The world's biggest risks

You'll never guess what's killing America's teens

There is a new epidemic quietly infiltrating America, ravaging families and killing some of the best and brightest among us.

This story is becoming all too common. Ben was a typical high school sophomore. He lived with his family in a solid middle-class town in northern New Jersey, played football and loved to hang out with his friends on the weekends. So when his parents got a phone call late one Saturday night that Ben (his name has been changed at the request of his family) had been drinking at a party, they were upset and disappointed but not overly alarmed.

After marijuana and alcohol, prescription drugs are the most commonly misused substances by Americans age 14 and older.
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On reflection, Ben's parents now view this event as a stomach-churning preview of what their lives would become over the next three years. Their son quickly moved beyond alcohol to pills and was soon crushing and snorting OxyContin to get a faster and stronger high. When the pills proved too expensive, he turned to heroin. By the time he was 18, Ben had been in and out of three drug rehabilitation centers, each time returning home to use again. At the family's lowest point, Ben's dad was forced to kick him out of their house for good, fed up with the stealing and terrified of the toll his son's heroin addiction was having on his other children.

There was a time not too long ago when heroin addicts weren't high school students—or suburban moms or middle-aged business executives, for that matter. Those days are over. In July a report issued by the Centers for Disease Control and Prevention (CDC) cited a major rise in heroin deaths and overdoses in the U.S. over the past decade. More disturbingly, the increases were seen across the board among men and women in most age groups, including teens, and all income levels. What used to be almost exclusively an inner-city problem is now plaguing small towns and suburbs.

As tragic as those numbers are, equally chilling is this: 45 percent of people who used heroin, according to the CDC report, are also addicted to a host of opioid painkillers, including those otherwise known by their brand names OxyContin, Vicodin and Percocet, to name just a few. And that connection, drug-abuse experts say, presents an even bigger threat to our country's health and economic well-being.

Multibillion-dollar crisis

According to the Department of Justice, the overall cost—both directly and indirectly—from the abuse of prescription drugs in this country is more than $200 billion a year. In February, President Obama announced that to help combat the growing problem of opioid addiction in the U.S., his 2016 federal budget would include $133 million in new funding to aid states with drug monitoring and prevention programs.

At the same time, pharmaceutical companies are introducing new and stronger painkillers—and widening the patient population that can have access to them. Last year, California drug maker Zogenix received approval for Zohydro, the first prescription narcotic that contains a pure dose of hydrocodone, the main ingredient in the powerful and highly addictive painkiller Vicodin. Before Zohydro, hydrocodone was available only in formulations that also contained non-addictive pain medication, such as acetaminophen.

And just last month, the FDA granted approval to Purdue Pharma to prescribe the powerful and often abused opioid OxyContin for patients as young as 11 who have suffered significant trauma or undergone major surgeries.

The upshot is a population with greater access to increasingly stronger narcotics and a medical community that is doing a woefully inadequate job of educating patients about the potential risks of prescription drugs, including addiction and diversion.

The number of prescriptions written for opioid pain relievers in the U.S. has risen from around 76 million a year in 1991 to nearly 207 million a year in 2013.
National Institute on Drug Abuse

"Most people can't understand how leaving pain medication in your medicine cabinet after wisdom teeth surgery possibly contributes down the road to some kid injecting heroin," says Dr. Joseph Lee, a medical director with the Hazelden Betty Ford Foundation in Minnesota. "That's not an intuitive connection, but the fact remains that prescription pain medications are actually very close cousins to heroin."

And a scary number of Americans are using those pain pills. A recent presentation by the National Institute on Drug Abuse (NIDA) stated that the number of prescriptions written for opioid pain relievers in the U.S. has risen from around 76 million a year in 1991 to nearly 207 million a year in 2013. The agency estimates that up to 36 million people worldwide abuse prescription painkillers, and of that number, the U.S. accounts for 2.1 million. Granted, not every prescription leads to abuse, but the numbers are high enough for the NIDA to label it a "serious global health problem."

The perfect storm

How did it get to this point, and—more importantly—what can be done to curb this abuse?

The short answer to the first question is access. As the numbers above show, doctors are simply writing more prescriptions today—and for a wider variety of painkillers. Experts say that upward trend started in the early 1990s, when the Institute of Medicine released a statement expressing concern that physicians were not identifying and treating pain adequately and, as a result, patients were suffering.

