On Friday evenings, I walk along Mount Auburn Street — the epicenter of social life for many Harvard students — amidst the pungent odor of marijuana, open bottles, and the cacophony of voices waiting outside parties for a less than memorable night. Several blocks away, I enter the basement of a church, complete with people chain-smoking cigarettes outside, uncomfortable chairs, and lackluster black coffee.
“My name is Donovan, and I am an addict.”
A common theme reverberating from many in the halls of Alcoholics Anonymous and Narcotics Anonymous is the impact opioids have had on their lives and families. Unfortunately, addiction does not discriminate, preying on homeless persons, Harvard affiliates, and everyone in between. The room is filled with an arguably more diverse group than Harvard itself; business executives, attorneys, tattoo artists, former professional athletes, and single parents alike line the walls.
According to the National Safety Council, people are more likely to die from an opioid overdose than a motor vehicle accident for the first time in U.S. history. This sobering statistic demonstrates the growing threat posed by the opioid epidemic. Although myriad socioeconomic factors contribute to the prevalence of addiction, big pharma played a large role in facilitating this ongoing crisis through its unethical, aggressive marketing of opioids to physicians and consumers alike. While the opioid epidemic and sway of big pharma are most notable in the United States, this is an increasingly international phenomenon, with nations ranging from India to Australia feeling the effects.
Under the Influence
The pharmaceutical drug and biomedicine industry, colloquially known as “big pharma,” has a much greater influence than an average American would know. The Center for Responsive Politics — a non-partisan research group tracking money in politics — found that pharmaceutical companies spent over $900 million on lobbying between 1998 and 2005, which was significantly more than any other industry. During this same period, big pharma donated $89.9 million to political parties and federal candidates to push their agenda. This spending excludes the vast quantities spent on advertising, marketing, and incentives for both pharmaceutical sales representatives and physicians.
In the mid-’90s, vigorous lobbying by organizations such as the American Pain Society championed the importance of addressing pain as a public health priority in the United States. These lobbying efforts were successful, resulting in pain being designated as the fifth vital sign. However, this posed a unique challenge; the first four vital signs — body temperature, blood pressure, respiratory rate, and heart rate — can be easily quantified, whereas pain is a subjective measure reported by patients. It is no coincidence that after pain was made the fifth vital sign in 1996, Purdue Pharma began marketing its time-released oxycodone, OxyContin, the same year.
From 1996 to 2000, Purdue more than doubled its internal sales force as well as its physician call list. In 2001, the average Purdue sales representative’s salary was $55,000, but annual bonuses far exceeded representatives’ salaries, totaling $71,500 on average. In addition to implementing these lucrative commission bonuses, Purdue aggressively distributed branded promotional items to healthcare professionals, including OxyContin fishing hats, stuffed animals, and music CDs, a move unprecedented for a Schedule II opioid. Finally, Purdue severely misrepresented the risks of OxyContin, training its sales representatives to carry the message that the risk of addiction was less than 1%. While an affiliate of Purdue, alongside three company executives, pled guilty to criminal charges for misbranding OxyContin by claiming it was less subject to abuse and addiction than other opioids, it came only a decade after the drug’s release. As Piers Kaniuka, the Director of Spiritual Life at Granite Recovery Centers and author of Real People Real Recovery, told the HPR, “Oxy was marketed as having little or no potential for abuse … so the first wave of addicts in the opioid epidemic were not drug seekers. They were merely being medically compliant.”
Purdue’s sophisticated marketing strategies contributed to the exponential growth in pain medication prescriptions and subsequent side effects. Big Pharma compiles prescriber profiles for individual physicians detailing their prescribing habits and patterns, which allows Purdue and other pharmaceutical companies to identify physicians and zip codes with the greatest number of patients experiencing chronic pain. This same database also identifies which physicians were the most frequent prescribers of opioids or the least discriminate prescribers. “This means that the origins of the current opioid epidemic lay with the reckless and unethical (but not illegal) marketing of pain medication to unwitting consumers,” Kaniuka said.
