Solving The Opioid Crisis
Andrew Vickery, TribeRx
My introduction to the opioid crisis came in the summer of 2014 when I entered what the world knows as a “28 day program”. I had no idea what I was embarking on and how what I was about to learn would change my life forever. I had been a highly successful guy who over time wasted everything. Finding myself stuck in a cheap hotel near the Tappan Zee Bridge, all I knew was that I was terribly ill and unable to figure out what to do next. I had lost my house, my car, most of my relationships and both my mental and physical health. Finally, I realized I had a simple choice: get help or die. That moment, full of equal parts clarity and fear, was a turning point.
Driven into action out of necessity more than desire, I called a hotline number, told the rep some of my real story and was referred to a state licensed and funded treatment program which inducted me immediately without checking for insurance (I had none). In many states, this wouldn’t have been possible. Fortunately for me and countless others, New York has dedicated significant resources to treating those with substance use and other behavioral disorders, with or without insurance.
I had a series of revelations over the course of the next few weeks: 1) I had a substance use disorder (admitting it was the revelatory part), 2) what I had was a disease (not a rebellious lifestyle choice), 3) there was a cure for my disease. All of this was shocking, and by the end of the 28 days I had decided to completely change my life. I felt like a patient suffering from pancreatic cancer who has always heard that the disease is inevitably terminal, only to suddenly discover that there is a simple way to get better (hard and painful and long, but ultimately simple nonetheless). And then I learned that the best way to continue getting better is to help others to do so as well. I realized that Peer Support was as critical to humans (or at least this human) as food or shelter. We have a need to connect and share this journey with others, a truth borne out of our evolutionary biology that we ignore more and more with each passing day. I was almost overwhelmed by the power of the secret I had discovered. Little by little, I made the choice to commit my life to helping others with the same disease and to helping others avoid contracting it.
But there was one more big surprise for me. I went in to rehab thinking that the vast majority of people who had my disease abused alcohol. By 2014 that was no longer true; by then more than 60% of people (especially younger people) with substance use disorders had a problem with opioids (and the percentage was continuing to increase). So, while alcohol use disorder remains a critical issue and requires our continued attention, it is a relatively well-understood, stable and controlled problem with known answers. I decided that If I wanted to make a difference, I needed to focus on what was clearly not well understood, stable or controlled: opioid use.
By now there is a broad consensus that our nation has an opioid crisis. According to the CDC, overdose deaths were around 72,000 in 2017 compared to 4,000 in 1999 and 16,000 in 2010. Overdose is now the leading cause of death for Americans under 50, and 68% of all drug overdoses are caused by opioids. This is staggering information and raises two questions: how did we come to this crisis and how do we fix it? As someone who works in the field, I take some solace that at least the crisis has attracted the attention of the public and our elected officials. My experience has taught me that there are real, actionable solutions to the opioid crisis. However, this is a complex challenge requiring a comprehensive approach at all levels of healthcare and policy: those managing the provider systems, regulators and third-party payers. Often operating in silos, these key change-makers had for a long time been missing the needs of the forest for fear of harming their own trees.
Today, I assist patients who have had opioid overdoses in the emergency rooms of hospitals all across NYC. In this capacity, I have seen dozens of patients and read reports on hundreds more. I do this at nights and on the weekends. My full time job is in designing and implementing a biopsychosocial program that works with doctors to comprehensively treat those with chronic pain. The idea is to treat these people without creating additional statistics. So, I see the system from all angles. As a result, I have a unique perspective on the opioid crisis that arises from both an epidemiological understanding and that of someone with actual lived experience in the field. In other words, I have seen the stats and read the studies, but have also dealt (and lived) directly with real patients who have just awoken to realize that they narrowly escaped death (and then spent time talking to them about what happened, why and what comes next).
There is a notion (often misattributed to Albert Einstein) that you cannot solve a problem with the same consciousness that created it. In the case of the opioid crisis, we cannot begin to address the challenge until we fully understand it. What has become clear to me is this simple yet radical truth: we don’t have an opioid crisis. We have 3 distinctly different crises with different causes and solutions. In my view, the only sensible way forward is to address each of these crises individually.
