The Opioid Epidemic is NOT About Opioids And It’s NOT An Epidemic (part 1 )

and how only Blockchain can Fix it (part 2)

You would think that facing the worst man-made epidemic, with 66,000 deaths at a cost of half a trillion dollars last year and another 500,000 projected to die in the next decade, we would figure this one out.

Source: CDC, NCHS Data Brief № 294, December 2017

But we haven’t and after treating thousands of patients using opioids, suffering from chronic pain and addiction, I have come to two conclusions:

(1) We are ‘blind’ to the root cause of the opioid crisis. (It’s not about opioids).

(2) We keep calling this an epidemic and it’s not. (It’s a Syndemic- an aggregation of concurrent epidemics).

The US, which constitutes 4% of the world population consumes 80% of the world opioids (CDC)

1. We are ‘blind’ to the root cause of the opioid crisis

Even the 3000 attendees that came last week to the 7th Annual National Drug Abuse and Heroin Summit in Atlanta and listened for 3 days to dozens of presentations, including President Bill Clinton, Senior Counselor to the President Kellyanne Conway, six members of Congress and leaders of CDC, FDA, NIDA, and NIH, had trouble figuring out what to do.

This is not due to ignorance, ineptitude or lack of funding, but rather that the type of solution presented, largely depended on how the problem was framed.

When asked “what is an elephant? “, six blind men responded: “It’s a snake, it’s a rug, it’s a spear, it’s a trunk, it’s a wall, it’s a rope”, each convinced with his own truth… (Ancient Indian parable, circa 1500 BCE)

For example (from least creative to most):

1. State Prosecutors have started suing prescription opioid manufacturers for alleged fraudulent marketing regarding the risks and benefits of prescription opioids, as well as pursuing ‘addict brokers’ recruiting unsuspecting and desperate patients to under-qualified treatment centers.
2. Regulators like the FDA have requested companies to remove their opioid pain medication from the market over concerns that benefits of the drug may no longer outweigh its risks. Other petitions to remove ultra high-dose opioids from the market are pending.
3. The State of Kentucky is considering to institute an Opioid Tax on drug distributors, to support medication assistance treatment centers, drug courts and community-based education systems.
4. Payors are employing big data and artificial intelligence to address the high rate of relapse from substance use disorder. The idea is to improve patient risk models and better predict (and prevent) recidivism. Other payors are considering to fund directly addiction treatments, although recent changes to the ACA have made long-term funding uncertain.
5. Hospitals have launched opioid safety pilots in emergency departments by offering alternatives to opioids, as a first-line of treatment for pain in the emergency room and offer needle and syringe exchange programs.
6. Pharmacists and prescribers can minimize the risk for early opioid exposure by using e-prescribing and Prescription Drug Monitoring Programs (PDMP’s) to detect at-risk behavior (misuse, abuse, diversion) and provide patients an opportunity for education and outreach.
7. Innovators have designed prescription bottles with a built-in tamper resistant stopwatch timer in the cap to prevent abuse and public boxes with Naloxone can be used now (like defibrillators), as a life-saving measure to reverse the effects of a witnessed overdose.
8. Physicians are starting to use clinical decision support systems based on patient reports, shared databases and virtual behavioral health services for pain and addiction, now that telemedicine is being more readily reimbursed.
9. Scientists are pursuing the development of non-addictive pain killers, as well as gene therapies and vaccines for pain and addiction.

Despite a plethora of excellent solutions, none of them can, or are designed to stop the opioid epidemic. Therefore we need to seriously consider that maybe

the opioid epidemic is not (just) about opioids nor is it an epidemic.

2. The opioid epidemic is a Syndemic

By calling the opioid crisis an epidemic we are referring to it as “an outbreak of a disease that spreads quickly and affects many individuals at the same time”.

Besides this definition being inaccurate (opioid deaths have been rising since the early 90's) this leads us to think that the cause of this crisis is either due to the undertreatment of pain (thus there is a need to continue to develop new and ‘better’ drugs) or as an over-treatment (thus devising policies that unintentionally discourage treating individuals suffering from chronic pain).

However, I think that the opioid crisis fits the definition of a Syndemic:

“an aggregation of the multiple and sequential epidemics”

Thus realizing that deaths from opioids are interdependent with deaths associated with other epidemics like: depression, anxiety, post-traumatic stress, addiction to benzodiazepines, cocaine, stimulants, hepatitis C and HIV. These deaths may also be linked to the epidemics of obesity, diabetes, heart disease, or as Ethan Siegel pointed out — guns.

This is an important distinction because Syndemics develop under health disparity caused by poverty, stress, joblessness and structural injustice. Solving it requires us to depart from a traditional biomedical approach, which studies and treats diseases independent of their social context.

A clue that the opioid crisis is a syndemic and that the deaths we are witnessing are “deaths of despair” came when two Princeton economists discovered that between 1999 and 2013, white middle-aged men were dying at an alarming rate from drug overdose, alcohol and suicide (see below).

Their study forced us to recognize that drug abuse is not, as previously thought, a cultural malady afflicting only poor, minority, inner-city communities, but rather is an across-the-country phenomenon. Interestingly, the under-treatment of minorities ‘protected’ them from overdose, reducing a decades-long death-rate gap between whites and non-whites.

Case and Deaton showed that all-cause mortality in developed countries is declining, with the exception of middle-age white, non-Hispanic Americans [red line] (PNAS 2015;112(49):15078–15083)

The main causes of death were from opioid overdoses (red), suicide (blue) and alcohol related diseases (green) (same reference)

This means that whatever medical or social policy funded, it should be first and foremost designed to activate, incentivize and engage affected individuals, families, workplaces and communities to achieve wellness. Before implementing any medical, digital, technological or enforcement solution, we must ask ourselves:

Does this approach decrease or increase the social capital and resilience of an affected community?

In summary and as I posted previously, once we recognize the role of social connectedness and advocate that the opposite of health is isolation rather than disease, we can start to ‘demedicalize’ our existential suffering. In other words:

“The opioid crisis is not about opioids, it is not a medical epidemic, but a social syndemic.”

In part two, I will discuss why until we implement a decentralized economy in healthcare, the opioid crisis will continue to worsen; and how such an economy will disrupt the current business model, change our behaviors and end these senseless deaths.

(While reading this post one person has died from an opioid overdose)