Like much else in the United States at the moment, the sheer scale of the problem is breathtaking. Every day, 115 Americans die after overdosing on opioids, a class of drugs that includes prescription painkillers, heroin and potent synthetics like fentanyl. That’s more than 42,000 deaths a year, more than result from motor vehicle deaths or gun violence or suicides. In fact, drug overdoses are now the leading cause of death among Americans under fifty, and are responsible for the shocking decline in life expectancy in the United States.
Much of the responsibility for the fivefold increase in deaths since 1999 lies with illegally manufactured synthetics. In 2016, drugs like fentanyl were linked to more than 19,400 fatal overdoses, traditional opioid prescription painkillers like oxycodone accounted for about 14,400, and heroin for just over 15,400. (These deaths total more than 42,200 because more than one type of opioid is involved in some cases.)
The problem has become too big even for the White House to ignore. Donald Trump has claimed several times that his administration is taking serious action. Last October, he declared a ninety-day public health emergency and promised to “liberate” Americans from the scourge of addiction. By the time the declaration ran out in January, it had done little more than draw attention to the crisis.
The epidemic was a key issue in the recent special election in Pennsylvania, which saw a surprise Democrat win in what was considered Trump territory, and it is likely to be a key issue for voters at the November midterm elections. Amid growing Republican fears of a “blue wave” of Democrats, this will pose a particular test for Republican candidates: the counties most affected by the opioid crisis — areas of economic decline, social stress and downward mobility — are those where Trump did well in 2016. Nationally, of the eighty-two counties with the highest opioid death rates, seventy-seven voted Trump in 2016. Most are predominantly white and rural, and it’s no coincidence that residents also have poor access to healthcare services.
There is no shortage of good advice about what needs to be done. What is in short supply is leadership from the White House and evidence-based policy-making from law-makers and administration bureaucrats. Trump chose to ignore an excellent report from the surgeon-general waiting for him when he took office, and instead established his own President’s Commission on Combating Drug Addiction and the Opioid Crisis. Its report, which included more than fifty recommendations for federal, state and local agencies but was silent on funding, was released just days after Trump’s public health declaration. So comprehensively has it been ignored that one commission member, former Democrat Representative Patrick Kennedy, characterised the process as a “charade.” He is far from alone in his concerns.
The outrage is justified. It is not just the White House that is failing to act aggressively to combat the problems; the big-spending bipartisan budget passed by Congress in February included just US$6 billion over two years to boost mental health and opioid abuse treatment — nowhere near the “tens of billions” of dollars a year experts say is needed to meet the challenge. And while a multitude of bills dealing with the problem are before Congress, even the most ambitious of them — from New Hampshire senators Jeanne Shaheen and Maggie Hassan — calls for funding of only US$45 billion over ten years, and none has been taken up so far.
Meanwhile, the president and his party continue to look for ways to undermine Obamacare. Their main target is the federal funding of Medicaid expansions, ignoring the vital role Medicaid plays in dealing with the opioid crisis — a role highlighted in the presidential commission report — and its potential to do more. (Medicaid currently covers 40 per cent of non-elderly adults with an opioid addiction.) Indeed, some Republicans in Congress have sought to blame Medicaid expansions for the increased access to opioids.
But what really stands in the way of meaningful action is the conservative notion that drug problems are best dealt with via “just say no” campaigns, interdicting illegal drugs, toughening law enforcement, and other punitive initiatives, rather than with a public health approach that supports prevention, treatment, harm reduction and, in some cases, drug decriminalisation.
The conservative view was exemplified in Trump’s State of the Union speech, which asserted that building a border wall and ending “chain migration” across the border would “support our response to the terrible crisis of opioid and drug addiction.” It was there again when the president revealed in New Hampshire last month that his plan to tackle the opioid epidemic focused on enforcing the death penalty for drug traffickers. (He has spoken admiringly of countries like China, Singapore and the Philippines that execute people accused of drug crimes.) The speech was described by a New York Times editorial as “full of sound and fury but signifying nothing.” The public health community was frankly alarmed.
The origins of the epidemic lie in the mid 1990s, when doctors were persuaded to treat pain, especially chronic pain, as a serious medical issue. Pharmaceutical companies were quick to seize the opportunity, using vast marketing campaigns to encourage medics to prescribe strong oxycodone products (including Oxycontin, Vicodin and Percocet) previously used to ease cancer pain, while offering reassurances that patients would not become addicted to them.
This was despite the fact that the evidence in support of using opioids to treat long-term chronic pain has always been weak, while the evidence that they can cause harm is strong. Opioids are addictive even when they are taken exactly as prescribed, and they can easily be ground up and snorted or injected for a more potent high. Doctors ignored or were blind to these facts, and to the growing evidence of black marketing and abuse.
