America is indeed in the grip of an unprecedented opioid crisis, with a lot of blame to go around, but not everybody is at risk and there is hope.
A couple of days ago, I wrote a post with questions and comments that occurred to me after watching HBO’s Warning: This Drug May Kill You, a documentary about the opioid addiction problem America is facing. Today, I received an email from Neo-neocon directing me to a just-published, superb Sally Satel article about the opioid crisis in America. Briefly, here are my questions and the answers drawn from Satel’s article. I urge you to read the whole article, though.
My first question: Is this really an “unprecedented” crisis, given all the other unprecedented drug crises I’ve been through in my lifetime? Satel’s answer is that yes, it is:
An estimated 2.5 million Americans abuse or are addicted to opioids — a class of highly addictive drugs that includes Percocet, Vicodin, OxyContin, and heroin. Most experts believe this is an undercount, and all agree that the casualty rate is unprecedented. At peak years in an earlier heroin epidemic, from 1973 to 1975, there were 1.5 fatalities per 100,000 Americans. In 2015, the rate was 10.4 per 100,000. In West Virginia, ground zero of the crisis, it was over 36 per 100,000. In raw numbers, more than 33,000 individuals died in 2015 — nearly equal to the number of deaths from car crashes and double the number of gun homicides. Meanwhile, the opioid-related fatalities continue to mount, having quadrupled since 1999.
Honestly, I had no idea. That’s just devastating. I’m so used to discounting media hysteria, and trying to factor in the multiplication effect of the fact that everyone now photographs and videotapes scenes that were long hidden from view, that I wasn’t ready to accept HBO’s unsubstantiated conclusion that the opioid crisis is “unprecedented.” That’ll teach me….
My second question: Who’s to blame? The documentary wanted to blame the pharmaceutical companies; the suffering families want to blame the doctors. Satel’s answer is that it’s complicated, with blame to go around, including the bad effects of good intentions:
In the early 1990s, campaigns for improved treatment of pain gained ground. [snip] In 2001 the influential Joint Commission on Accreditation of Healthcare Organizations established standards for pain management. These standards did not mention opioids, per se, but were interpreted by many physicians as encouraging their use.
Soon, clinicians were giving an entire month’s worth of Percocet or Lortab to patients with only minor injuries or post-surgical pain that required only a few days of opioid analgesia. Compounding the matter, pharmaceutical companies engaged in aggressive marketing to physicians.
The culture of medical practice contributed as well. Faced with draconian time pressures, a doctor who suspected that his patient was taking too many painkillers rarely had time to talk with him about it. Other time-consuming pain treatments, such as physical therapy or behavioral strategies, were, and remain, less likely to be covered by insurers. Abbreviated visits meant shortcuts, like a quick refill that may not have been warranted, while the need for addiction treatment was overlooked. In addition, clinicians were, and still are, held hostage to ubiquitous “patient-satisfaction surveys.” A poor grade mattered because Medicare and Medicaid rely on these assessments to help determine the amount of reimbursement for care. Clearly, too many incentives pushed toward prescribing painkillers, even when it went against a doctor’s better judgment.
The chief risk of liberal prescribing was not so much that the patient would become addicted — though it happens occasionally — but rather that excess medication fed the rivers of pills that were coursing through many neighborhoods.
Packing a large dose into a single pill presented a major unintended consequence. When it was crushed and snorted or dissolved in water and injected, OxyContin gave a clean, predictable, and enjoyable high. By 2000, reports of abuse of OxyContin began to surface in the Rust Belt — a region rife with injured coal miners who were readily prescribed OxyContin, or, as it came to be called, “hillbilly heroin.”
Around 2010 to 2011, law enforcement began cracking down on pill mills. In 2010, OxyContin’s maker, Purdue Pharma, reformulated the pill to make it much harder to crush. In parallel, physicians began to re-examine their prescribing practices and to consider non-opioid options for chronic-pain management.
Controlling the sources of prescription pills was completely rational. Sadly, however, it helped set the stage for a new dimension of the opioid epidemic: heroin and synthetic opioids. Heroin — cheaper and more abundant than painkillers — had flowed into the western U.S. since at least the 1990s, but trafficking east of the Mississippi and into the Rust Belt reportedly began to accelerate around the mid-2000s, a transformative episode in the history of domestic drug problems detailed in Sam Quinones’s superb book Dreamland.
Attention plaintiffs’ counsel: Much as you’d love to find a deep pocket to sue, it looks as if the problem is so diffuse, both in prevailing treatment paradigms and intentions, that there really isn’t a good lawsuit out there. The only ones that deserve to be sued, but somehow always seem to go to ground when the lawyers show up, are the prescription mills that deliberately handed out drugs to known addicts for purely profit motives.
My third question: Do all of those who get prescriptions become addicted or are they even at risk of becoming addicted. Satel’s answer is that, no, they don’t:
Much of the conventional wisdom surrounding the opioid crisis holds that virtually anyone is at risk for opioid abuse or addiction — say, the average dental patient who receives some Vicodin for a root canal. This is inaccurate, but unsurprising. Exaggerating risk is a common strategy in public-health messaging: The idea is to garner attention and funding by democratizing affliction and universalizing vulnerability. But this kind of glossing is misleading at best, counterproductive at worst. To prevent and ameliorate problems, we need to know who is truly at risk to target resources where they are most needed.
In truth, the vast majority of people prescribed medication for pain do not misuse it, even those given high doses. A new study in the Annals of Surgery, for example, found that almost three-fourths of all opioid painkillers prescribed by surgeons for five common outpatient procedures go unused. In 2014, 81 million people received at least one prescription for an opioid pain reliever, according to a study in the American Journal of Preventive Medicine; yet during the same year, the National Survey on Drug Use and Health reported that only 1.9 million people, approximately 2%, met the criteria for prescription pain-reliever abuse or dependence (a technical term denoting addiction). Those who abuse their prescription opioids are patients who have been prescribed them for over six months and tend to suffer from concomitant psychiatric conditions, usually a mood or anxiety disorder, or have had prior problems with alcohol or drugs.
Satel’s answer about the risk of addiction jives with my instincts, especially about the number of people who self-medicate. My Mom essentially self-medicated because of intractable pain that was first undertreated then overtreated. Current and former substance abusers I know self-medicated for everything from bipolar disorder, to acute depression, to debilitating social anxiety. And as I said, a whole lot of people now claim that they’re self-medicating for ADHD or ADD. Some were alcoholics and are much more functional and healthy now that they quit drinking and started drugging.
Satel’s article is long but every word is worth reading. It provides all the nuance that the HBO documentary lacks. America’s heartland is suffering, nobody intended for that to happen, drug cartels are benefitting, not everyone is a victim or at risk, and there are things that will help (including tincture of time, as many addicts simply stop using for whatever reason).
Photo credit: Drugs by Dimitris Kalogeropoylos. Creative Commons license; some rights reserved.