Prescribing an Epidemic: The Medical Community’s Role in Addiction
I think if you asked anyone if opioid abuse is an epidemic in the United States, they would likely agree that it is. According to the Centers for Disease Control and Prevention, 70,630 people died from drug overdoses in 2019 alone. Of those deaths, 70.6% involved an opioid.
The U.S. Department of Health and Human Services defines opioids as “a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.”
Their website notes that even legal opioids that can be obtained from a doctor’s prescription are addictive and often leave the door open for the conversion to illegal drugs.
But how did the opioid crisis even begin? That answer is not so straightforward.
In my area of Appalachia, drugs and overdoses are rampant. Everyone knows someone who is either abusing prescription pain killers or buying heroin in a motel room. It isn’t unusual to hear of a young person overdosing in a car at a gas station parking lot. But, to place blame solely on addicts or drug dealers who are supplying people these drugs is an unfair evaluation. After starting the book Dreamland by Sam Quinones, the institutional side of the epidemic has become more clear.
Much of the struggle we are seeing today stems directly from the medical industry as a whole, from pharmaceutical companies creating the drugs to doctors prescribing them to insurance companies paying for them. As I was reading Dreamland, I couldn’t help but see the striking similarities between those selling illegal black tar heroin and the medical companies pushing the long term use of OxyContin.
For example, Quinones points out that the Mexican group, who he calls the Xalisco Boys, were marketing masters when it came to selling their black tar heroin. They would willingly hand out free samples to potential customers for them to try their product. Once struggling addicts consumed the heroin, they needed more. And while it may sound odd for drug dealers to give away free product knowing it cuts into their profit, Purdue, the maker of OxyContin, did the exact same thing. When the product was being launched they sent coupons to doctors which would allow patients to fill a free onetime prescription for Oxy, leading to 34,000 coupons being redeemed. Both Purdue and the Xalisco Boys were playing the long game when it came to customers.
One key difference between the heroin dealers and the OxyContin sellers was that the heroin dealers knew their product was addictive. That was the backbone of their business model. However, Purdue aggressively marketed OxyContin as being non-addictive. Being one of the largest drug companies in the world, one would assume that there had been extensive research into this possibility especially considering that oxycodone was known to be addictive. But one would be wrong. Purdue stood on this assumption based on nothing more than the idea that because OxyContin was wrapped in a time release capsule, that it would prevent the user from getting too much of the drug at one time, thus preventing the euphoria associated with oxycodone.
However, Oxy is easy to abuse. Simply crush the pill and you can get the whole dose at one time. Purdue was aware of this because they put a warning label to not crush the pills on the bottles. Purdue also admitted that they did not know the pills could be dissolved in water which addicts often did in order to inject the drug into veins. All of this was made easier by the fact that OxyContin was made of 100% oxycodone as opposed to other painkillers that contained some kind of deterrent like acetaminophen. Despite decades of abuse, it took Purdue until 2010 to make this change — 14 years.
The only other evidence backing the statement of Oxy not being addictive was a one paragraph letter to the editor that was published in a medical journal years before that stated only about one percent of users get addicted to opiates. This letter was specifically about hospitalized patients under direct supervision of medical staff and not the long term outpatients that Purdue marketed OxyContin to.
Which is worse, knowingly selling a harmful substance and keeping addicts in their addiction or being so negligent in the pursuit of a dollar that a trusted medical institution never properly researched a product they mass marketed to the public creating a new supply of addicts?
The assurance from Purdue in turn gave many doctors the confidence to prescribe the drug despite it going against their professional education. Some doctors even embraced the idea from the beginning. These doctors were who opened what is now known as pill mills. Pill mill doctors were know for spending less than three minutes with a patient before writing them a prescription. They didn’t take vital signs, kept dodgy records, and took payments in cash. On any given day there would be a line around their medical practices as clients waited to get their legal OxyContin. Doctors like this received hundreds of thousands of dollars in bonuses from big pharma. More and more doctors followed this pattern, prescribing millions of pills a year to cities with populations of just thousands. Word spread quickly about these locations and anyone looking to score some pills would travel hours to these clinics.
All of this is only intensified by a corrupt insurance system. Often an insurance company’s decision on what they will cover for a patient will determine what treatment that patient will receive. So while the original pain management movement was focused on a multidisciplinary approach where painkillers played a small role, there was also a lot of emphasis put on the psychological stressors that could be contributing to pain. Patients would meet with therapists and social workers to address topics such as being unemployed, going through a divorce, or family estrangement. But insurance companies didn’t want to pay for that even with evidence showing it was effective. Insurance would rather pay for a doctor to prescribe a few hundred pills and kick the patient back out on the street until the next month. In this cycle the patient’s pain never truly improves.
As one doctor in Dreamland says “insurance companies don’t want to fund addiction treatment with enough duration and intensity because we as a society do not demand it.” In a way we are almost perpetuating a problem that everyone wants to see solved. It takes anywhere from 30–90 days for a mind addicted to opiates to be able to begin making rational decisions and up to two years for dopamine receptors to begin functioning properly. But rather than accept addiction as a physical disease and provide the long term assistance needed in recovery, it is easier for insurance to throw an addict in rehab for a couple of months, pretending this has somehow healed them. Not only is this not conducive to recovery, it plays a role in overdose deaths. Once someone has stopped using drugs for a couple of months, their tolerance begins to shrink. Not recovered from their addiction and not realizing that they can no longer take their previous dose, it is incredibly easy to overdose.
Heroin and painkillers met in a perfect storm, just as each was pushing further and further into the country. Heroin already had its markets, but it is unlikely that it would have reached the epidemic numbers it has reached if it were not for Oxy paving the way. Once pills no longer brought the needed relief and became too expensive for an addict’s habit, the transition to heroin was an easy one. A government study found that 80% of people who reported using heroin had used prescription painkillers first.
We all have free will in this country. No one is force feeding people pills or heroin, but the pain management movement that so forcefully pushed long term dependence on drugs like OxyContin is very close to it. People struggling with chronic pain were promised relief by medical professionals who assured them they would not become addicted if they took the pills as prescribed. Some doctors believed this to be true, but found themselves worn down as they saw the effects the drug was having on their patients. Not knowing what to do they just kept prescribing the pills. Others saw a quick way to make a lot of money of the suffering of others. All of it left the door open for desperate people to seek out a cheaper, more accessible way to not experience the dope sickness they were now experiencing. And no one was more willing to walk through that open door than heroin.
