The media have been abuzz this past week about the other epidemic that’s plaguing America, namely drug overdoses. A recent government report has linked this trend to more than 100,000 deaths in the 12-month period ending in April, three-quarters of which were opioid overdoses. This latter category, and in particular fentanyl, now represents the number one killer of Americans between the ages of 18 and 45. Fentanyl kills more Americans in this age group than motor vehicle accidents, cancer, suicide or Covid-19.
Most of the blame for these astonishing numbers falls on the supply side, that is, the manufacturers and purveyors of the opioids, including so-called “pill mills,” and perhaps well-meaning doctors who over-prescribe the pills for legitimate purposes. (Fentanyl use often is related to illicit street sales.) In general, internet drug sales and pill mills and have been a source for much of the trafficking in prescription pain killers for years, while it’s believed much fentanyl now comes from China by way of drug cartels in Latin America. Just this past week the United States sanctioned four Chinese chemical companies and one leading Chinese businessman for their role in supplying opioids and/or anabolic steroids to the US; additionally, the government is offering a $5 million reward for the arrest of the Chinese businessman, Chuen Fat Yip. (The bounty may seem a hollow gesture, but may make the individual named think twice before travelling abroad.)
Also last week, a jury in Cleveland found that the Walgreen Co., CVS Health and Walmart all failed to exercise due diligence in curbing the flow of opioids into two northern Ohio counties. According to an in-depth report on CNBC, 80 million prescription painkillers between 2012 and 2016 were prescribed in one of the counties alone, or about 400 for each man, woman and child living there.
And, you probably already know about Purdue Pharma and its multi-billion dollar settlement over its OxyContin sales, though the settlement was tossed out by a judge this past week because it had shielded members of the Sackler family that founded the company from individual liability.
But Who Is to Blame?
A Walgreen Co. spokesperson promised to appeal the jury verdict (damages apparently have not yet been determined) and decried the law under which the three pharmacy giants were held liable, namely that they were operating a public nuisance. The spokesperson has a point – they don’t manufacture or separately market the painkillers, but only fill legal prescriptions written by someone else.
Walgreens et al are part of the supply chain, I suppose, so they become a choke point to stop the flow. I assume that’s why prosecutors and a jury in Cleveland went after them. That seems a noble purpose, but I don’t know if that justifies a novel interpretation of the law, and I say this while acknowledging the unbelievable misery addicted individuals must experience, as well as the pain they in turn cause their families and loved ones.
One might think that the demand side for opioids can be addressed by drug education and counseling, but that’s been tried for decades, including DARE, or “drug abuse resistance education” in elementary schools. I don’t know how we reliably assess that program’s success, but a coalition of 240 civil rights, drug policy, criminal justice reform, public health, and faith-based organizations has claimed to have knowledge of evidence-based programs that work, and this month urged Congress to pass four initiatives:
1. $69.5 million in funding to increase access to overdose prevention, harm reduction, and syringe service programs through the CDC’s Infectious Diseases and the Opioid Epidemic program.
2. The Mainstreaming Addiction Treatment Act, which eliminates the outdated requirement that practitioners apply for a separate waiver through the Drug Enforcement Administration to prescribe buprenorphine for the treatment of substance use disorders.
3. The Support, Treatment, and Overdose Prevention of Fentanyl Act, or the STOP Fentanyl Act, which improves fentanyl surveillance and detection.
4. The Medicaid Reentry Act, which would allow Medicaid to cover health services during the last 30 days of incarceration and create better linkages to community-based care during reentry.
It’s all going to face resistance because of the cost, I’d say, but we shall see. The counter-argument is going to be that not doing enough to curb the problem will cost more in the long run.
Separately, New York City opened the nation’s first overdose prevention center last month, intended to provide a supervised setting for people who use drugs in a monitored space with nurses, clinical staff or peers who work to ensure the person does not overdose. New York City alone experienced 2,000 overdose deaths in 2020. Frankly, such centers are going to be a tough sell nationally because of NIMBY, the well-known “not in my backyard” phenomenon. Needle exchange programs, where they exist, have long been resisted by middle-class residents and typically have been pushed to otherwise marginalized neighborhoods.
Often ignored in the discussion over opioid addiction is that some people really need painkillers. I had total knee replacement surgery in 2019 and experienced the most sustained physical pain I’d ever experienced. I had to refill my hydrocodone prescription weekly, and I took a lot of pills, but I made myself get off the roller coaster when I started to see the world around me very, very differently, not so unlike what I’ve read about people who take hallucinogenic drugs. High doses do curb pain, but they are dangerous tools.
Nonetheless, the present state of affairs cannot continue. I hate to say we have to “do something” without knowing what that “something” might be, but I suppose the first step in solving a problem is to admit we have one. This goes for nations as well as individuals.
I have had 2- total knee replacements, and a back fusion, and most recently hand surgery. I was prescribed pain killers for all 4 surgeries, and was able to use them as prescribed with no I’ll effects, or addiction. I suppose I don’t have the body chemistry that “needs” that type of medication beyond the pain killing need. I haven’t ever felt a “high” or a CEA ing for the opioids the problem with what’s happening, and with the govt. putting a slow-down on use, hurts those who legitimately need the pain killers.
I hope there can be a “happy median” so those who truly need opioids for real pain relief, can get them, and those who need the “high” and get the help they need to quit using.
As a former prescriber, I witnessed the tidal wave of opiates that washed over America from the 80’s til now. Our practice received unsolicited samples on a regular basis to the point where they expired in our supply closet and we just threw them in the trash. It was hard to tell who was shipping this generic hydrocodne.
There was no accounting for their receipt or disbursement other than notes entered on patient files.
I was a stingy provider especially when reseach showed that over-the-counter NSAID’s were providing similar pain relief.
It was always pretty clear which patients were seeking prescriptions beyond medicinal usage. They often called on Fridays or had fanciful stories about the loss of their written prescription. It was helpful when Indiana changed the law and no longer allowed providers to phone in prescriptions for opiates. Indiana also set up a great online portal which allowed a provider to search the prescription filled history of an individual patient. Some of them were very busy and innovative.
I was hit by a car while cycling last summer and had a couple of pelvic fractures. Upon release from the er they injected me with a bolus of Dilaudid and my first thought was “Wow, I can see how people get hooked- this is terrific!”
Opiates seem to be irresistible to a certain type of body chemistry. Some patients took a small dose and refused any additional. Some patients took a small dose and then couldn’t get enough. My experience with them was similar to Tylenol. At the same time my best friend’s 20 something daughter died at the hands of them. Or it could have been fentanyl and she did or didn’t know.