the abuse of narcotics in the healthcare setting

Running Head:ARE NARCOTICSABUSED IN THE HEALTHCARE SETTING? 0
Darleanne Lindemann
May 27, 2015
Are Narcotics Abused in the Healthcare Setting?
Substance Abuse
Spring 2015
Prof. Hinklemann

“Then Helen, daughter of Zeus, turned to new thoughts. Presently she cast a drug into the
wine whereof they drank, a drug to lull all pain and anger, and bring forgetfulness of every
sorrow. Whoso should drink a draught thereof, when it is mingled in the bowl, on that day he
would let no tear fall down his cheeks, not though his mother and his father died, not though men
slew his brother or dear son with the sword before his face, and his own eyes beheld it.” The
Odyssey, Homer (Ninth century BC).
Opium has been ingested by humans for thousands of years, and many cultures
throughout history have documented its medicinal value. Opiates act as an agonist at endorphin
receptor sites in the brain, especially the hypothalamus and limbic systems. Exactly how and
where they react is still being studied. The most frequent use of narcotic medication is the relief
of acute or severe pain. In some people, the introduction of the drug after an injury or surgery
may open the proverbial door to addiction, but for most it does not. Opium and its derivatives
are habit forming and can cause both a physical and psychological reliance. Once the
dependence has taken hold, the withdrawal is extremely uncomfortable, and the user will go to
great lengths to obtain more of the medication. The dependency on narcotics has significantly
impacted health care in the emergency room and inpatient settings, creating difficulty for the
patients who have chronic pain as well as for the physicians who treat them. This paper will
discuss opium and its impact on humanity with euphoria, pain relief, addictions, death and the
law.
Opium, the original opiate derivative is a thick and tacky substance that seeps
from the unripe seed pod of the poppy flower if it is cut. This unprocessed material is the base in
which morphine is taken out and used (Hart, Carl L., Ksir, Charles 2011). As early as the eighth
or ninth century Arab traders shared opium with India and China, and it made its way to Europe

somewhere between the tenth and thirteenth century. It would seem that the traders had also
brought the addictions as well. Turkey, Egypt, Germany, and England have manuscripts that
describe abuse and dependence starting in the sixteenth century. Beginning in the seventeenth-
century addiction was documented as rampant in China due to the prohibition of tobacco
smoking (Brownstein, M. J. 1993). In the eighteenth century scientist isolated morphine and
then codeine from the opium produced from the poppy. Toward the end of the nineteenth
century, a chemical change was made to morphine that resulted in the origin of heroin, a
substance that is three times more potent as morphine, and faster acting.
American’s used morphine orally often in patented medications, by smoking as
introduced by the Chinese immigrants, and later by injection. There were many who became
addicted, and a large amount of money was exchanged which became a motivator for the
Harrison Act established in 1914 by Senator Harrison of New York. While useful to bring in tax
money, this Act did not make the use or prescription of opiates illegal. It was the Jones-Miller
Act passed by Congress in 1922 that made opioid smuggling and the possession of illicit opiates
a crime with a stiff penalty (Hart, Carl L., Ksir, Charles 2011). Addictions to the substance
persisted; and along with it was the stereotype that minorities were the abusers and worse still,
the belief that they were creating crime and chaos within society. More controls came with
amendments and by 1970 the Drug Enforcement Act was established which ensured that certain
drugs would be restricted. There was a new addition to the Justice Department called the Drug
Enforcement Agency or DEA. This agency plays a large role in the control of opiates in the
present strict regulation of opioids in current American culture (Brownstein, M. J. 1993).
There are two classes of opiates, opium alkaloids (includes natural and semi-synthetic
derivatives of the opium poppy) and opium synthetics (synthetic compounds that mimic

morphine). Natural opiate products include Morphine and Codeine. Semi-synthetic products
include Heroin and Diamorphine (these are not medically available in the United States). Lastly,
the synthetic opiate products include Methadone, Meperidine, Oxycodone, Oxymorphone,
Hydrocodone, Hydromorphone, Dihydrocodeine, Propoxyphene, Pentazocine, and Fentanyl. All
opiates whether they are natural or synthetic work on the Mu, Delta and Kappa receptors in the
brain and release endorphins. Natural endorphins are activated in our brain in response to stress
or pain, often helping to reduce these unpleasant experiences. They also cause a sense of
wellbeing, and at times euphoria like that of the runner’s high (Jordan, B. A., Cvejic, S., & Devi,
L. A. 2000).
Opiates mimic the action of our natural endorphins. However, the effects of the opioid
will last for hours, unlike our individual endorphins that we will only feel for minutes. Also, with
opiates we have the added capability to self-administer and thereby control the release of
endorphins creating a gateway to abuse. Opiates cause inhibitory effects on the central nervous
system. It acts as an agonist at the endorphin receptor sites especially in the thalamus and limbic
system and creates lethargy, sedation, amnesia, muscle relaxation and a sense of euphoria. Some
medical uses of this drug have been as a cough suppressant (codeine), and as an analgesic for
severe pain. Opioids can also cause depression of respiratory actions, nausea, low blood
pressure, mental clouding and constipation. Overuse of this substance can lead to coma and death
(Alavijeh, M. S., Chishty, M., Qaiser, M. Z., & Palmer, A. M. 2005).
Opiates can cause tolerance and dependence in some users due to the pleasure received
and the body’s adjustment to the medication. Opioid tolerance happens because the body starts to
metabolize the drug at a faster rate, creating the need for more of the drug to have the same
effects, specifically the feelings of euphoria. The tolerance for the euphoric experience grows

