Meher Ahmad over at Jezebel brought our attention to some chilling information on deaths attributed to prescription painkillers in the US: Women are dying of overdoses at a rate 400% higher than in 1999, according to a Centers for Disease Control and Prevention study, and while men are still more likely to die of overdoses, women are on their way to catching up.
There’s a lot going on here, and it needs to be picked apart very, very carefully in discussions about prescription painkiller deaths, most of which are related to opiods. Because this is a complicated conversation, and it’s one with a lot of serious implications.
Let’s start with the statistics, laid bare by the CDC and pretty indisputable: more women are dying of prescription painkiller overdoses than they were historically. What these statistics do not tell us is why this is happening, and that’s something worth speculating about, and studying, because it has to be considered in any evaluation of the best approach to take when saving women’s lives.
The CDC study points out that many of these deaths are complicated by the use of multiple medications. In other words, women who are also taking mood stabilizers, antidepressants, sedatives, and similar mental health drugs can be at more risk of overdose from pain management medication, sometimes without realizing it. For women who are also using heroin, cocaine, and other illegal drugs, similar adverse drug interactions are a problem.
In other words, some of these deaths are undoubtedly a result of not using medications appropriately, or not being aware of the potential risks of drug interactions. The burden for this is often put on patients; “she should have known not to mix those drugs.” But what about the prescribers? How many doctors and pharmacists are taking time to educate their patients about how to use their medications safely?
And, as commenter Gemmabeta pointed out on Jezebel, how many patients are familiar with the Time of Onset issue, which is a key one in pain management? In a nutshell, it doesn’t matter how many pills you take: your medication is still going to take effect at exactly the same time as it would if you just took one. For patients with severe pain, it may be tempting to take more in the belief that the medication will act faster, but that’s not how it works.
Why is it that patients often wait until their pain is severe before taking their meds, thus putting them at risk of potentially taking more drugs to try and dull the pain? Well, social stigma about the use of painkillers is a pretty major contributor. Women, who are more likely to experience chronic pain, often feel like they need to stick it out as long as possible rather than trying to evenly control their pain, because using medication is evidence of being an addict, or because the drugs make it hard to function -- it’s hard to perform basic tasks when you have vicodin on board.
Especially in the increasingly high doses chronic pain patients need to manage their pain effectively. Which brings up another issue: tolerance. The longer patients take such medications, the more they need, because their bodies develop a tolerance, but the pain signals don’t stop.
With women more prone to chronic pain than men, you have a situation where women are more likely to need long-term painkillers, and are more likely to need dangerously high doses over time to manage their pain. That’s not because they’re addicts or drug-seekers, but because their very bodies are making war on them, and because medically, we haven’t made a lot of progress when it comes to appropriate management of chronic pain. Part of the reason for that, of course, is that this is an issue that primarily affects women.
Some of these deaths, thus, are undoubtedly accidents. Others may well be suicide. And here’s where the numbers start to get sticky, because the CDC data do not distinguish between accidental overdoses and suicide, which is a rather critical difference.
Especially with suicide rates on the rise across multiple categories in the US. Among people aged 35 to 64, the suicide rate went up by almost 30% between 1999 and 2010. For women between 60 and 64, the rate really went up, with a 60% increase. That’s a huge jump, and it’s notable that over the same interval, “poisoning” deaths (which includes painkiller overdoses) went up 24%.
In other words, more people were committing suicide between 1999 and 2010, and more of them were choosing poison as a manner of death. While firearms are still the leading cause of death when it comes to suicide, other methods appear to be gaining ground, and pills may be leading that charge. One reason for that could be the increased availability of a range of medications, including those that interact poorly with opiods, particularly in older adults. Which would explain why suicide rates in middle-aged people and older adults are increasing radically.
But the claim that young women can easily access pills to off themselves is misleading at best. Young women who experience chronic pain often have extreme difficulty finding health care providers (more on this in a moment) who will actually evaluate them and develop a treatment plan. It can be even more difficult to integrate pain management into that treatment plan; a doctor may be reluctant to work with a patient on chronic pain management, or may not be willing to consider a range of options even if a patient is ready and willing to work on supplements or alternatives to pills for controlling her pain.
For their trouble when it comes to finding appropriate health care practitioners for their needs, young women are slapped with the “doctor shopper” label. The widespread myth of a woman just out to score more prescription painkillers contributes to the stigma surrounding such medications, making women with chronic pain reluctant to seek appropriate treatments even as they’re searching for a pain specialist. While it’s considered perfectly acceptable to shop around for other care providers -- a therapist who better meets your needs, or a surgeon with more experience, for example -- there’s a lot of judging of women who look for a doctor who can help them manage their chronic pain, which is often unendurable.
And, surprise surprise, chronic pain can often be accompanied by depression and suicidal ideation, especially when combined with the ostracization and loneliness some patients experience. Oddly enough, when you’re in pain all the time, your friends stop visiting, and people brand you a useless addict, you can start to think there’s not a lot worth living for. And yes, you may well have a cabinet with an assortment of prescription medications that, when combined, can quietly put an end to it all.
It’s not surprising to see the suicide rate going up, given current social conditions -- it's worth noting too that suicide rates have an important racial, not just gender, component, with American Indians and Alaska Natives experiencing suicides at a rate almost as high as that of the white population. And I’m not surprised that women are experiencing an increase in suicides right alongside men. What I’d like to see is more drilling down into the data to see why women are committing suicide by pill, and what kinds of complicating factors are present. Is it just a matter of “freely available drugs,” as many people claim, or is it something more complex?
For that matter, what about the way addicts are treated under this framework? People who genuinely are addicted to habit-forming medications can find it hard to access and complete treatment in a society that treats them like garbage. It’s again not surprising, though sad, to see an increase in overdose rates given these conditions, but the people to blame here are not the addicts who are often rebuffed when seeking help. More often, the fault there lies with the society that slaps their hands rather than lending a lift up.
The problem here isn’t the “prescription painkiller epidemic!!!11!!!!!” -- but rather, the complex interlocking systems that are pushing women toward suicide, uninformed use of medications, and, in some cases, addictive behaviors. We need to be talking about the uses and abuses of pain management medication, but in a context that admits that chronic pain is a serious medical issue, and that our current pain management methods are woefully inadequate.