The Milwaukee Post

Big Pharma helped relax doc- tors' attitudes toward prescribing opioids with an unprecedented marketing campaign, but the UW and a few other researchers built the intellectual foundation first. Before the late 1990s, people generally couldn't get opioids from family doctors; they were for surgeries and terminal cancer care, says Dr. Michael Miller, addiction center director at Oconomowoc's Rogers Memorial Hospital. He's an intellectual who has served on many national and state boards. And to Miller, and other experts, it's clear how this happened. If you complained of knee, back or other chronic pain before the late 1990s, you left the doctor's office with ibuprofen. For decades, doctors, especially those in primary care, feared opioids' addictive nature. Now, prescrip- tions are easy to get, Miller says. "There was a big push to mar- ket this to a much broader market — the chronic pain market," says Miller. And that was a very big mar- ket, he stresses — some 76 million Americans. UW researchers had role It was on the campus of Wisconsin's flagship university that this effort grew. How influential were the UW researchers in changing doctors' prescribing patterns? "Very," says Miller, emphatically. "The driving force." Was their influence national? He nods, then adds: "International." Miller believes David Joranson and Dahl were the most influen- tial. He thinks they were "well- intentioned" but should "revisit" their theories. However, the UW researchers don't hide their role in changing how pain is treated across the nation; they're proud of it. After all, the relaxation in prescribing of legal opioids has also alleviated the pain of millions and their efforts to make treating pain a pri- ority for society have become so accepted that Wisconsin Gov. Scott Walker just declared September Pain Awareness Month, saying pain costs $100 bil- lion in lost productivity. A UW site praises Dahl as "cat- alyst for the new pain standards in the USA." A Joranson bio says he helped "develop consensus about the use of opioids in chronic pain." The group con- sidered pain relief "a human right," says a glowing UW Alumni magazine fea- ture. Others see the darker side. As with yin or yang or the creation of any new tech- nology, the increase in prescriptions was a double- edged sword; for all its potential, it's widely recog- nized as fuel- ing the rise in heroin use, a cheap- er drug whose users almost always start with prescription opioids, which, after all, come from the same poppy plant. "Their influence was enor- mous," says Andrew Kolodny, a leading national opioid addiction expert, of the UW researchers. "They played a central role in ush- ering in this epidemic." In Greek mythology, stories capture the tragedy of unintend- ed consequences. There's Daedalus, brilliant inventor, whose benevolent attempt at genetic engineering caused nega- tive consequences. Dahl chafes at the well-inten- tioned label. "It implies we were wrong," she says. Were they? "No." Others strongly disagree. Dahl says opioid and heroin deaths are a small percentage of the population, and the media largely ignore the broader crisis of undertreated pain (including in cancer patients). Prescription opioids killed over 16,000 Americans in overdoses one recent year, and heroin thousands fewer (alcohol kills some 88,000 a year). But drug overdose deaths are now the leading form of U.S. injury death, and three of four involve opioid pain relievers, the government says. U.S. Attorney General Eric Holder called heroin an "urgent and growing public health crisis" this spring, saying heroin deaths are up 45 percent, and tying them to opioid pill abuse. Nationwide, opioid pre- scriptions rose tenfold in five years after OxyContin's 1995 release (southern states have highest rates; we're 31st). Drug company funding Peter Jackson, whose daughter Emily, 18, died after taking OxyContin, is incensed by the rev- elation in the media several years ago that the UW's Pain & Policy Study Group — which Joranson founded — took several million dollars from drug companies — including Purdue Pharma, OxyContin's maker — to help fund research arguing for less reg- ulation in the past decade. Joranson, now retired, who did not return requests for comment, founded the UW group in 1996, a year after Purdue introduced the powerful new pill that resulted 11 years later in criminal convic- tions against three executives for misrepresenting its addictive properties. Dahl has never been part of the UW pain and policy group. She worked closely with it though and co-authored important research on the topic with Joranson. Dahl took drug company grants