The Opioid Crisis: North Alabama doctors on the drug’s rise, effects and finding better treatments

HUNTSVILLE, Ala. -- WHNT News 19 is taking a closer look at America's opioid problem and the crisis it has generated.

As part of that coverage we spoke to two North Alabama physician, TOC pain specialist Dr. Michael Cosgrove, and Dr. Shivani Malhotra, an assistant professor at UAB in Huntsville, about the nature of opioids, how they affect the body and brain and the rise of opioid prescriptions and how to address the problems today.

Dr. Shivani Malhotra, assistant professor at UAB in Huntsville.

Neither Dr. Cosgrove or Dr. Maholtra was practicing during the beginnings of the opioid prescription boom.

"The habit-forming potentials of opium have been known since the early 1900s, that's why the federal government restricted it," Dr. Cosgrove said. 

 But in the mid-1990s things changed. 

In 1995, the FDA allowed  the label for Oxycontin to say the drug was less likely than other opioids to be abused, allowing, "Delayed absorption as provided by Oxycontin tablets is believed to reduce the abuse liability of a drug." 

That turned about to be false.

Around the same time, Medicare and hospital accreditation agencies established a protocol focusing on pain management. 

"If you go back and see that there was an increase in opioid prescriptions because initially, it seems like pain was becoming like a vital sign and the physicians were actually forced kind of to treat the pain," Dr. Malhotra said. 

 Doctor and hospital reimbursements were tied, in part, to patient satisfaction ratings for their pain management. That practice continues today. 

Pain is not an objective measure, but there was now a scorecard. 

Dr. Michael Cosgrove, pain specialist at TOC.

"It became sort of a bellwether and a point for reimbursement even for hospitals and health care systems, on how well they addressed pain," Dr. Cosgrove said. "And patient scores on how well they addressed their pain. And so it was a big push to write more pain medication."

In 1996, Oxycontin's maker Purdue Pharmaceuticals had $48 million in sales, by 2000 sales had reached just over $1 billion.

 In 2007, the company settled with the U.S. Justice Department for $600 million after admitting it misled the public and doctors – by claiming Oxycontin didn’t pose addiction risks.

But Pandora's box had been opened.  

From 2006 to 2012, 76 billion Oxycodone and Hydrocodone pills were sold in the U.S., according to DEA figures. 

There were 1.7 billion pain pills just in Alabama.  And they are addictive.

 "It can happen to anybody. and as I said, [there's not] a clear consensus that how many days of the prescription can increase risk," Dr. Malhotra said. 

Alabama still ranks first in the country for pain pill prescriptions per resident. 

The most recent figures show the national average is 59 pills per 100 residents, Alabama is at 107 per 100 residents.

The pills treat pain -- and trigger the reward center in the brain.

"This dopamine is responsible for feeling of reward, pleasure, satisfaction, and euphoria. and the stimulation of this brain remote area by opioids actually reinforces the action of taking the drug," Dr.  Malhotra said, "and the user to take this drug again and again, to repeat this pleasant experience."

 The problems can start with a prescription and a susceptibility to abuse.  

 "If you take pain medication and you have pain I think it affects your body differently then when you take the pain medication and you don’t have pain," Dr. Cosgrove said.

And over time, it's no longer about the pain, or the euphoria created by the opioid. 

"Once they become dependent, like once your body is dependent, it's not that the user wants to take it," Dr. Malhotra said. "But your brain mechanism changes and your body asks for it. There's a craving and more and more dose is needed to avoid the withdrawal symptoms. So that fear of withdrawal symptoms I think puts the user in that cycle that they want to continue seeking that drug."

Given the problems of withdrawal, Dr. Malhotra says it’s not good enough to 'say no' to a patient seeking more pain pills. 

"For me saying just flat no actually may harm that patient," she said. "Because once you're opioid-dependent then you need something to avoid withdrawal symptoms. And the user can be seeking for less expensive options. So you don't want these people, to be thrown into where they are seeking less expensive but more dangerous options.

 Dr. Cosgrove, a pain specialist at TOC in Huntsville says the practice's focus certainly includes alternative treatments to opioids.  He said there are a number of effective treatments for pain that don't involve opioids and he and his colleagues are continuing to monitor best practices, including benchmarks for opioid pain treatment for various injuries and conditions. 

He said there are a number of good treatment alternatives.

"In times when there weren’t as many options interventionally, procedurally, more specialized physicians could do for them, to keep them functioning better, a pain pill was it," Dr. Cosgrove said. 

Doctors stand at the front lines of this crisis and Dr. Malhotra says more needs to be done.

"Again, I emphasize, that the opioid addiction is a disease process," she said. "We all need to step up as a coalition. Other members of the medical community need to come together and help with this crisis because it's going out of our hands." 

We're airing a special, "Opioids: From the Cradle to the Grave" at 6:30 p.m., Thursday.

Updated at 1:15 p.m., Thursday noting Oxycontin was labelled as be being "less" likely to be abused. 

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