Crisis 1: Prescription Pain Medication
A major push to increase the demand for and availability of stronger, longer lasting, opioid pain medications began in the mid-1990s. In 1995 the American Pain Society introduced the “pain is the 5th Vital Sign” campaign and in 1996 OxyContin was released. In the next 15 years prescriptions for pain medication increased threefold and fully a third of those prescriptions were for drugs more powerful than morphine. Both the number of prescriptions and the percentage of those prescriptions that were stronger than morphine continued to increase at double digit rates through 2016. It is beyond the scope of this article to address whether pharmaceutical manufacturers and distributers knowingly misled the medical community, regulators and the public to massively increase sales of their products and thereby created hundreds of thousands of deaths and millions of patients with opioid use disorders, many of whom went on to using street drugs. The court system is going to sort that out over the next couple of decades (spoiler alert: the companies did exactly that and they are going to pay for it).
Whatever happened, more than one hundred million people in America report suffering from prolonged (“chronic”) pain. According to the CDC, some 20 million Americans deal with “high impact” chronic pain that impacts their quality of life (including their ability to work) on a regular basis. Over the last 30 years, doctors and patients have been educated to believe that everyone has a “right” to be pain free and that opioids are the best way to achieve that. And the truth is that there are some conditions that can be effectively treated with opioids. For acute pain, short term prescription of opioids may be effective and the risks reasonable. For chronic pain, long term use of opioids may be necessary and the risks manageable. Having said that, any use of opioids creates risks that have to be monitored and managed. This is particularly true for long-term users, with increasing risk for dependence and opioid-induced hyperalgesia (where opioids actually increase a person’s pain).
Pain is a complicated thing. The experience of pain varies individually and even an individual’s perception of pain varies depending on a huge variety of factors. Just as an example, it is widely recognized that loneliness, fear, stress and lack of sleep increase the perception of pain enormously.
Just as there are many factors that determine an individual’s perception of pain, there are a variety of non-pharmaceutical tools for addressing that perception of pain.
I spend a lot of time thinking about how to manage chronic pain in order to improve the lives of sufferers by treating their pain while minimizing the risks of opioids. We work with pain management specialists, primary doctors and other healthcare providers to provide a comprehensive biopsychosocial solution that improves outcomes while minimizing risks and costs. To be clear: we acknowledge that opioids can play an important role in treating chronic pain as long as they are integrated into a comprehensive treatment plan that includes social support, resilience training and self-management education. Further, a person who has been relying on opioids for their own quality of life for years should not be forced into an involuntary taper without being presented with sufficiently effective (and accessible) alternatives. As we have seen, the results of forced tapers have been devastating, causing an increase in suicide rates among people with under-treated chronic pain. At TribeRx, our approach to chronic pain care is novel. However, in many ways it is parallel to how major depression or other mental health conditions are treated. As appealing as it may sound, medication by itself isn’t the answer. There is now a consensus that the answer to any serious problem involving both mind and body is never “just take a pill”. One thing we have learned that isn’t yet widely appreciated is that social isolation is a driving factor in all aspects of behavioral health including an individual’s perception of pain, how to manage that pain, the risks of developing an opioid use disorder and the likelihood of improving any of these. Recovery requires support of all kinds, particularly social support.
Utilizing a comprehensive approach like this can treat those suffering from chronic pain while minimizing the risks of creating or sustaining opioid use disorders. In fact, it is possible to help those with chronic pain to reduce their dependence on opioids over time.
Crisis 2: Fentanyl: An Import Problem Without Consequence
Fentanyl resulted in almost 30,000 overdose deaths in 2017, up from less than 5,000 in 2014 and relatively small numbers prior to 2010. In addition, it played a role in more than 10,000 additional deaths that also involved cocaine or benzodiazepines. Although Fentanyl is the leading cause of overdose deaths, it is also perhaps the easiest issue to address. First, for those who don’t use opioids or work in the field, it is important to note that fentanyl is not a recreational drug. Unlike other opioids, very few people seek fentanyl out for its psychoactive properties. Fentanyl is mixed in to what is sold as heroin, cocaine or counterfeit pain or anti-anxiety pills. Experienced users of opioids only use fentanyl unwittingly, or because they are experiencing withdrawal and feel that they have no other choice.
