Over 20 million opioid (Vicodin and OxyContin) prescriptions were supplied principally by two drug distributors to only two local pharmacies (from 2006 to 2016) in Williamson, West Virginia. That’s about 2 million pills a year to a town with a population of 2900 people. If we do the math, that’s 690 pills per person per year, more than 57 pills for every person per month. An even smaller town in West Virginia, Kermit (pop. 400), was shipped 5.7 million pills from 2005 to 2011; in 2008 alone, more than 5600 pills were supplied, enough to supply every child and adult in this town more than 468 pills per month. In yet another town, one drug wholesaler/distributor sent 3,000 Vicodin pills per day for a year (2008), a tenfold increase from the prior year.
This inundation of opioids, the cruel commercialization of addicting drugs, is not restricted to these few towns, where it literally has been drowning W. Virginia residents. The persistence of this flood of opioids in this state is even more bizarre because it has the highest overdose fatality rate in the country.
How did W. Virginia, and many other epicenters of the opioid epidemic (including midwestern, southern and northeastern states), arrive at these deadly and surely unneeded levels of prescriptions? And how can we control this deadly inundation?
Two principal drivers happened in the 1990s that launched the “supply-side” of what we have seen for almost two decades. First, in 1997, The American Academy of Pain Medicine and the American Pain Society, in statements written by a paid speaker for Purdue Pharmaceuticals (more about them below), asserted that prevailing views about addiction and the abuse of opioids were a “medical myth”, an irrational phobia by doctors and hospitals. Second, also in the ‘90s, pain was termed the “5th Vital Sign”. Hospitals and doctors were required by their accrediting bodies to query patients about pain using a simple emoticon illustrated, self-assessment scale.
Doctors, as a rule, want to make their patients feel better. They don’t like to have a patient leave unhappy as if nothing was done to help. In an eight to10 minute office or ward visit, with a vast number of patients in acute or chronic pain and with a patient report that went into the medical record, what’s a physician to do? Especially if the pain score is 7, or 8, or 9 out of ten? The doctor can write a prescription for a pain pill. And it would help, but of course, there were consequences. Large numbers of pills, with many refills, were supplied. Patients then began to energize the “demand-side” of the epidemic as they felt the effectiveness of the opioids, and over time, a dependence on them.
A second “supply-side” driver was the phenomenal marketing campaign by Purdue Pharmaceuticals, the distributors of OxyContin. This drug had previously been sparingly used for terminal illnesses. But Purdue advanced the idea that its powerful drug (it is no different from heroin in the brain) should be used for all forms of pain, like arthritis, GI and GYN pain, injuries, shoulder and back aches, etc. Why should patients suffer, they trumpeted? And Purdue used a 1980 letter (of five-sentences) published in the New England Journal of Medicine in a massive ad campaign to declare that long-term treatment with opioids was not addictive. In 2007, Purdue paid more than $600 million for their unscrupulous promotion of this highly addictive drug. By then, however, they had made billions and had seeded the country in opioids. Their recent announcement to cut their sales staff and stop promoting their opioid is more likely a means of reducing the litigation exposure they are facing (from states and individuals out to sue them) than a humanitarian endeavor.
The demographics of opioid use also have been changing (2004-2014). There was a near to 100 percent increase in the use of heroin in 20 to 34-year-old, non-Hispanic whites, while rates actually decreased among non-Hispanic blacks. Whites were now prominent in the epidemic, with a reportedly 80 percent of new users having “graduated” to heroin from opioid pain pills, which had become more difficult to obtain from doctors, and quite pricey on the black market.
Opioids work (until they don’t): they are an immensely effective means of alleviating physical and psychic pain, as well as quieting the social despair that grows from lack of work, and chronic pain, in communities dependent on manufacturing and physical labor. Still, it was not until heroin gained popularity that the death rate escalated, more so when its potency was amplified 50-500 times by fentanyl and carfentanil. So, with an opioid epidemic making headlines in so many towns, as well as the high rates of use and mortality, it persisted. Why?
Because of the dogged attachment in this country to two, ideologically rooted yet repeatedly failed, policy and program approaches to this epidemic, namely control and consequences.
The control strategy to psychoactive substances of all sorts is perhaps best exemplified by Prohibition. That had a short half-life, though it made the mafia big business. Then we had the ‘War on Drugs’, dating back to President Nixon, a myopic, federal effort that concealed racism and political gain. Nixon pursued his “southern strategy” aimed to castigate and incarcerate people of color and hippies (and win the southern vote). Today, we have Attorney General Sessions increasing enforcement personnel and policies against drug use, urging his AGs to seek maximum sentences, including for possession of marijuana. The President, of course, wants to build a wall when the deadliest opioids are coming in from China (and Russia).
The consequences approach is one of alarm: “This drug will kill you!” Have officers in blue go to school classrooms to “scare straight” our youth. President Trump seems to like this approach, as he uses his older brother (who died of alcoholism when he was 43) to warn about drugs. The White House is also seeking to launch an advertising campaign, purely based on trying to create fear. Not only don’t scare tactics work, they paradoxically can heighten interest among adolescents whose brains are wired to seek risk.
So, “supply-side”: Pharma commercialization and doctors and hospitals trying to do the right thing. “Demand-side”: patients pursuing pain relief; the social malaise and ennui from a future with few prospects; and the inattention to proven strategies to effectively combat addiction.
The opioid epidemic is a public health problem. And public health approaches have ended or contained so many an epidemic in our history, still do. Think of polio, cholera, Ebola, and motor vehicle deaths from not using seat-belts. Strategies for control and consequences are not central to public health. Instead, there is prevention, early detection and comprehensive treatment, research into non-addicting medications and central nervous system magnetic and electrical stimulation, and not blaming people for having an addiction (which only drives them further away from care).
Some states (and cities) Attorney Generals are suing Pharma distributors and manufacturers for the damage they have wreaked. Recall the tobacco settlement and how much money that has produced to reduce smoking rates and treat those already ill.
It has been said that a million deaths are a statistic, and one death a tragedy. The spirit needed to turn around our country’s dependence on opioids (and other drugs) lies with individuals and families, towns, counties and states. Neither the necessary funding or policies will emerge from the current Washington administration. But there are proven public health and treatment strategies that work. We must, and we can, follow those.
Dr. Lloyd Sederer is a psychiatrist and public health doctor. The opinions offered here are entirely his own.
His next book, The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs, will be published by Scribner (Simon & Schuster) in May, 2018.
Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS), through 2.2016 - https://www.samhsa.gov/samhsa-data-outcomes-quality/major-data-collections/reports-detailed-tables-2016-NSDUH