A Prescribed Epidemic

Prescription opioids (aka painkillers) like morphine, OxyContin, Percocet, and Vicodin (to name just a few) peaked in 2012, with 81.3 prescriptions per 100 persons. The rate of prescriptions has since fallen, but the United States still represents 80% of world opioid prescriptions (via 2015 data), and has high rates of opioid prescriptions among people under the age of 65 (i.e. the population that is younger and should be healthier). This problem of prescription is deeply embedded in how the United States (fails to) regulate the pharmaceutical industry:

Unlike most of the developed world, the United States puts minimal constraints on aggressive marketing by pharmaceutical companies, whether the target is patients, prescribers, or medical and scientific societies. U.S. pharmaceutical manufacturers have been highly successful at promoting prescription opioids in this lightly regulated, profit-driven health-care environment.

vicodin
Image via postsecret.com

Opioid abuse is rampant, and is frequently cited as one of the “gateway” drugs to heroin . Opioids are highly addictive drugs because they target parts of the brain that are susceptible to feeling pleasure. Since opioids are more intense than the natural endorphins that humans produce, users of pharmaceutical opioids or illegal opioid drugs (like heroin) feel pulled to chase the high, continue using opioids (and use in increasing amounts), and may become addicted.

Prescriptions for opioids have fallen since an all-time high in 2012, but are still above CDC recommendations. Additionally, length of prescription was found to have actually increased between 2006 and 2015, meaning patients are exposed to the affects of prescription opioids for longer periods, against CDC recommendations. Prescriptions are also doled out unevenly, and a CDC report found that  “the places with the largest number of prescriptions filled tended to have more white residents and higher rates of poverty and unemployment…” See the maps below. On left, rates of opioid prescriptions by state in 2012, on the right, poverty rate by state in 2013. States with higher rates of poverty also have higher rates of opioid prescription.

Just about this time last year, Last Week Tonight did a segment on opioid prescriptions that highlighted the role of aggressive marketing from pharmaceutical companies to influence doctors’ prescriptions of opioid painkillers. [Note: There are some things I find grating in the format of Last Week Tonight but I think this does really quality work at communicating the history of opioid marketing and prescription in the US.] In sum – big pharma played fast and loose with marketing, many doctors fell for it, and now we have huge rates of opioid abuse.

It takes time to change trends in medical practices. It took time for the prescription rates to reach the 2012 highs! So it tracks that it’s going to take some time, even with increased surveillance, research, and awareness before doctors really change opinions about what pain management strategies should look like.

Most articles that I see in local news focus on the opioid epidemic in population health – through interviews with people affected by the opioid crisis and investigations into the areas where opioid addiction is most prevalent. I think many of these articles are great, but they do obscure the macro-level issue of how opioids have come to saturate the medical industry. Fortunately, now more attention is being paid to the source: big pharma. 

41 States of Investigate Pharmaceutical Companies over Opioids (9.19.17 via NPR) – A coalition of state attorneys general have come together to investigate potential impropriety in pharmaceutical companies’ role in the opioid crisis.

“Our subpoenas and letters seek to uncover whether or not there was deception involved, if manufacturers misled doctors and patients about the efficacy and addictive power of these drugs,” New York Attorney General Eric Schneiderman said during his press conference announcing the investigation. “We will examine their marketing practices both to the medical community and the public.”

Are Pharmaceutical Companies to Blame for the Opioid Epidemic? (7.2.17 via The Atlantic) – “Big Tobacco” faced lawsuits in the pursuit of improved public health and has been required to make changes – this article examines the legal possibility of states attorneys general pursuing these cases.

With the tobacco-industry lawsuits, customers were using the product as instructed and got sick. With opioids it’s a different story: Customers are not using the pills as directed, and so it is harder to blame the pharmaceutical companies for the effects of that misuse, according to Lars Noah, a professor of law at the University of Florida. In addition, doctors, not consumers, were the ones targeted by the aggressive marketing campaigns undertaken by pharmaceutical companies, so it can be difficult to link consumer deaths with aggressive marketing.

Whether suits against pharmaceutical companies will be successful is to be determined – already cities and states that have been hit hard by the opioid crisis have taken steps to sue pharmaceutical companies, and it’s possible that in the next year or so we could see court decisions go one way or another. I’m definitely interested to see what happens — but hopeful that this increased attention on the issue of opioid prescriptions will ultimately result in better treatment for those facing addiction and helpful changes made in medical care to prevent exacerbating an already unfortunate epidemic.

 

Links Roundup: Opioid Addiction

Opioid abuse is a growing epidemic in the United States, and frequently makes headlines. I think it’s particularly hard to get nuanced stories about the opioid epidemic because drug use is highly stigmatized and many journalists, even sympathetic ones, frequently write stories pumped with *shocking* details and descriptions, which is less humanizing than what they’re probably hoping for.

That said, it is a significant issue, and one that is tied to the over-prescription of opioid painkillers. Prescriptions are down since 2010, but even short-term prescriptions for opioid painkillers increase one’s risk of developing an addiction. In 2015, drug overdose was the “leading cause of accidental death in the United States,” with 38% of those drug overdose deaths from prescription pain killers and 25% from heroin.

I find reading stories about the opioid crisis, especially in my home city of Philadelphia, to be particularly difficult not because of the subject matter, but because of many people’s total disdain and disgust for people who use drugs. Reading comments on the internet is always a (mentally) dangerous endeavor, but people are particularly cruel about drug addiction, and this simply does nothing to help the crisis.

The above video from Vox is a really helpful primer on one of the reasons why heroin deaths are spiking, but I also read 2 articles this week that I thought offered some really important, nuanced perspectives on what the lives of opioid drug-using women are like:

Sex Workers and Drug Users Speak Out in Philadelphia – The Fix

Establishing a sense of empowerment and community is crucial – even lifesaving –for sex workers, said Amanda Spitfire and Aisha Mohammed, Project SAFE volunteers and the evening’s organizers.

“A lot of the stories were really painful, involved a lot of pain and sadness and hardship and difficulty, and I think that that’s really important to recognize that that’s a part of it, too,” Mohammed said after the event. “But that’s not a reason to abolish the sex industry altogether. Those are the reasons to make it safer – to make conditions safer and better and more lucrative for people who are doing it.”

Getting An Abortion In Alabama Is Hard. The Opioid Crisis Is Making It Even Harder. – Huffington Post

Although the patient Parker and Johnson were talking about was from Birmingham, she was 21 weeks and 1 day pregnant, which meant her procedure would have to be a dilation and evacuation, or D&E. Parker would have to use drugs to soften her cervix to conduct the abortion procedure in order to be able to insert his instruments into her uterus and remove the fetus.

…The clinic wouldn’t be open again until the following Wednesday, by which point she would be perilously close to the 22-week cutoff. … To add to the patient’s concerns, Alabama has been aggressive about prosecuting women who use drugs while pregnant. Given the abortion restrictions in surrounding states, given the looming public holiday and given this woman’s desire not to become a mother, Parker and Johnson both knew they were her last best hope.

It’s a complicated topic, but I hope that when readings articles about opioid addiction that you look for articles that present facts in a neutral tone and with respect for the people they’re interviewing.