faster than the tolerance for the other effects, particularly the depression of the respiratory
system, which is what commonly causes overdose leading to coma or death. Tolerance will
often result in dependence due to the brains adapting to the high levels of endorphin. The body
will automatically change the chemicals to create homeostasis, contributing to the tolerance.
After some time, this chemical change becomes the “normal” state. When the substance is not
ingested, withdrawal symptoms will appear and cause the opposite effects that the body has with
the medication. For example, the medication causes constipation, low blood pressure, relaxation
and euphoria; however withdrawal causes diarrhea, high blood pressure, restlessness, and
discomfort. Because the withdrawal effect can be severely uncomfortable, the appeal to use
again is enormous.
In modern medicine, opioids are prescribed by a physician, but controlled by the
Department of Justice and the DEA. Only physicians or dentists that have registered with the
DEA may prescribe opiate pain killers, and must have registered for any location that they will
be writing prescriptions. The providers are mandated to maintain a record of all prescribed
controlled prescription drugs (CPDs) for at least two years, although the optimal is three to four
years. The prescriptions must have all of the information complete on tamper-resistant pads and
logged in order according to the registration number. There should not be any breaks in the order
to the registration number. The DEA may audit all records for compliance. Prescriptions for any
opioids must be written on the regulated pads as detailed before, and cannot be called into the
pharmacy. Additionally, the medication cannot be filled for longer than 90 days without a new
written prescription. All providers are encouraged to register for CURES access as soon as
possible in observance of new mandates established by SB 809. California Health & Safety Code
section 11165.1 (a)(1)(A). This means that health care practitioners authorized to prescribe,

order, administer, furnish, or dispense Schedule II, Schedule III, or Schedule IV controlled
substances must submit an application for approval to access information online regarding the
controlled substance history of a patient that is stored on the Internet and maintained within the
Department of Justice before January 1, 2016 (Prescription Drug Monitoring Program n.d.).
In 2013, the National Drug Threat Assessment Summary stated “pain relievers are the
most common type of CPDs taken illicitly and are the CPDs most commonly involved in
overdose incidents.” The most frequently reported avenue to obtain the CPDs has been from a
friend or relative for free (53.0%) according to the 2013 National Survey on Drug Use and
Health. The report also indicates that more users obtain the CPDs from one doctor (21.2%), and
very few patients get the medication from more than one physician (2.6%). Another study
reviewed 146.1 million opioid prescriptions and found that only 0.7% was obtained from one
patient via multiple prescribers (McDonald, D. C., & Carlson, K. E. 2013). According to the
DAWN study on drug-related mortality rates in 2007, opiates were the drugs most commonly
related to drug-related deaths. Research also shows slight to moderate frequency of the drug-
seeking behavior in the medical settings (Grover, C. A., Elder, J. W., Close, R. J., & Curry, S. M.
2012).
The above mentioned studies show that prescription opiates are one of the leading causes
of overdose deaths, yet there are statistically low amounts of patients abusing the medical
systems to obtain them. This indicates conflicting data that make it difficult to understand this
complex issue entirely. Because of the strict regulations, added pressures from the Department of
Justice, and the media sensationalism, many physicians in the emergency rooms and hospitals
have become alert and wary of prescribing opioid medications. This situation has resulted in
many patients receiving inadequate pain management, an issue that affects patients and

physicians in a complex system that both advocates and opposes the use of opioids for pain
management.
In the scope of healthcare, there are many who have chronic pain, caused by known and
sometimes unknown medical issues. The evaluation and management of pain rely on the
physician’s comprehensive assessment. Because pain is individual and subjective, a patient’s
own evaluation is an crucial part of the doctor’s judgment. The information gained from the
patient centers on: “temporal features (onset, pattern, and course). Location (primary sites and
patterns of radiation). Severity (usually measured with a verbal rating scale, e.g., mild,
moderate, or severe, or a 0–10 numeric scale); quality; and factors that exacerbate or relieve the
pain. These characteristics combined with information from the physical examination and review
of laboratory and imaging studies, usually define a discrete pain syndrome. They also clarify the
known extent of disease and the relation between the pain and specific lesions and allow
inferences about pain pathophysiology.” (Portenoy, R. K., & Lesage, P. 1999).
There are not many who abuse this system of care, but individuals who profit from it do
exist. For instance, according to Dr. Kevin Parkes, Director of Emergency Services at San
Antonio Regional Hospital: “There are those that actively seek prescriptions of narcotics with the
sole intent of selling them on the black market”. Some individuals want to gain an ample supply
to abuse, but some make their living by selling them. Additionally, there are individuals that
seek the intravenous dose of narcotics to obtain the euphoria that they are no longer able to get
from oral medications. These individuals seek attention in the Emergency Department setting for
the sole purpose of the opiate high and will promote any behavior necessary to obtain their
objective. While these individuals are not as common as those that truly need medical

intervention, this phenomena does have a corrupting effect on emergency department
practitioners and will significantly impact those who are truly in need of pain management.
Because there are individuals that manipulate the emergency department processes and
exhibit drug-seeking behaviors, some Emergency Department Physician’s become cynical about
abuse. According to Dr. Parkes, there are some indications that patients are exhibiting drug
seeking behaviors. “Patients will present with multiple pain complaints without objective
findings. They complain of pain in various parts of their body that are subjective in nature, and
state multiple allergies. (while some patients are truly allergic to many medications, allergies to
all pain medications except narcotics raise a red flag). They will also show reluctance to try other
treatment options besides narcotics”. Dr. Parkes states that all of these findings have to be taken
in the proper context. None of them definitively mean that the patient is a drug seeker; these are
just tools physician’s can use to assess individual patients.
Dr. Parkes was questioned about the possibility of patients that have health issues causing
high levels of pain accidentally being mistaken as a drug seeker due to the cynicism of the
clinicians and he reported: “This is a very real and concerning issue and one we struggle with in
the emergency department. Given the short amount of time we have with our patients and the
lack of history, it can be hard to obtain enough information to make a reasoned decision. We do
have providers in the emergency department who feel that most people are drug seekers, but we
also have providers who will prescribe narcotic medication quite freely. There is a broad
spectrum. My opinion is that a large part of our job in emergency department medicine is to treat
acute pain, and that is something that we can do well. While I look for the red flags that I
mentioned earlier, my bigger fear is to not treat somebody who is in pain out of concern that they
are drug seeker. My personal practice is to treat the pain and if a prescription is indicated to

prescribe a small amount of medication. I understand that some drug seekers may get medication
from me, but they will not get a lot. Those are in pain will get the medication that they need”.
The emergency department is not the only area that narcotics are an issue. Patients
admitted to the hospital are regularly undertreated for pain due to medical bias and the dread of
addiction. However, some patients do demand high levels of narcotics both in the emergency
department and as an inpatient, making physicians uneasy. There is a realistic fear from the
clinicians in giving a patient with high tolerance the amounts of medication that they request and
at times it becomes a very difficult and volatile situation. Not only does the physician cautious of
overdose, they are also sensitive to the fact that all orders for opioid medications are tracked by
the Department of Justice and the Medical Boards.
It is often complicated to weigh the importance of pain relief for someone with long term
chronic and painful conditions against the reliance and tolerance that relieving their pain over a
long period of time has created. The Medical Boards have in the past disciplined physician’s for
prescribing opiates outside of the boundary of “the most severe pain”. Also cultural, medical and
religious impediments, entrenched political and legal barriers discourage adequate pain
management. Recently however doctors have been disciplined for underprescribing medications
to treat pain. (Hoffmann, D. E., & Tarzian, A. J. 2003). The physicians in today’s medical
climate are walking a tightrope between the two philosophies with only their clinical judgment to
rely on.
Opioids are still the best choice to relieve suffering, regardless of what has caused it. The
fears of abuse, addiction, and diversion persist and form the policies on narcotics (Brennan, F.,
Carr, D. B., & Cousins, M. 2007). Additionally, these fears will also continue to have long

reaching effects on patient care and quality of life for those living with chronic pain. Opiates are
a reliable treatment; however there are physicians that will still not order them for moderate pain.
Studies continue to indicate that even with therapeutic intervention, 40% of postoperative
patients report inadequate pain relief or pain of moderate to greater intensity. Additionally, it was
found that half of patients with terminal diseases had moderate to severe pain during their last
days of life (Brennan, F., Carr, D. B., & Cousins, M. 2007). Because of the rampant stigmas
regarding the misuse of this useful medication, the trend will continue to be cautious and sparing
in its use. The only exception seems to be those who are diagnosed as terminal, and placed on
hospice.
In conclusion, abuse of opioids is not a new situation. There will always be individuals
that abuse the substance and will manipulate ways to obtain it. While some studies state that the
misuse of CPDs has significantly increased, others show that only a small percentage of
individuals abuse them by prescription gathering. Modern society has created an extremely
difficult situation for physicians having to decipher a patient’s alleged pain against their possible
dependence. Making the circumstances more difficult than the conflicting studies are the
alarming messages coming from the media and the tightening restrictions coming from
government mandates. The difficult task of creating a balance between adequate pain control
while mitigating abuse of the CPDs remains a challenge for physicians.

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