This article is Part One of a two-part piece. Read Part Two, "Opioid Dependency: What's It Got to Do With HIV?."
"Pain is experienced by people and families not by nerve endings." -- Dame Cicely Saunders
A nightmare for some and a godsend for others, some people become addicted to opioids because opioids have become their recreational drug of choice, while others become addicted because their pain symptoms are so severe that they have no choice. Either way, a problem has arisen which threatens social stability in whole communities, especially in North America, and makes authorities unsure which way to turn.
You may see this as a "far from my bed" phenomenon but as I will explain later, many people living with HIV find themselves involved with opioids before they know it and have to live with the consequences of this sort of treatment simply because there is no better way of treating their pain.
First some statistics to highlight the scale of the problem:
- According to the US Institute of Addiction Medicine, in 2007, 23 million people over the age of 12 needed treatment for substance abuse in the USA.
- Between 1992 and 2003, abuse of prescription drugs increased by 140%.
- Given that Americans represent 5% of the world's population, 80% of the world's supply of opioids and 99% of the global availability of hydrocodone is used within the US borders.
- Because opioids are legally available as prescription drugs, this availability has been matched by a 63% increase in opioid-related deaths between 1999 and 2004.
- Many studies have shown that abuse or misuse of these drugs averages out at between 20% and 58% of people who have been prescribed opioids for chronic pain.
- In 2005 it was established that almost 2 million Americans were opioid dependent but more alarmingly ...
- Approximately 4.7 million teenagers and adults used opioids for non-medical purposes and ...
- Over 32 million Americans reported having used them for non-medical purposes at least once in their lives.
Shocked yet? Actually these statistics were assembled before the current explosion in opioid addiction and abuse that has recently begun to hit the headlines across the western world. The figures, five years later in 2012, will be far higher; and the number of deaths and serious health problems resulting from both opioid prescription and the black market will now be alarmingly high. It's a problem that is almost unrecognised in its expanse, and a social time bomb that we still seem unwilling to acknowledge.
Still, why should this be relevant to people living with HIV? The answer is that many people with HIV are also chronic pain patients, something that is often overlooked when reading about the negative aspects of being positive.
According to The Well Project, many people with the virus have to manage chronic pain symptoms for the following reasons:
- Peripheral neuropathy (between 25% and 40% of people with HIV) -- nerve damage with over 100 causes, amongst which are the virus itself, diabetes, cancer treatment, toxic medications and even high alcohol consumption.
- Abdominal pain (26% ...) -- as a side effect of some HIV drugs; parasitical infection or bacteria; problems and irritability in the intestines, including irritable bowel syndrome; inflammation of the pancreas caused by some HIV meds; too much fat in the blood; or drinking; bladder or urinary tract infections and in women, uterus, cervix and ovary conditions.
- Headaches and migraines (17% ...) -- from mild to severe brought about by a variety of causes including certain HIV drugs
- Joint, muscle and bone pain (5% ...) -- can also be from mild to severe and be HIV-related to forms of arthritis, rheumatism, bone disease and bone density problems. It can also occur when using drugs for high cholesterol and especially hepatitis.
- Herpes pain (5% ...) -- many people may see herpes as par for the course when you're sexually active but a cold sore, or sore on your genitals, represents its mildest form. If you've ever had shingles, you'll know that the pain can be excruciating and as the herpes virus can frequently re-occur, it's something that can plague your life if you have HIV.
- Skin problems and rashes -- side effects of certain HIV medications or other drugs.
- Chest pain caused by lung infections such as TB, bacterial pneumonia, or PCP pneumonia.
- Mouth pain caused by ulcers or fungal infections.
- Pain due to cancer in all its forms.
According to pain.com, in 2005, 8% of HIV individuals were on long-term opioids (especially Oxycodone and Tramadol) for severe pain, which was more than double the non-HIV population. However, the good news is that the explosion in opioid use since then has not been paralleled in the HIV population. This is possibly because opioids are prescribed for valid reasons to HIV patients and there is less incidence of recreational opioid use which has worsened the problem in the general population.
Before everybody writes in to say that they're fine and have never had a problem with the virus or the medication, please be reassured that you are some of the lucky ones. Of course only a certain percentage of people living with HIV will suffer chronic pain in one form or another but a significant proportion of those will eventually have no option but to start taking opioids as the only painkillers that will help. It's not a choice; some pain is so severe that it just doesn't react to over-the-counter medications, or medications meant for other diseases. Opioids, if used properly, are a very effective solution. The problem is that they are not always used properly, as the statistics above clearly show.
Recreational use of opioids could also be said to be the result of psychological 'pain': fulfilling a need to escape from the harsh edges in life (it could also be simply the well-known search for a kick that has got out of hand). However, recreational drug use and the reasons for its popularity are really subjects for other articles. What we need to know to arm both ourselves and people we know with knowledge, is that it gets out of hand when people don't realise how quickly and easily they can become seriously addicted.
So, with the facts out of the way, it's perhaps useful to illustrate the problem by giving some examples of what opioid abuse and the authorities attempts to crack down on it have been doing to people.
Information From the USA
In July this year, the FDA instructed companies to cease the manufacture and distribution of certain drugs containing Oxycodone (Oxycontin). These are specifically single ingredient and immediate release drugs, including capsules, tablets and oral solutions. The principal reason for this is the ease with which they can be abused. Crushing a pill and smoking or snorting it will provide an instant high and therein lies the danger for speedy addiction problems.
The idea is that these immediate release drugs will be taken off the market thus nipping the problem in the bud. However, it is a slightly clumsy measure for two reasons: determined addicts will head underground or on the internet for their supplies from other countries and people in genuine medical need will be cut off from their source. The pharmaceutical companies are busy developing new versions of opioids which only have a delayed release effect but the ban came before these were widely available. The word 'distribution' in the ban also meant that doctors and pharmacies could no longer supply their patients with their regular pain relief, thus creating a vacuum which has only increased suffering for many people.
Apart from the FDA trying to cover their backs in relation to the prescription abuse epidemic, the U.S. Senate ordered an investigation into the pharmaceutical industry and in particular Purdue Pharma, the manufacturers of Oxycontin. Not only that but the investigation extends to their funded pain organisations and physicians who are suspected of profiting from the prescription drug problem.
An article in the Salem News, discusses the problem:
"Senate Finance Committee Chairman Max Baucus of Montana and Senator Chuck Grassley of Iowa sent letters to Purdue Pharma, Endo Pharmaceuticals, Johnson & Johnson and nine pain organizations, saying "there is growing evidence pharmaceutical companies that manufacture and market opioids may be responsible, at least in part, for this epidemic by promoting misleading information about the drugs' safety and effectiveness."
And from the same article:
"'Improper relationships between pharmaceutical companies and the organizations that promote their drugs can put lives at risk. These painkillers have an important role in health care when prescribed and used properly, but pushing misinformation on consumers to boost profits is not only wrong, it's dangerous,' Sen. Baucus said in a statement."
The official line then seems to be based on sound concerns and we must applaud people who keep a close eye on the workings of the multi-billion dollar pharmaceutical industry but in this case, it doesn't solve the immediate problem. There are hundreds of thousands of people, including many living with HIV, who need their pain relief to get through the day and for genuine reasons. Then there are the many addicts who also can't be cut off without help and some sort of slow weaning-off program. To many people's surprise, this very dilemma has led to a resurgence in heroin use -- these people need something, they can't just be abandoned to get on with it themselves.
Kentucky officials recently began a system of electronically tracing pills and found that there was a pipeline of opioids coming in from Florida. Cracking down on this sort of supply route means that opioid analgesics become much harder to find, even on the illegal circuit; but this also leaves the door open for substitutes such as heroin. The heroin has been traced back to Mexico and Central America and as always, supply and demand runs the show. A single Oxycodone pill can cost between $80 and $100 and a single hit of heroin, with 24 hours working value, can cost as little as $15 to $20! You do the math.
They should really have waited until there were sufficient delayed-release opioid pain killers on the market before removing them from official outlets and cracking down on drugs pipelines; but they didn't, and people addicted for whatever reason have needed to deal with their pain. Heroin, however attractive, is a frightening option and hopefully legitimate patients will never go down that road.
It's important to remember that Oxycontin is by no means the only opioid that has these troubling side effects. Morphine family members -- including amongst others, Tramadol, Dilaudid and Percodan -- all have their own stories of widespread addiction after delivering relief from chronic pain.
A paper produced by the Ontario Addiction Treatment Centres makes for very interesting and alarming reading, the chief points of which are as follows:
- The main causes of drug-attributable deaths are suicide, overdose and AIDS contracted from sharing needles - all of which are strongly associated with injection drug use.
- Each year, about 1% of opioid users will die from an overdose.
- In 1995, opiate poisoning was the cause of about 160 out of 804 drug-related deaths in Canada, and opioids accounted for 11% of the 6,947 hospitalizations attributed to illicit drug use. (This does not include the hospitalizations for inappropriate use of prescription opioids.)
- People who are opioid dependent are also extremely vulnerable to life-threatening blood-borne diseases, such as HIV and hepatitis C. Between 1985 and 1999, the proportion of people in Ontario diagnosed with HIV through injection drug use rose from 0.45% to almost 15%. In 1999 alone, injection drug users accounted for 24% of new HIV infections in Northern Ontario and 15% of new HIV infections in Ottawa. As of 2000, 63% of newly diagnosed cases of hepatitis C are related to injection drug use.
- In 1999/2000, drug possession or drug trafficking accounted for 7% of new admissions to correctional institutions (2,110 people), 5% of new admissions to probation (1,809 people) and 16% of new admissions to conditional sentences (694 people). These figures do not include the number of people convicted of theft or other crimes to support a drug habit.
- The Ministry of Community and Social Services estimates that about 3% of users of the social assistance or welfare system have a history of drug dependency, which affects both their employability and their ability to maintain employment.
It's again important to remember that this paper was drafted some years ago and since then the opioid problem is said to have 'exploded', which if true, is a frightening thought. Whether the problem has really become so much greater since 2000 is open to discussion. The truth may be closer to the fact that the media in western countries has finally cottoned on to the extent of the problem and has devoted column inches to lurid and sensationalist headlines which make it look as though the opioid addiction problem is explosive and threatening to the social fabric.
This and other posts are based on my opinions and impressions of living with both neuropathy and HIV. Although I do my best to ensure that facts are accurate and evidence-based, that is no substitute for discussing your own treatment with your HIV specialist or neurologist. All comments are welcome.
Read Part Two of this piece, "Opioid Dependency: What's It Got to Do With HIV?."