In my recent column on the opioid epidemic, I cited some of the factors contributing to our current crisis, and some of the solutions that have been tried both in the US and abroad. This article generated a larger than usual level of reader interest, and I thought I would take some of the reader questions and add some new ideas in this follow-up.
Recommendations: Runnin’ (STAT) and Dreamland (Sam Quinones)
For readers who are interested in further information about the opioid epidemic, I have two recommendations.
I had the chance to view a powerful local documentary produced here in Boston by STAT called Runnin’. Runnin’ is a very poignant set of interviews with local people who have survived opioid addiction but lost many friends and family members.
I also reread a fabulous book on this topic titled Dreamland: The True Tale of America’s Opiate Epidemic by the reporter Sam Quinones, published by Bloomsbury Press in 2015.
1980s and 1990s: Dreamland and My Own Experience as a Physician
Dreamland presents very deep background on why the opioid epidemic took hold in the United States. Mr. Quinones explains that starting in the 1980s, the medical community’s attitude towards the prescribing of opioids took a hard turn. He explains how Dr. Katherine Foley, a leading physician at Sloan Kettering Cancer Center, moved the medical community forward on prescribing adequate doses of opioids for patients with severe cancer pain. (On a personal note, I edited an article Dr. Foley wrote in the Journal of the American Medical Association (JAMA) titled, “A 44-year-old woman with severe pain at the end of life.” JAMA 1999; 281; 1937-1945.)
At around the same time, a short letter by Dr. Herschel Jick to the New England Journal of Medicine suggested that hospitalized patients rarely developed addiction to opiates after receiving them. In 1984, Purdue Pharma released MS Contin, a long-acting form of morphine. I personally know this drug was highly effective and useful in treating severe pain as I myself prescribed it to many patients with cancer pain starting in the 1980s.
In 1995, Purdue Pharma released OxyContin. By then, the pharmaceutical companies recognized the opening offered up by the medical community, and ran with the message that opioids were safe and non-addictive. Thousands of drug reps swarmed doctors’ offices all over the country, strongly pushing the use of opioids for non-cancer pain – back aches, fibromyalgia, you name it.
I was taught in the 1980s in medical school and residency to prescribe opioids very sparingly. But this old (and wise) teaching was upended by the hard turn to prescribing opioids for all manner of pain, including brief post-operative pain and labor pain. Well-meaning physicians began prescribing opioids to large numbers of patients, resulting in addiction. Some people even talked about lawsuits against doctors who undertreated pain.
2000s: A Well-Intended Idea Spurs the Growth of “Pill Mills”
In 2001, the Joint Commission on the Accreditation of Hospitals (JCAHO) mandated that hospitals assess pain levels in every patient and developed the concept of pain as the “5th vital sign”. Of course, pain is not a vital sign, like temperature, heart rate, respiratory rate and blood pressure. But the concept further accelerated the notion that all pain must be diagnosed and treated aggressively.
And then some unscrupulous doctors, many who themselves were addicts, started the notorious “pill mills” in which millions of opioid tablets went out the door to patients with virtually no medical oversight. A high percentage of these tablets were then re-sold on the street, addicting a new crop of unwitting victims.
The Arrival of Black Tar Heroin
Mr. Quinones then carefully details how the production of something called “black tar heroin” in parts of Mexico changed the game dramatically. Black tar heroin is far stronger than the powder that had been entering the US for years from Mexico, Central America and Asia. The black tar heroin quickly began to replace the Oxycontin as it was cheaper and stronger. The death rates rose fast.
Mr. Quinones explained the brilliance of the drug dealers in managing sales down at the local level with sellers in cars, with cellphones and just enough heroin for the needs of the day. This way, the large dealers eluded capture and they were able to expand their reach into many urban, suburban and rural areas.
In summary, Mr. Quinones demonstrates the startling demand for opiates in the US, and the highly efficient methods of supply coming mostly from Mexico. In my opinion, physical border controls will be of limited effectiveness in controlling the movement of illegal drugs. As long as the demand for opiates persists, the sellers will find ways to supply them.
More Questions from Readers
The following questions were some of many that came in response to my earlier column on this topic.
Can you draw some more detailed comparisons between the crack cocaine epidemic and the opioid epidemic? How did the death rate compare over time?
The crack epidemic mainly affected black people in urban areas. The death rate was far below what we have seen with heroin and fentanyl simply because it was not as powerful a respiratory depressant. Overdose patients almost always die due to the depression and cessation of breathing.
The opioid epidemic is affecting white people proportionally more than blacks or Hispanics compared with the crack epidemic of the 1980s.
How much do you think race factors into the public perception of the crack epidemic v. the opioid epidemic, and about appropriate responses?
I do think most people perceived of the crack epidemic as mostly affecting the African-American population, whereas the current opioid epidemic is breaking more over disadvantaged white people – though all races are affected.
Though we hear about opioids in more affluent areas, this is still predominantly an epidemic of the lower and mid-socioeconomic strata.
Appropriate responses did not occur with the crack epidemic as the focus was on arresting dealers and users, and much the same is unfortunately still happening with the opioid epidemic. I am not suggesting that there isn’t a place for law enforcement. I am simply stating that the so-called “war on drugs” started in the Nixon administration always was, is, and will be a failed strategy.
You mentioned the US and Canada – are other parts of the world experiencing this the same way we are?
Though I do not have data on all the countries around the world, it appears that the opioid epidemic in the US is a particularly American problem for the reasons stated above. In general, other countries do not have the incredible demand that we do, nor do they have the huge supply right on the other side of their borders.
Shouldn’t drug companies be taken to task more? Especially given that it appears they were lying about addiction rates – saying 1-2% when really it was more like 13%. (And even if it is 1-2%, is that an acceptable rate?)
Purdue Pharma was taken to task over the false advertising of OxyContin. They paid huge fines and three executives went to prison, but unfortunately the damage was already done.
What is our federal government doing about the opioid crisis?
Many readers have asked this. Here is a link that takes you to the CMS (Center for Medicare and Medicaid Services) opioid website.
From my perspective, the federal response could be summarized as too little and too late. The federal government still perceives of people addicted to opioids as law breakers rather than patients in need of treatment.
Buprenorphine (Suboxone) is clearly the most effective drug at treating opioid addiction, though it is not without its own addictive properties. Nevertheless, the federal government has put forth minimal support for training doctors to prescribe Suboxone or supporting clinics with adequate behavioral health resources to assist the doctors with the complex level of multidisciplinary care these addicted patients require.
A June 20, 2018 article in the New York Times summarizes the plethora of bills before Congress regarding the opioid crisis.
In my last blog piece on the opioid crisis, I suggested that hopelessness is the chief fuel driving people to use and then become addicted to opioids. After further reading and research, I would add the elements of loneliness and social isolation as serious co-factors. Complex problems of this magnitude require a huge response. We are a nation of great resources and ingenuity. We can solve this – or at least do better.
Have a question for Dr. Parker?
At Arcadia, we’re always happy to talk about value based care. Simply fill out the short form below to send a note to Dr. Parker.