, usually a spouse or a parent.
The survey did not include people who were treated for cancer or a terminal illness. At the time of the interview, 45 percent of long-term users were no longer taking the drugs, while 55 percent were still taking them. Users were slightly more likely than the general public to be white and far more apt to be middle-aged.
Nearly all long-term users (95 percent) said that they began taking the drugs to relieve pain from surgery, an injury or a chronic condition. Just 3 percent said that they started as recreational users.
More than 8 in 10 said that they tried to manage their pain with nonnarcotic medication; about 7 in 10 said that they tried alternative treatments, such as physical therapy and acupuncture. More than half (57 percent) found those methods ineffective.
Charles Stonesifer, 74, a former bricklayer who lives in Baltimore, has taken Tylenol with codeine and then Tramadol over the past two years. “Both my knees are shot,” he said, adding that he would be unable to walk without narcotics.
Stonesifer said that he had no trouble giving up the drugs when he tried, but his pain returned and he was forced to resume taking them.
“If they actually stopped you from getting the [drugs], it would be very difficult for me,” Stonesifer said. “It would put me in a wheelchair instead of being able to get around. And once you’re in a wheelchair, you never get up.”
Nancy Horton, 62, of Martinsburg, W.Va., admits that she is addicted to the 190 milligrams of oxycodone she takes daily to dull the pain of rheumatoid arthritis. Without the drugs, “I get the shakes. I am very anxious,” she said. “I just pace constantly. I can’t get comfortable.”
After 15 years on opioids, she said, “I look back now and think, ‘What could I have done differently?’ ”
Sizable minorities of respondents report using the drugs for purposes other than managing pain. Such behavior is much more common among people who say they are addicted or physically dependent on opioids. Among this group, 47 percent say they sometimes take the drugs for “fun or to get high”; 38 percent use them to “deal with day-to-day stress”; and 30 percent use them to “relax or relieve tension.”
Side effects are widespread. Over half of long-term users said that they have experienced constipation; almost as many felt indigestion, dry mouth or nausea; and 15 percent said that they have had breathing problems. One in 5 (21 percent) have taken additional medications to treat those symptoms.
More than half (52 percent) of long-term users said that they have taken other prescription medications for anxiety, depression and sleeplessness while on opioids, and 1 in 6 said that they have consumed the drugs along with alcohol — risky combinations that could have dire consequences. Overall, nearly 6 in 10 said that they take at least four prescription drugs, and about one-third said that they take seven or more medications.
The survey revealed a largely positive relationship between opioid consumers and their doctors. Large majorities said doctors have warned them to avoid alcohol, cautioned them about possible side effects and explained the risk of addiction.
But 61 percent said that their doctors did not suggest a plan for getting off the drugs when they were first prescribed, and more than half said doctors have not altered their dose or frequency. Among long-term users who stopped taking opioids, 34 percent said the termination of their prescription was a reason.
Just 4 percent said that they have a prescription for naloxone, the drug that can be administered by someone else in an emergency to reverse the effect of an overdose.
While about a quarter of long-term users said a friend or family member has suggested they stop taking the drug, two-thirds said that they are “not too” or “not at all” concerned about becoming addicted. And about 6 in 10 of those who report being addicted have not sought treatment or other help.
Yngvild Olsen, chair of the American Society of Addiction Medicine’s public policy committee, said doctors “have a vital role to play in addressing the epidemic, not only by changing their prescribing patterns and learning a lot more about chronic pain management and addiction, but also by stepping up to the plate in learning how to treat addiction.”
Emily Guskin, Monica Akhtar and Erin Patrick O’Connor contributed to this report.