Pain Killer
That “reckless and unethical” marketing has had immense consequences in precipitating the opioid epidemic. Purdue and the other giants in the pharmaceutical industry are notorious for stressing the benefits of medication while minimizing the side effects; this unethical practice has had immense consequences in precipitating the opioid epidemic. Between 1997 and 2002, there was a national increase of 226%, 73%, and 402% for fentanyl, morphine, and oxycodone prescribing, respectively. According to the Drug Abuse Warning Network, during this same period, emergency department visits for fentanyl, morphine, and oxycodone rose by 641%, 113%, and 346%, respectively.
Unsurprisingly, drug overdose has risen to become the leading cause of accidental death in the United States. To put this into perspective, in 2016 alone, an estimated 64,000 Americans died of opioid overdoses — more than the combined death tolls for Americans in the Vietnam, Afghanistan, and Iraq Wars. From 2000 to 2010, the overdose rate quadrupled, and admissions to addiction treatment programs increased six-fold.
While the rising death toll and millions of individuals affected by addiction are enough of an imperative to effect policy change, there is seldom discussion of the broader societal and economic costs of opioid addiction. According to the Recovery Centers for America, drug and alcohol use costs the U.S. $1.45 trillion annually, including $578 billion in economic loss and $874 billion in societal harm through quality of life adjustment and premature loss of life. These economic losses’ meteoric rise coincides with the onset and progression of the opioid epidemic, with a large portion of cases derived from prescription and illegal opiate use.
Opioids Overseas
Although the opioid epidemic and Big Pharma are primarily discussed in a U.S. context, opioid misuse, addiction, and overdose are sadly an increasingly global phenomenon. After facing scrutiny for aggressive marketing campaigns and unethical sales tactics in the U.S., many pharmaceutical companies have shifted gears towards other markets. Representative of this is the current crisis in Australia, where both opioid prescriptions and overdose deaths have doubled between 2006 and 2016. A majority of overdoses have been attributed to prescription opioids rather than heroin, which is worrisome in and of itself. Down under, more than 3 million Australians, over an eighth of the population, have at least one opioid prescription.
Meanwhile, Mundipharma, owned by the same Sackler family that owns Purdue Pharma, has been actively lobbying to expand its predatory opioid prescribing initiatives abroad. In Poland, Mundipharma’s efforts have facilitated new legislation allowing any physician, rather than specialty pain doctors, to prescribe opioids. Mundipharma has also partnered with pharmaceutical titans in populous developing countries, including India. From Delhi to Mumbai to Kolkata, for-profit pain clinics are proliferating, and addiction is rising significantly. This had led many small and medium-sized pharmaceutical companies in India to push powerful opioids for all kinds of pain, oftentimes using legal loopholes to avoid regulation or engaging in illegal diversion. Similar tactics are being utilized in Brazil, where prescriptions for opioid painkillers have grown by 465% in merely six years.
Countries such as Mexico and China have also faced dire consequences from opioids and their misrepresentation, leading them to produce and export heroin and fentanyl to satiate demand. This is especially problematic because fentanyl, a synthetic opioid painkiller, is approximately 50 times stronger than heroin and has permeated many countries, including the United States. Worldwide, fentanyl overdoses have grown 540% in the past three years.
Finding a Fix
Admittedly, there is no simple solution to this complex problem. RAND Corporation public health policy expert Dr. Ryan McBain stresses the importance of a comprehensive approach. “I think the treatment response needs to be multifaceted — community de-stigmatization efforts, provider education about appropriate opioid and non-opioid prescribing practices, and increased supply of medication-assisted treatment,” he told the HPR.
