Whether or not the musician Prince died of an overdose of prescription painkillers, as some suspect, his death has refocused attention on a problem that has taken a back seat to heroin in the national conversation.
Yet nearly twice as many people die each year overdosing on pain pills than heroin. And even in a state like Ohio, which has been rocked by heroin deaths, prescription drug deaths account for nearly half of all unintentional drug overdoses.
“There is such a misperception that prescription opiates are safe simply because they can be prescribed in a legal manner,” said Andrea Hoff director of prevention and early intervention at the Alcohol, Drug Addiction and Mental Health Services board of Montgomery County. “But they do have the potential for abuse. They have to be looked at just like you would with any other type of illicit substance like heroin, like cocaine, and be as careful.”
Like heroin and other opioids, prescription pills like Oxycontin, Percocet and Vicodin can shut down the central nervous system, said Dr. Josephine Wilson, a Wright State University addiction researcher and professor.
“It’s going to turn off your medulla,” she said. “You’re going to stop breathing. You’re going to die.”
No autopsy yet
It’s not clear yet what killed Prince, who died in his suburban Minneapolis home on April 21, six days after his private plane made an emergency landing in Moline, Ill., while returning from an Atlanta concert.
It’s been widely reported that the singer and composer fell unconscious and received the overdose reversal drug Narcan while on the runway. He was taken to a hospital but declined to be admitted. Sources have said that a reaction to Percocet prompted the emergency landing.
But the musician returned home to Minnesota and even appeared on stage during a dance party at his home that weekend. His death days later shocked the world.
Much speculation since has focused on his use of pills for pain, including hip and other ailments due to wear and tear from a career of on-stage performing.
Montgomery County Coroner Dr. Kent Harshbarger isn’t surprised that the autopsy results have taken this long.
Harshbarger, whose office is on pace to do 2,000 autopsies this year, said the ruling in the singer’s case is complicated by a number of factors.
“At the time the autopsy’s done, it’s not only potentially a painkiller death. We’re ruling in and out other mechanisms,” he said. “Was someone else involved in the death? Was it an accident? Is there trauma? Is there natural disease?”
In the prescription drug cases he’s encountered, Harshbarger said tests often reveal multiple substances are present.
“More of what we see is the worst combination, using the drug in combination with something else. Significant levels of ethanol — alcohol — and other benzodiazepines and other classes of drugs. That mix,” he said.
Since 2000, deaths from drug overdoses containing opioids — both pain relievers like Percocet and illicit drugs like heroin — have jumped 200 percent, pushing drug overdoses to the leading cause of accidental death in the U.S.
This should put the numbers in perspective: More people die from drug overdoses every year than traffic accidents.
In 2014, overdoses claimed 47,055 lives — more than any year on record. Of those, 18,893 were related to prescription pain relievers and 10,574 related to heroin, according to the Centers for Disease Control and Prevention (CDC).
But the actual number of pain-reliever deaths is probably much worse. About one in five overdose death certificates in 2013 and 2014 didn’t list information about the specific types of drugs involved, according to the CDC.
America’s appetite for pain pills — and the ease at which they are obtained — is so ingrained in society and the practice of medicine that the U.S., which has roughly 5 percent of the world’s population, consumes an estimated 75 percent of the prescription drugs worldwide, according to a 2011 report from the United Nations Office on Drugs and Crime.
“The United States has a terrible problem with prescription medications,” Hoff said. “We have this quick-fix culture where we feel like we should never be in pain.”
Sales of prescription opioid medications has increased 300 percent since 1999 with a fourfold increase in deaths since that year, according to a recent study in the Annals of Internal Medicine.
The United States and New Zealand are the only two countries in the world that allow pharmaceutical companies to advertise prescription drugs, and drug makers spent up to $4.5 billion in advertising as late as 2014, according to market research firm Kantar Media.
The American Medical Association sought to ban drug advertising last year, saying it contributes to over-prescribing and pushes up the price of medicine.
‘We never talked about addiction’
The nation’s physicians, who had a large hand in creating the opioid epidemic, can now play an important role in weaning the nation from its addiction to drugs, said Wilson, who directs a substance abuse program at Wright State University’s Boonshoft School of Medicine.