because there's a "deficit" of money for pain research. She won't take them now but insists, "I was never told what to say." Joranson's group, which hasn't taken drug company money for four years and is run by a new leader, is doubling down on its mission. They want global impact. "Our advocacy for balance implies that the medical commu- nity must pay attention to deaths related to opioid use," insists David Cleary, the group's current director. "Patients and physi- cians alike need to have correct information about how to use these medicines properly. We believe strongly, however, that broad restrictions on access are not the most effective way to achieve that goal." He explains the group's "role is to ensure access to controlled sub- stances, where it is deemed med- ically appropriate. ... In many cases achieving balance has required the removal of regulato- ry restrictions that were barriers to opioids for pain relief." Cleary says the group's budget was $9 million from 1999 through 2012, and $1.7 million of that came from unrestricted grants from pharmaceutical companies. The rest came largely from grants from foundations as well-known as the American Cancer Society and Princess Di Fund. One of the foundations, though, was the Robert Wood Johnson Foundation, started by a Johnson & Johnson heir. A Johnson & Johnson subsidiary grows pop- pies for American prescription drugs in Tasmania. Asked about that, Cleary says he is not aware of any links between that subsidiary and the foundation, which he calls the "largest philanthropy devoted to public health." There is no direct taxpayer support of the UW Pain Group, he says. Cleary, a cancer physician, has "seen up close the devastating consequences of uncontrolled pain during serious illness. When opioids are used as pre- scribed and appropriately moni- tored, they are indispensable to patients who need them." As to the heroin link, he adds: "It is clearly important for the whole community to contribute to ensure a balanced situation. This includes physicians, patients, pharmacists, regulators, politi- cians and pharmaceutical compa- nies. A scale that has tilted too far in either direction is not bal- anced." The problem with the current balancing act is that people who weren't prescribed take prescrip- tion opioids from people who were (and sometimes those people switch to the cheaper and even easier to obtain heroin), and the definition of "serious" is debated — today it might be someone's knee or migraines, not just severe cancer pain. Jackson wants the group to "take steps to end deaths and addiction and publicly support the growing tide against the use of opioids for chronic non-cancer pain." Otherwise, he insists, "the university must close them down. "Here we are years down the road, with all of the evidence of the fallout, and they are still hold- ing onto their old mission," he says, sounding fatigued. "I want no diversion, and cer- tainly not of this magnitude," Dahl stresses. Diversion means pills used improperly. She says education is the answer because doctors "prescribe carelessly," don't reassess patients and give out too many pills (other experts agree). Dahl was born in Hudson to a telephone operator mother and railroad father. She obtained a Ph.D. in chemistry, and followed her chemistry professor husband to Madison in the 1950s, eventual- ly becoming a tenured pharmacol- ogy professor. From cancer treatment to drug of abuse The 1980s were pivotal in the pain management movement, which initially focused on termi- nal cancer patients, who some- times couldn't get opioids. A member of the state's Controlled Substance Board, Dahl met Joranson, a staffer. A turning point came when Congress rejected an attempt to legalize heroin to treat cancer patients in 1984. A journal article says up to 80,000 cancer patients were suffering and 26 countries, notably England, allowed med- ically administered heroin. Dahl and Joranson opposed legalizing heroin ("a more contro- versial form of morphine," she says) but agreed terminal cancer pain was undertreated. "When people get to the point of death from cancer, their pain is so severe that only opioids relieve 6 • Milwaukee County Post • September 19, 2014 See HEROIN on Page 7 Wisconsin opiate-related deaths per 100,000 population, 2000-2011 0 2.25 4.5 6.75 9 2000 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 2.19 2.43 3.16 3.6 3.93 4.96 6.12 6.77 6.62 7.13 7.08 8.08 Source:Wisconsin Department of Health Services, Division of Public Health Heroin: UW researchers played role in upping opioid use continued from Page 1 Miller Dahl

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