"That's when the pendulum started swinging from under-prescribing for acute pain to over-prescribing," explains Dr. Sharon Levy of the Center for Adolescent Substance Abuse Research at Boston Children's Hospital. At the same time, pharmaceutical companies were bringing to market stronger, longer-lasting opioid drugs to treat pain.

While this development no doubt offered great relief to many people, it also opened the door to these drugs—with their high addiction potential—being over-prescribed, misused and diverted. "It was the perfect storm," Dr. Levy says.

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All of this was compounded in 1997 by an FDA decision that significantly changed the landscape. That year, the agency issued guidance enabling pharmaceutical companies to more easily pitch their drugs directly to consumers. Suddenly, TV commercials and magazine ads started appearing, touting the benefits of drugs treating depression, anxiety, rheumatoid arthritis, erectile dysfunction and every human ailment in between. Patients were able to march into their physicians' offices, tick off their symptoms and ask for the specific drug they saw advertised the night before.

The result, drug-abuse experts say, is a population with easier access to more, and stronger, drugs. And because these pills are prescribed by a doctor or dentist, "the belief is that prescription medications must be safe," says Dr. Lee of the Hazelden Betty Ford Foundation.

In addition, physicians—and dentists, in particular—have also come under strong criticism for prescribing many more doses of these powerful painkillers than may be necessary. Dr. Nora Volkow, director of NIDA, points out that it's not unusual for doctors to prescribe a week or even two weeks' worth of painkillers when three days may be more than enough.

Just last month, the FDA granted approval to Purdue Pharma to prescribe the powerful and often abused opioid OxyContin for patients as young as 11.
Drugs are prepared to be used intravenously by a user addicted to heroin in St. Johnsbury, Vermont.
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Few experts are arguing that doctors suddenly begin clamping down or denying medication to patients who genuinely need it. The National Institutes of Health estimates that more than 100 million people in the U.S. are affected by some form of chronic pain and need opioids to manage their condition to achieve any sort of quality of life. But at the same time, drug-abuse educators say there's little doubt that physicians need to do more. This includes a better job explaining to patients the risks associated with opioids and looking for signs that an individual might be at risk of addiction.

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"Education is a critical component of any effort to slow the abuse of prescription medication, and that includes better education for doctors," says Dr. Volkow. She points out that NIDA has developed Centers of Excellence for Physician Information in partnership with eight medical universities across the country. In addition, prescription drug monitoring programs (PDMPs)—essentially a central repository of prescribed and dispensed opioids—are in place in nearly all 50 states. The goal: to reduce the chance that a pill abuser could doctor shop for prescriptions. But problems with data formatting between states needs to be resolved.

The FDA argues that it is also trying to do its part to curb prescription drug abuse. In 2013, it issued guidance to encourage pharmaceutical companies to develop new abuse-deterrent formulations of opioid drugs and ruled that any approved generic form of an opioid must have abuse-deterrent formulations as well. This came three years after Purdue Pharma put out a reformulated version of OxyContin that makes it harder for patients to crush the pill to get a faster high. At the same time, the FDA also announced the formation of a task force to target opioid misuse, abuse and addiction, calling the problem a "major public health challenge to our nation."

Pharmaceutical companies are starting to respond. Recently, three new painkillers with abuse-deterrent properties were approved by the FDA. Purdue Pharma's Targiniq ER combines oxycodone with naloxone, the latter of which is a drug often used to treat an opioid overdose. If Targiniq ER is crushed and snorted, or crushed, dissolved and injected, the naloxone is released and blocks the euphoric effect of the oxycodone. The long-acting narcotic painkiller Hysingla ER, also by Purdue Pharma and approved by the FDA, is difficult to crush and, if cut into small pieces or is dissolved, turns gooey. The third is Embeda, by Pfizer, an extended-release morphine designed to deter oral and intranasal abuse when crushed. About 30 others are in development, according to the FDA.

Still, some experts are concerned these abuse-deterrent formulas could mislead both users and prescribers into thinking that the underlying medications are less addictive.

Only time will tell if any of these measures can stem the tide of addiction sweeping over every strata of society.

—By Susan Caminiti, special to