Pushed by the aggressive marketing, American doctors have been prescribing opioids at an astounding rate. Around 80 per cent of the global opioid supply is consumed in the United States. In 2015 alone, roughly 240 million opioid prescriptions were dispensed, or nearly one for every adult. Doctors often ignore prescribing guidelines: one survey, by the National Safety Council, revealed that a staggering 99 per cent of physicians exceed the recommended three-day dosage limit, with a quarter of them writing prescriptions for a full month.
The shocking examples of corporate irresponsibility don’t end there. Pharmaceutical drug distributors shipped 12.3 million doses of opioids to a single pharmacy in a tiny West Virginia town with fewer than 2000 residents over an eight-year period. Mapping clearly highlights that the highest rates of drug overdoses occur where the most opioids are prescribed.
Recent efforts to rein in prescribing have caused concern that the appropriate use of these medicines will be unreasonably restricted. One recent article claimed that tighter regulation would lead to the “increasingly inhumane treatment of patients with chronic pain.” It’s worth noting that many of the most vocal patient advocacy and medical groups receive significant funding support from the companies that manufacture opioids.
Trump has declared more than once that he will go after the pharmaceutical manufacturers. Attorney-general Jeff Sessions recently announced a taskforce to target manufacturers for their role in the opioid epidemic, and the Department of Justice has said it will file a statement of interest in lawsuits brought against the manufacturers by cities, municipalities and medical institutions, and will seek payment for federal damages. But it’s also been claimed that the Drug Enforcement Agency is no longer acting against distributors who fail to monitor and report suspicious opioid orders and deliveries.
Meanwhile, hospitals continue to send patients home with an oversupply of inappropriate painkillers and doctors worry whether their patients (or patients’ family members) are abusing their medications or “doctor shopping” for opioids. Some states have mechanisms to identify doctors and pharmacists involved in overprescribing, but there is no federal coordination of these efforts.
The failure to act has been so great that this has become an “epidemic of epidemics.” Opioid use is causing a dramatic increase in hepatitis C infections, as well as in the dangerous bacterial infections that cause endocarditis and can require multiple open-heart surgeries. There are also fears that the United States could face an increase in HIV infections. Yet it is estimated that just one in ten people with drug-use disorders get the treatment they need.
All this means that there was something sad and symbolic about last week’s advisory from the surgeon-general urging individuals to learn how to use naloxone, an opioid antagonist that reverses the effects of an overdose, and to keep it in reach because “any individual can be a hero and save a life.” Yet the increased availability of naloxone has attracted controversy, with a recent study in midwest states finding that new naloxone-access laws have been followed by an increase both in arrests for possession and sale of opioids and in opioid-related emergency department visits. Most worryingly, the overall death rate failed to fall. Not surprisingly, pharmaceutical companies have duly hiked up the price of naloxone, making it increasingly unaffordable for medical facilities and first responders.
Access to treatment is important, but the socioeconomic problems and poor physical and mental health that indirectly cause addiction also need to be tackled. The opioid crisis is unlikely to abate until something is done about the lost hopes and opportunities that have fed the demand for drugs in America’s most disadvantaged families and communities.
Experts agree that Australia is moving into the same dangerous territory. A report last year by the National Drug and Alcohol Research Centre found that in 2013, the last year for which complete data were available, 668 Australians died from an accidental overdose of opioids, with 70 per cent of these deaths attributed to opioids other than heroin, including prescription painkillers. Deaths from fentanyl increased eighteenfold over the decade to December 2015.
Overprescribing is a key problem. Australia ranks eighth among the world’s top users of prescription opiates, with about 20,000 doses prescribed for every million people (the US rate is 50,000 per million). These medicines readily find their way onto the streets, where they have been described as easier to buy than heroin. Australians’ increasing opioid use is largely driven by the fact that these medicines are now subsidised by the Pharmaceutical Benefits Scheme for the treatment of non-cancer pain.
Initiatives aimed at reducing opioid misuse and abuse have included a national prescription monitoring system to target doctor shopping, and new clinical prescribing guidelines and abuse-deterrent drug formulations. The Therapeutic Goods Administration is considering a range of further regulatory changes. But the fact that rates of misuse and overdose deaths continue to rise suggests that these initiatives aren’t well-targeted and/or sufficiently effective.
Like the United States, Australia must do more to ensure that people with addiction problems can get access to affordable treatment services, both community-based and residential — especially in rural areas, where addiction rates are highest. These services need to reach out to people who may not even realise they are addicted and provide them with effective alternatives for pain management. The recent efforts to up-schedule over-the-counter products containing codeine highlight how fraught actions around pain medications can be. ●