Policy experts and addiction specialists echo those sentiments. Dr. Corrie Vilsaint, a principal investigator at the Recovery Research Institute and Center for Addiction Medicine at Massachusetts General Hospital, also argued for a multilateral effort to improve outcomes amidst the opioid epidemic in an interview with the HPR. Vilsaint suggests we “continue the prescription monitoring program, medication disposal programs, and increase the availability of treatment and recovery support services.” She also champions expanding “implementation efforts for easy access to Narcan and medications for opioid use disorder while plugging holes in the continuum of care, like emergency departments that do not provide Suboxone (and thus overdose protection) to patients who are discharged after surviving a drug poisoning.”
Other countries have averted an opioid crisis altogether by implementing these safeguards and initiatives from the get-go. In 2016, 10 times as many Americans died from opioid overdoses than their German counterparts, and Germans experienced opioid addiction at less than a third of the rate at which Americans do, even though only the U.S. outranks Germany in the total volume of opioid prescriptions. A chief reason for this is that German doctors must first try alternative treatment modalities, which are typically covered by the nation’s universal health care system. Similarly, doctors must get special permission before prescribing opioids and screen patients for their individual risk of addiction. Unlike the U.S., which has an extensive history of pursuing tough-on-crime policies and a war on drugs, Germany treats addiction as a medical and public health issue rather than a criminal issue or moral failure. By implementing harm-reduction strategies, including safe injection sites, Germany has demonstrated a progressive, proactive model to avoid an opioid epidemic.
Albeit controversial, Portugal’s decriminalization of all drugs beginning in 2001 has proven successful in ameliorating the physical, emotional, and fiscal costs of addiction. Alongside this decision, the number of people voluntarily entering treatment has risen significantly, overdose deaths and the incidence of HIV among drug users has plummeted, and incarceration for drug-related offenses has decreased. To put things into perspective, the lethal overdose rate in Portugal is now five times lower than the EU average and stands at one-fiftieth of the United States’ rate. Portugal’s human-centric approach and emphasis on harm reduction are archetypal of the types of reforms the U.S. should implement because, as Vilsaint notes, this “treatment has been demonstrated to establish physical stability, increase health and nutrition, decrease injection drug use, reduce criminality, increase employment, and stabilize lifestyles.”
Similarly, the Netherlands has taken a progressive approach to combating drug abuse. Rather than pursuing tough-on-crime policies and ramping up arrests, the Netherlands integrated perspectives from healthcare, law enforcement, social services, and the mental health fields. By implementing services such as needle exchange clinics and helping those at risk access treatment, the Netherlands enjoyed a considerable decrease in its heroin-using and homeless populations, improving outcomes for both those most vulnerable and society at large.
Thus, to reduce the influence of big pharma and the deleterious effects of the opioid epidemic, the world must follow the model of countries such as Germany, the Netherlands, and Portugal. However, Kaniuka remains unconvinced that the U.S. has the ability to do so. “Our system will not permit us to institute harm reduction as it is practiced in Holland or Portugal. We simply will not pay for the wrap-around services (housing, job placement, education) that are made available to addicts in those countries. Here, you can get a subsidized dose of Suboxone and still have to sleep on the street and eat in a soup kitchen.” That being said, the Recovery Centers of America calculate that if everyone in the U.S. that needed treatment for substance abuse received it, it would cost approximately $224 billion but save $368 billion, resulting in an economic gain of $144 billion and a happier, healthier population.
Given the return-on-investment and pervasive need to address the opioid epidemic, instituting these reforms and effecting policy change should be a bipartisan imperative. While decriminalizing all drugs in the U.S. would likely prove difficult given our past draconian drug policies, small steps like enhanced screening for both physicians and patients regarding opioid prescriptions and expanded accessibility to recovery resources including medication-assisted treatment could lead to important progress, especially if paired with innovative reforms such as safe injection sites. Only by doing so can we effectively combat the American opioid epidemic and serve as a model for other struggling nations.
Image Credit: The Air Force Medical Service / Mark R. W. Orders-Woempner
