The Opiate “Epidemic”

America’s opiate “epidemic” is a little bit like an iceberg. Its massive reach is difficult to comprehend if you are just taking it in via the surface level sound bites and headlines available in the news media. But, once you begin to dig deeper into the problem of opiate addiction and overdose deaths in America, the depth and breadth of the problem becomes a lot more apparent. Some of the staggering statistics associated with the problem include: nearly 50,000 combined deaths in the U.S. in 2016 attributed to opiate drugs.¹⁰ Additionally, roughly 2 million Americans were battling addiction and abuse of opiates in 2015. ¹⁷

After hearing a lecture by author Sam Quinones as part of my physical therapy education as well as reading his book “Dreamland: The True Tale of America’s Opiate Epidemic,” I have a better perspective and understanding of the greater social context for how our country has ended up in this predicament. Quinones weaves an intriguing and equally disturbing tale of how addiction to prescription opiate painkillers and cheap heroin from Mexico (“black tar” heroin) have insidiously taken a foothold in cities across the U.S. in the last 20-30 years.¹⁵ Implicated in the steep rise in addiction and overdose deaths from opiates were the increase in availability of prescription opiates as well as a parallel influx of cheap, but potent heroin from Mexico in a form called “black tar” heroin. ^{7, 15} Both substances have unique histories; but the spread of both was motivated largely by the promise of profit for the sellers and followed, in many cases, by the deterioration of health for the users including addiction and in some cases overdose and death.

In the case of prescription opiate drugs, the parties that profited from the wider distribution and consumption were large pharmaceutical companies such as Purdue Pharma. ^{7, 9, 15} In the case of Mexican “black tar” heroin, poor Mexicans (most from Xalisco county in Nayarit Mexico), were motivated by the allure of an avenue out of poverty and an alternative to the hard labor and poor economic return from agricultural pursuits in their home towns. ¹⁵ One of the major ways that use of these two substances spread so quickly and had such a wide-reaching impact across the U. S. over the last 20 or 30 years was the degree to which they were marketed. One of the key marketing forces behind prescription opiates was the late Arthur Sackler, who helped revolutionize the marketing of pharmaceuticals as a leader in his company Purde Pharma. One example of this was the marketing campaign for the opiate drug OxyContin, where drug representatives marketed aggressively to doctors with promises of free bonuses and perks and also armed with taglines from research that they themselves had funded and doctors they had paid to argue against the addictive properties of opiate drugs ^{7, 9, 15} One article describes Arthur Sackler’s marketing tactics as, “sometimes blatantly deceptive.”⁷ Furthermore, claims from doctors were often taken out of context or grossly misrepresented in order to convince the medical community that opiates were safe and risk of addiction was low. One example of this was a heavily cited, single paragraph letter to the New England Journal of Medicine, now known as “Porter and Jick” that was held up as proof that opiates were not addictive despite it not being a scientific study and the fact that the observations from Dr. Jick referred to a specific population of patients in a limited data set. ^{7,8, 14, 15}

Similar Story Lines?

Pharmaceutical Industry, Tobacco Industry, Agricultural Industry

The story line of a large industry becoming rich by promoting health damaging (and indeed addictive) products is unfortunately not a new one. This same story has played out in the tobacco industry as well as “Big Ag” (industrial agriculture), both of which have been implicated in their own public health crises: tobacco use with the increased risk of lung cancer, heart disease, and stroke and industrial Ag’s poor quality “food products” (born out of an overabundance of cheap corn) with the rise in obesity, diabetes, and heart disease.^{1,3, 12, 13} In fact, the U.S. is plagued by these public health “epidemics” associated with the collateral from industries’ profits; including “the obesity epidemic” and now “the opiate epidemic”.

To further elaborate on the parallels, there are similarities to be found in the marketing, legal repercussions, and targeted populations. Just as in the case of opiate drugs and large pharmaceutical companies, marketing founded on claims of misinformation or industry-funded research were utilized in the tobacco industry as well as in the agriculture industry.^{1, 12, 13} Another parallel between these industries has been the monetary fines levied on certain responsible parties due to the corruption and false advertising claims that were made. For example, in 2007, Purdue Pharma pleaded guilty to misbranding of OxyContin and the company was forced to pay out over $600 million in fines. ^{2, 8, 9} As of 2013, the tobacco industry had paid over $100 billion in settlement money!¹¹

