Flicker: Chris Potter
This is a guest blog by Josh Torrance
Despite constituting less than 5% of the global population, the United States consumes 80% of the global opioid supply. US opioid prescriptions quadrupled between 1999 and 2014, while the number of problematic users tripled. Patients seeking pain relief can inadvertently end up with long term substance abuse problems that become very profitable for both doctors and pharmaceutical companies. The US pharmaceutical opioid trade is worth $9 billion annually, and there are implications that lawmakers prioritise powerful corporate interests over public health. In 2015 alone, the US saw 22,000 deaths involving prescription opioids – the equivalent of 62 per day.
In early 2011, authorities in Florida called time on its prescription opioid epidemic. For years Florida had been prescribing ten times more oxycodone pills than all the other US states combined. It had no system in place for monitoring opioid prescriptions, allowing patients to go “doctor shopping” - acquiring multiple prescriptions from numerous different clinics. Certain doctors and clinics became notorious for handing out painkillers to whoever asked, advertising on-site dispensation – no trip to the pharmacy required. In Broward County there were more pain clinics than McDonalds, waiting rooms were full to bursting and visitors were travelling from all over the US to stock up. Clinics, doctors and pharmaceutical companies were cashing in.
Clearly, something had to give. Florida legislators created a database to track painkiller purchases and the DEA began to indict the owners of rogue ‘pill mills’, even arresting some doctors. This was in addition to a reformulation of oxycontin medication, making it impossible to snort or smoke effectively. These measures meant it became increasingly difficult for users to acquire or misuse the painkillers. However, little was done to help the users who had become dependent on opioids.
2016 research from Stanford University contradicts the rhetoric of a tiny number of ‘pill mills’ being the problem, finding instead that a ‘broad swathe’ (10% of general practitioners) accounted for 80% of prescriptions in the US, meaning the over prescription problem is far more widespread and embedded than previously thought. This would explain why misuse of prescription opiates remains a huge problem despite Florida-style measures. Similar problems are also evident in Australia, Canada and the UK. The All Party Parliamentary Group on Drug Misuse estimated there are 1.5 million people involuntarily addicted to tranquilisers in the UK. In October Harry Shapiro, director of Drugwise, labelled opioid over-prescription in the UK a ‘great public health disaster… ruining the lives of millions’ in a meeting of the All Parliamentary Party Group for Prescribed Drug Dependence.
With increasing US restrictions on prescription opioids, dependent users are faced with a problem. Instead of going through the distress that withdrawal brings, many substitute the painkillers for an opioid that is more effective and easier to obtain – heroin. At roughly one-eighth of the price per dose compared to prescription opioids, the temptation to make the switch is obvious. There are certainly less hurdles to obtaining heroin from a drug dealer than a prescription from a doctor, especially with open-air drug markets in US cities.
Opioid over-prescription – and the subsequent clampdown has been linked by numerous analysts to the five-fold increase in heroin use in the US over the past decade. In 2015 Florida saw over seven times as many heroin related deaths as it did in 2011. This is alongside a disturbing 72% rise between 2014 and 2015 in Fentanyl-related deaths across the US. Fentanyl is a short acting but highly potent synthetic opioid that is incredibly easy to overdose on, around a hundred times more potent than heroin. Produced cheaply in China, it is increasingly being used to cut heroin - grown by Latin American cartels. Mexican officials estimated a 50% increase in opium poppy cultivation in 2014 alone. Interestingly, it seems as if cartels are responding to market forces; a drop in demand for Mexican cannabis combined with an increase in demand for heroin in the US.
On the positive side, tighter prescription regulations do mean that less new patients are exposed by doctors to opioid addiction. But US policymakers made a grave error in how they managed existing problematic users - simply cutting them off ‘cold turkey’ without support. Predictably, this led to displacement to other illicit opiates, including heroin. This represents a serious failure of US medical professionals, and raises serious questions surrounding ethical care and addictive prescriptions.
In terms of positive change, a surprising trend has been demonstrated. The proliferation of cannabis dispensaries has been linked to a reduction in opioid mortality rates. Comparing 1999 and 2010, researchers found that states with medical cannabis laws had on average 25% less opioid deaths annually than those without. The researchers theorise that access to medical cannabis reduces the use of opioids for chronic pain relief.
Opioid over-prescription is a problem of frightening magnitude. The fact that some people genuinely suffering from pain are inadvertently ending up with lifelong substance abuse problems is deplorable. How much of the five-fold increase in heroin use can be attributed to profit-seeking doctors and pharmaceutical companies? It is certainly a stark indictment of a health system based on profits, a continuation of supply-side enforcement and a refusal to enact evidence-based policies. Having said this, a recent White House listening session on the opioid epidemic (hosted by Trump) was surprisingly focussed on treatment and education rather than enforcement – although harm reduction measures such as naloxone received no mention. This is at odds with the ongoing rhetoric of a reinvigoration the drug war from the Trump administration.
Pharmaceutical companies will always try to maximise their profits. To balance this, there needs to be better regulatory oversight, making sure that doctors are not cash incentivised when writing prescriptions. With the opioid crisis in full effect, the US needs to maintain the progress on treatment funding the Obama administration made, which includes insurance coverage for drug treatment. If the Trump administration does not learn lessons from innovative harm reduction interventions including naloxone, prescription heroin and Supervised Injection Facilities, American lives will continue to be needlessly wasted.