“Nobody ever told me about addiction when I was in dental school more than 30 years ago,” she said. “We never talked about addiction. We talked about stopping pain. You just write that prescription for an opioid.”
Doctors in the 1980s and 1990s were taught to gauge pain as a “fifth vital sign” along with heart rate, blood pressure, respiratory rate and temperature, Wilson said. Writing prescriptions became “rote stuff,” she said, and patients routinely went home with seven to 10 days of prescription painkillers.
“Medical education in the United States is probably among the best in the world,” Wilson said. “I just think that doctors have been so used to approaching a problem one of two ways: you either write a prescription or you do surgery.”
That attitude has begun to change at medical schools across the country, including at Wright State. Wilson said she and a colleague, Dr. Stuart Leeds, have developed a new protocol for teaching medical students and residents learning to be family physicians to manage nonmalignant pain.
Some regions of the country lack pain specialists and family physicians must juggle that responsibility with little training, Wilson said. The checklist-driven system aims to help physicians identify a patent’s risk factor for prescription abuse and exhaust non-opioid alternatives first.
Similarly, the federal Department of Health and Human Services and the CDC in March issued new prescribing opioid guidelines for chronic pain unrelated to cancer care, palliative or end-of-life care.
The guidelines recommend physicians attempt non-opioid therapies first, which can include physical therapy or other drugs to combat chronic pain.
‘They switch to heroin’
Ohio, led by Attorney General Mike DeWine, cracked down on “pill mills” beginning in 2011 in an attempt to quell the easy accessibility of opiates.
As of March of this year, DeWine’s administration along with the state’s Pharmacy Board and Medical Boards had revoked the licenses of 20 pharmacists, two pharmacist interns, and three facilities and the licenses of 78 physicians. In all, scores of people have been convicted on charges related to the improper prescribing, dispensing, diversion or trafficking of prescription drugs, according to the Attorney General’s office.
But the pill-mill crackdown led to another problem.
“Back in the day of pill mills, they were able to get pills pretty easily,” said Wilson. “Now that the pill mills are closed up … they switch to heroin.”
Abuse of prescription pain pills — especially those who start crushing them to inhale or take intravenously — is an all-too-accurate predictor of who will go on to seek much cheaper, stronger and deadlier heroin and fentanyl as their brains and bodies build up a dependency and tolerance to opiates,” Hoff said.
“When people really start to go down the path of addiction they will grind them and snort them or inject them,” she said. “The research is really showing us the minute someone crosses that boundary and starts to snort or inject they are really at a high danger for addiction.”
One in 15 people who take prescription pain relievers will try heroin within 10 years, according to the National Institute on Drug Abuse.
Jay Meyer knows he easily could have become a statistic after getting started on pain pills in high school and then feeding his habit by stealing off the shelves after becoming a pharmacist in his hometown of Covington, Ohio.
“My pharmacy background in a lot of ways probably saved my life because I knew I was going to build up tolerance, but I found myself increasing the dose, needing more and more to get the same high that one pill may have given four years earlier,” said Meyer, 57.
“I’m a lucky one.”
Meyer took his first pain pills after he smashed up a knee playing basketball and had surgery just before his senior year at Covington High School.
“I was given a Tylenol with codeine,” he said. “I just totally remembered how good it made me feel. It not only took the pain away, it was like, ‘wow!’”
Meyer said he would down cough syrup with codeine whether he had a cough or not. He finally hit rock bottom around 1987 when the 10 to 12 doses of hydrocodone he was taking daily, coupled with 10 to 12 “uppers and downers,” burned a hole in his stomach, requiring emergency surgery.
He had a wife, two young sons and a daughter on the way. The career he had carved after graduating from Ohio Northern University was all but gone and he came close to landing in a jail cell and a morgue.
“I was really close to dying,” he said. “That’s when I started having thoughts about taking my own life. I feel real fortunate that those thoughts scared me.”
Meyer was scared enough to go into treatment and it’s probably why he’s here today.
He still has his family, his health and, remarkably, his pharmacy license. He was given a second chance at work, though he’s retired from pharmacy and is now a business consultant.
“I believe there are some of us who are more predisposed to be addicts than others,” he said. “So if somebody were to take a narcotic pain pill and feel like I felt, that’s when a red flag should go up. For me it was a euphoric feeling.”