However, the act of paying fines as retribution cannot take back the human suffering that has and continues to be born out by the affected individuals. In all three of these examples, there is emerging evidence regarding some of the factors that make battling addiction so difficult, including changes in brain chemistry and alterations in how reward is processed in the brain (and there is evidence that all substances: nicotine, opiates, and food have the potential to be addictive).^{1, 16} Once a person is addicted to a substance, it is often very difficult, if impossible, to quit using and therein lies the largest detrimental impact that these industries have unleashed. They have not only been successful in getting consumers to try their products, but they have insidiously downplayed the dangers of becoming addicted and left individuals (and society as a whole) to bear the burden of addiction.^{1, 15}

One of the sad truths that I have noticed with these “epidemics” is the targeting or disproportionate marketing to vulnerable populations. Quinones points this out for opiates with prescription opiates being marketed to populations in pain (chronic pain patients, athletes with multiple injuries, etc.) and the marketing of “black tar” heroin to “junkies” or individuals already fighting opiate addictions. ¹⁵ It has been noted that the obesity epidemic disproportionately effects minorities and an inability to access “real food” (fresh fruits and vegetables) or the presence of “food deserts” is more prevalent in low income areas. ^{3, 6, 12, 13} Also, smoking prevalence in adults is higher for those below the poverty limit.^{4, 5}

Where Do We Go from Here?

As a physical therapy student preparing to enter the health care industry, it is impossible for me to not care deeply about these issues as they relate integrally to people’s overall health and wellness. They can significantly affect physical therapy practice and treatments and in a hopeful way (I hope not naïve) I wish to be some small part of working to improve these areas and health behaviors. In order for change to be realized, I believe not only must people be aware of these issues, but we must truly find a way to alter the value system that we are promoting.

There must be a cultural change where health is valued above wealth, people are valued more than profits, and we make a concerted effort to protect the individuals of our society that are most vulnerable instead of exploiting them.

Only then will the health of individuals as well as the health of our society improve. Only then will our society strengthen its immunity to such public health “epidemics”.

“As long as a society protects the vulnerable among them, can they be expected to prosper and not decline.”

-from the Mahaparinirvana Sutta (a text of Buddha’s last teachings)

References:

1. Brownell KD, Warner KE. The perils of ignoring history: Big Tobacco played dirty and millions died. How similar is Big Food? The Milbank Quarterly. 2009;87(1):259–294.
2. Catan T & Perez E. A pain-drug champion has second thoughts. Wall Street Journal. December 17^th, 2012. https://www.wsj.com/articles/SB10001424127887324478304578173342657044604
3. CDC “Adult Obesity Facts”: https://www.cdc.gov/obesity/data/adult.html
4. CDC “Burden of Tobacco Use in the U.S.”: https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html
5. CDC “Health Effects of Cigarette Smoking” https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm
6. Hilmers A, Hilmers DC, Dave J. Neighborhood disparities in access to healthy foods and their effects on environmental justice. American Journal of Public Health. 2012;102(9):1644–1654.
7. Keefe, PR. The family that built an empire of pain. The New Yorker. October 30^th, 2017. https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain
8. Leung PTM, Macdonald EM, Stanbrook MB, Dhalla IA, Juurlink DN. A 1980 Letter on the Risk of Opioid Addiction. New England Journal of Medicine. 2017;376(22):2194-2195.
9. Meier B. In guilty plea, OxyContin maker to pay $600 million. New York Times. May 10, 2007. http://www.nytimes.com/2007/05/10/business/11drug-web.html?mtrref=www.google.com&gwh=A650C7AE165917FC6118B1FF1161A3F5&gwt=pay
10. NIH stats https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
11. NPR “15 Years Later, Where Did All The Cigarette Money Go?” All Things Considered. October 13^th, 2013. https://www.npr.org/2013/10/13/233449505/15-years-later-where-did-all-the-cigarette-money-go
12. Pollan, M. In Defense of Food: An Eater’s Manifesto. 2009. Penguin Books
13. Pollan, M. The Omnivore’s Dilemma: A Natural History of Four Meals. 2007. Penguin Books
14. Porter, J & HN, Jick. (1980). Addiction Rare in Patients Treated with Narcotics. The New England Journal of Medicine. 302 (2). 123.
15. Quinones, S. Dreamland: The True Tale of America’s Opiate Epidemic. 2015. Bloomsbury Press: New York.
16. Smith, F. The addicted brain. National Geographic. September 2017. 30-55.
17. Substance Abuse Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health: Detailed Tables. SAMHSA. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf.