America's Opioid Crisis

No one will dispute that today’s opioid epidemic is a crisis. Yesterday, the New York Times published an extensive and thoughtful analysis of the situation and offered some prospective solutions. Strangely, perhaps, the article appeared as an editorial.

How bad is it? The Times presents the facts:

Today’s opioid crisis is already the deadliest drug epidemic in American history. Opioid overdoses killed more than 45,000 people in the 12 months that ended in September, according to the Centers for Disease Control and Prevention. The epidemic is now responsible for nearly as many American deaths per year as AIDS was at the peak of that crisis.

Experts say that the death toll from opioids could climb for years to come. Millions of people are dependent on or addicted to these drugs, and many of them are increasingly turning to more potent, illicit supplies of heroin and fentanyl, which are cheap and readily available on the street and online. Yet only about 10 percent of Americans who suffer from substance abuse receive specialized addiction treatment, according to a report by the surgeon general.

The paper notes that we have been here before. In the late 19^th century many Americans were addicted to morphine and opium. It adds that China suffered its own opium addiction crisis in the 19^th century. And, it’s worth mentioning, the British fought a war in China to keep the nation addicted to opium from its colony in India. It was not the British Empire’s finest hour.

One of the more distressing truths of America’s opioid epidemic, which now kills tens of thousands of people every year, is that it isn’t the first such crisis. Across the 19th and 20th centuries, the United States, China and other countries saw drug abuse surge as opium and morphine were used widely as recreational drugs and medicine. In the West, doctors administered morphine liberally to their patients, while families used laudanum, an opium tincture, as a cure-all, including for pacifying colicky children. In China, many millions of people were hooked on smoking opium. In the mid-1800s, the British went into battle twice — bombing forts and killing thousands of civilians and soldiers alike — to keep the Chinese market open to drug imports in what would become known as the Opium Wars.

The Times continues:

As many as 313,000 people were addicted to injected morphine and smoked opium in the United States in the late 19th century, according to David Courtwright, a history professor at the University of North Florida who has written extensively about drugs. Another scholar, R. K. Newman, estimated that as many as 16.2 million Chinese were dependent on opium and smoked the drug daily.

We are not surprised to learn that the fault lies with our medical community, with the pharmaceutical manufacturers who have been pushing the drug, the physicians who have been prescribing it and the government bureaucrats who downplayed the risk:

In the 19th century, like today, the medical community was largely responsible for the epidemic. Doctors did not fully appreciate the risks these drugs posed. In the 1800s, many doctors viewed morphine as a wonder drug for pain, diarrhea, nerves and alcoholism. In addition to getting homemakers, Civil War veterans and others addicted, many doctors became addicts themselves. The drug was overused in large part because there were few alternatives; aspirin, for example, didn’t become available until the late 1890s.

It continues:

Today’s opioid crisis has its roots in the 1990s, when prescriptions for painkillers like OxyContin and Vicodin started to become common. Companies like Purdue Pharma, which makes OxyContin, aggressively peddled the idea that these drugs were not addictive with the help of dubious or misinterpreted research. One short 1980 letter to The New England Journal of Medicine by Dr. Hershel Jick and Jane Porter said the risk of addiction was less than one percent, based on an analysis of nearly 12,000 hospital patients who were given opioid painkillers. That letter was widely — and incorrectly — cited as evidence that opioids were safe.

Surely, our government regulators should have known better. They might, as the Times notes, have been swayed by the pharmaceutical companies, but what is their job if not to evaluate the evidence… objectively. As for the physicians, they will say that they were following the guidelines laid down in scientific journals and accepted by government officials. But, couldn't they see the dangers in their own patients?

Federal regulators, doctors and others were swayed by pharmaceutical companies that argued for greater use of opioids; there was increasing awareness that doctors had become too unresponsive to patients who were in pain. Patient advocates and pain specialists demanded that the medical establishment recognize pain as the “fifth vital sign.”

Mr. Courtwright says that this was not a simple case of historical amnesia. In the earlier epidemic, doctors “made mistakes, but it was a bad situation to begin with,” he said. “There was no equivalent of Purdue Pharma flying you off to the Bahamas for the weekend to tell you about the wonders of these new drugs.”

As for what can be done, the Times emphasizes pharmacological solutions. On the lines of methadone clinics and greater availability of a drug called buprenorphine. Happily, it does not pretend that the addicts should all be in therapy. Congress and recent presidents have failed to act:

Leaders in both parties are responsible for this crisis. Presidents George W. Bush and Barack Obama and members of Congress did too little to stop it in its earlier stages. While Mr. Trump talks a lot about the problem, he seems to have few good ideas for what to do about it. As we’ve learned the hard way, without stronger leadership, the opioid epidemic will continue to wreak havoc across the country.

And also:

Lawmakers so far have fallen far short of such a vigorous effort when it comes to opioid addiction. Congress has taken what can be considered only baby steps by appropriating a total of a few billion dollars of discretionary opioid funding in recent years. This funding amounts to a pittance relative to what is needed: substantial long-term funding for prevention, addiction treatment, social services and research. Andrew Kolodny, co-director of opioid policy research at Brandeis University, says at least $6 billion a year is needed for 10 years to set up a nationwide network of clinics and doctors to provide treatment with medicines like buprenorphine and methadone. Those drugs have a proven track record at reducing overdoses and giving people struggling with addiction a shot at a stable life. Today, large parts of the country have few or no clinics that offer medication-assisted treatment, according to an analysis by  amfAR, a foundation that funds AIDS research.

Apparently, the bureaucrats who signed off on addictive opioids are slow walking approval of buprenorphine. I will not offer a comment on matters I know nothing about, but I will signal that France has used the drug for more than two decades, reducing heroin overdoses:

Next, lawmakers need to remove regulations restricting access to buprenorphine, an opioid that can be used to get people off stronger drugs like heroin; its use is unlikely to end in an overdose. Doctors who want to prescribe the drug have to go through eight hours of training, and the government limits the number of patients they can treat. These limits have made the drug harder to obtain and created a situation in which it is easier to get the kinds of opioids that caused this crisis than to get medicine that can help addicts. France reduced heroin overdoses by nearly 80 percent by making buprenorphine easily available starting in 1995. Yet many American lawmakers and government officials have resisted removing restrictions on buprenorphine, arguing it replaces one addiction with another. 

As I said, I am not qualified to offer an opinion about pharmacological treatments of opioid addiction. I think that the Times has addressed the problem seriously, to its credit. At the least, it has offered some guidelines for addressing the problem. They are not the last word, but they ought to provoke a serious discussion of what we can do.