Prescription painkillers outpace cocaine in OD deaths

LOS ANGELES, CALIFORNIA.- Overdose deaths from abuse of prescription painkillers in the U.S. now outnumber deaths involving heroin and cocaine combined, the Centers for Disease Control and Prevention reported Tuesday.

In 2008, drug overdoses caused 36,450 deaths in the U.S. One or more prescription drugs were involved in 20,044 of these deaths, CDC researchers wrote in the journal Morbidity and Mortality Weekly Report. Opioid pain relievers, including oxycodone, methadone and hydrocodone, were involved in 14,800. In 1999, only about 4,000 people were killed by overdosing on this type of drug, the CDC said.

Death rates among non-Hispanic whites and American Indians were three times higher than rates in blacks and Hispanic whites, and were highest among people ages 35 to 54. People in rural counties were about twice as likely to overdose on prescription painkillers as people in large cities.

Sales of the drugs soared along with the death rates, rising fourfold from 1999 to 2008.

In 2010, 4.8% of Americans 12 years or older used opioid pain relievers nonmedically -- that is, without a prescription or purely for the feeling the drug causes. The report calculated that by 2010, "enough opioid pain relievers were sold to medicate every American adult with a typical dose of 5 mg of hydrocodone every four hours one month."

The CDC recommended interventions including tracking prescription patterns, tracking overdoses, and limiting reimbursements to reduce inappropriate prescribing, but cautioned that officials "must strike a balance between reducing misuse and abuse and safeguarding legitimate access to treatment."

Nurse Jackie Peyton (Edie Falco) is having trouble managing her growing addiction to painkillers. Nevertheless, she continues to snort an opiate in the supply room and pop pills in the bathroom during shifts at the hospital. Jackie works in the busy emergency room, where she helps take care of a boy who wedged a dental mirror up his nose because he was trying to see his brain. Later, another young man is brought in after being found crushed under 2 tons of books (he and his father were part of a moving team that were clearing a library that was closing). By the time his father discovered him, his son was going into shock, with toxins being released into his bloodstream. In the hospital he goes into kidney failure, respiratory failure and then cardiac arrest. He cannot be saved. The father grieves and blames himself.

The medical questions

Do addictions to painkillers worsen with time, requiring larger doses and different kinds of medications? What are the potential complications from an object wedged into the nasal passage? How does being trapped under a heavy pile of books lead to organ failure and death?

The reality

Addictions to opioid painkillers, such as morphine and Percocet (Jackie's main drug), do get worse over time, says Jim Adams, associate professor of pharmacology at USC. As the addict builds up tolerance, he or she must take larger doses to get the same euphoria, or "brain reward," a process involving the neurotransmitter dopamine. The brain's own opioids — endorphins and enkephalins — shut down, making the addict more dependent on a drug-delivered "fix." Addicts frequently combine their opioids with other drugs and with alcohol, says Dr. Ben Honigman, chair of emergency medicine at the University of Colorado School of Medicine in Aurora.

Foreign objects wedged in the nose can cause significant bleeding, infections, pain and possibly penetrate the maxillary sinus, Honigman says. If the hard object goes far enough, it can pass through the base of the skull and into the lower brain compartments, producing neurological deficits. Young children commonly stick beads, beans, erasers, even batteries up their noses and then are embarrassed to tell their parents, adds Dr. Mark Morocco, assistant professor of emergency medicine at UCLA's David Geffen School of Medicine. The leak of caustic chemicals from batteries can cause significant inflammation.

People who are trapped under something very heavy for more than a few minutes can become victims of "crush syndrome," in which muscle cells are squeezed hard enough to cut off their blood supply, Morocco says. Muscle enzymes, electrolytes and acid are released into the blood, leading to kidney failure, heart arrhythmias and possibly death. The direct pressure of the books may also damage the heart and lungs and lead to significant bleeding, Honigman adds. Aggressive treatment with intravenous fluids and dialysis in an intensive care unit may sometimes save these gravely ill patients.