There are a variety of analogs of fentanyl that vary in strength. All of these analogs are at least 30x more powerful than morphine and 50x more powerful than pure heroin. Since all heroin sold on the street has been cut (diluted with a cheaper substance), fentanyl can be hundreds of times more powerful than the heroin that is generally publicly available. It is also cheap and relatively easily bought. Any dealer with a calculator and an internet connection can figure out that buying fentanyl, mixing it into any given base and selling it as heroin will produce enormous incremental profits (when compared with the traditional model of buying and cutting heroin for resale). Fentanyl has been readily available as well. It can be ordered on-line (generally from China). Its potency and availability mean that small amounts can be bought and shipped via normal mail carriers with little risk of interception and limited additional consequences if the shipment is intercepted. There is no need to build tunnels or semi-submersible subs, charter planes or boats or otherwise invest in expensive smuggling infrastructure and no need to find a network of couriers. Dealers just place on order on-line and wait for the mail to arrive.
Fentanyl has analogs so powerful that they have been used as chemical weapons (most famously by the Russians, against Chechen fighters holding hostages in a theatre in 2002). The most powerful analog, carfentanil, is banned by the international Chemical Weapons Convention. I am a libertarian at heart, and would prefer that individuals have the right to decide what they put in their own bodies, whether that be alcohol, marijuana, psychedelics, ecstasy, cocaine or heroin (these drugs are listed roughly in order of the ease with which they can be defended to the general population). But let’s be clear: Fentanyl is not a recreational drug. It is a deadly poison being foisted on a vulnerable, unwitting population. Drug dealers have made the decision to incorporate fentanyl in their products based on a simple cost/benefit analysis. They have weighed the cost and availability against the risk of being caught and the consequences thereof. Deaths among consumers is not an important factor in this analysis. (This is actually a complicated issue in real life. Some deaths in the buying population can lead to a short-term increase in demand because users assume that the dealer is selling a good product. Large numbers of deaths tend to reduce demand.) Currently, a dealer selling a product branded as heroin that contains a mix of heroin and fentanyl or simply fentanyl mixed with an inert base will make higher profits and incur almost no incremental risk. Even if customers die and the drug is traced back to the dealer, there are no additional risks to the dealer even though he knows (or, at least, should know) that the chances of causing death are much higher.
Given all of this, my solution to the fentanyl crisis is simple: pass a federal law that classifies fentanyl and all of its analogs as chemical weapons with all the commensurate regulation and penalties that would entail. The cost/benefit analysis described above would be radically altered if suppliers knew that they could face weapons trafficking, terrorism or equivalently draconian federal charges if caught. And this classification would allow us to work back the supply chain to go after the manufacturers who currently operate with impunity. The willingness to be involved in any illegal aspect of the production, transport or sale of fentanyl would evaporate (even among the cartels that supply what doesn’t come from China) and the costs would go up to a prohibitive level. Of course, there could be a medical exemption for those providing legitimate fentanyl to those who actually need it (primarily cancer patients and burn victims). While it may not be completely realistic to ban fentanyl by classifying it this way, it certainly could be classified so that the penalties are significantly harsher than for any existing recreational drug. The net result of my proposal would be that the supply of fentanyl would be reduced to what can be diverted from the medical supply chain, which is minimal in comparison.
Part II of this series will discuss Traditional opioid use disorder (and helping those with substance use disorders created by prescribed painkillers)
Andrew Vickery is Co-Founder and Head of Peer Programs at TribeRx (www.TribeRx.com), which provides comprehensive biopsychosocial support for people with chronic pain. He is also a technology investor and former investment banker who has completed more than $30 billion in transactions.