The opioid epidemic: How we got in, how we can get out
No way around it: Pain, which accompanies so many diseases and injuries, demands attention. But recent attempts to ease chronic pain with powerful prescription narcotics have gone wrong, horribly so.
Big Pharma’s profiteering, physicians’ lax prescribing, and misguided good intentions all around have become a lethal prescription for tens of thousands of Americans who have been inundated with potent painkillers.
This has created an opioid drug abuse epidemic, one of the deadliest public health scourges to afflict the nation in recent times. We need to reckon with its carnage — and figure out how to stop it.
The path forward has many avenues. This month, we explore some of the most promising.
Opioid prescription drugs are killing tens of thousands
Mary Jo Curtis, 57, was found dead in her bed in June 2014. How she came to that tragic end, with a fatal mix of painkillers and alcohol, is just one example of the nation’s rampant opioid crisis.
Curtis, a Manassas, Virginia mom and insurance executive, had fallen down stairs at her home and broken her ankle three years before. She underwent multiple surgeries to try to repair her ankle, all with the same doctor, Christopher Highfill, who practices with Northern Virginia Orthopedic Specialists. He would have seen at the outset from her medical records that Curtis struggled with alcohol and other substance abuse and bipolar disorder.
The doctor, a jury hearing a wrongful death suit against him would find, wrote Curtis weekly Percocet prescriptions, and in the last 14 months of her care without ever seeing her. The number of such pills the doctor would push toward her in 40 months of his care would total more than 7,000.
The jury in Prince William County Circuit Court assessed against Highfill damages of $100,000 for Shea Curtis, 27, of Richmond (a client of our law firm). She is Curtis’s only child (shown in photo above with her mom). Dr. Highfill admitted he was negligent, but denied responsibility for his patient’s death, which he contended would have happened anyway if he had not prescribed the Percocet. He also was reprimanded by the Virginia Board of Medicine, the state licensing authority, for prescribing narcotics to the patient without seeing her, which is a violation of state prescribing law.
How many more families can we spare from tragedies like what befell Curtis? How many overdose deaths might we prevent, and how many patients with medical records free of drug or substance abuse might we save from addiction if the nation could better grapple with its epidemic of abuse involving opioids, drugs named for how they react with pain-signaling receptors in the brain?
I don’t typically write in this newsletter about cases in which our firm’s lawyers are involved. But the Curtis case offers a tough reminder that abuses and overdoses of prescribed opioids, including related drugs like the synthetic painkiller fentanyl and illicit heroin, have become the leading cause of death for Americans 50 and younger, killing more than 64,000 in 2016 alone. Those fatality figures exceed those for major widespread killers of recent times, including car crashes (which peaked in 1972), the HIV-AIDs epidemic (peaking in 1995), and gun homicides (which hit their highs in 1992).
The public broadcaster also quoted Corey Rhyan, a senior analyst who helped calculate the epidemic’s giant tab, and he underscored its human cost: “The average age at which opioid deaths are occurring — you’re looking at something in the late 30s or early 40s. As a result, you’re looking at people that are in the prime of the productive years of their lives.”
The CDC says significant increases in overdose death rates from 2015 to 2016 were seen in the Northeast, Midwest and South Census Regions. The were a total of 27 states with notable increases in drug overdose death rates, the CDC found, including Maryland and Virginia.
Just how did the nation get so deep into such a mess with opioids?
At least two groups must shoulder considerable blame: Big Pharma and physicians. The links between the two are puzzling and disturbing.
Let’s start with doctors, who long have wrestled with their patients’ pain, including pain caused by necessary treatments.
Surgery was a grisly practice before scientific advances like sterile environments, antibiotics — and, of course, anesthesia. Oncology continues to be a challenging specialty because of the pain that can accompany many of its key therapies, including radiation and chemotherapy. And obstetrics-gynecology and pediatrics have been sometimes unpleasant fields to work in, with practitioners steeling themselves to suffering that women and children can endure while receiving medical care.
A major push to treat pain
But in the 1990s, doctors and hospitals — many say with a covert shove from Big Pharma — shifted their thinking about pain, slowly but surely elevating it as a central concern, with a rapidly rising group of specialists, calling themselves pain experts, pushing it as a “fifth vital sign.” It inarguably was something that doctors could and should have dealt better with. Still, patient advocates got so caught up in the push for pain management that they would make it a key quality measurement affecting the bottom line for doctors and hospitals.
Big Pharma watchdogs, including investigative journalists and medical experts, also have retrospectively scrutinized how drug makers fueled philosophical and practical changes in the way doctors and hospitals changed their views on pain and its treatment.
These findings, taken in total, offer a view of a big, pernicious campaign for the relentless promotion and sale of pain killers, often with counter-factual arguments and by taking advantage of doctors’ surprising weakness in their wishing just to be liked by their patients. Yes, others, such as insurers, played big parts, too. But only now, decades later, has deep digging by investigative reporters at media outlets like the Los Angeles Times disclosed the major perfidy, for example, of Purdue Pharma, which built a multi-billion-dollar enterprise for the philanthropic Sackler family, what the New Yorker magazine has termed an “Empire of Pain.”
Reporters, meantime, have detailed how, as the Los Angeles Times described it: “Purdue had extensive evidence pointing to illegal trafficking of its [OxyContin] pills but in many cases did not share it with local law enforcement agencies or cut off the flow of the drugs.”
Cities, counties, and states, including most recently Alabama, have sued Purdue, accusing it of pushing addictive painkillers through deceptive marketing. Plaintiffs assert the firm pooh-poohed the significant risk of OxyContin addiction, while vastly overstating opioids’ benefits in treating chronic rather than short-term pain, Reuters reported::
“Purdue and three of its executives pleaded guilty in 2007 to federal charges related to the misbranding of OxyContin and agreed to pay a total of $634.5 million to resolve a Justice Department investigation. That year, Purdue also reached a $19.5 million settlement with 26 states and the District of Columbia. It agreed in 2015 to pay $24 million to resolve a lawsuit filed by Kentucky.”
Purdue long has asserted that it sold drugs approved by the federal Food and Drug Administration, and it pointed to its efforts to reformulate its painkiller to make it less susceptible to abuse. But the Los Angeles Times noted that the independent, nonpartisan RAND Corp. and the Wharton School of Business at the University of Pennsylvania scrutinized data on Purdue’s much-touted product switch.
The company changed OxyContin, so the pills were tougher to crush up, and therefore became more difficult to snort, smoke, or inject. Wharton and RAND found that move didn’t stem the opioid drug abuse epidemic but sent it, instead, in a new direction — prescription painkillers became a gateway, but abusers then moved on to illicit alternatives, including heroin and fentanyl.
Purdue’s rise as a big-time Big Pharma enterprise stems from its start with the entrepreneurial Sackler family and their marketing savvy, the Los Angeles Times reported:
“Purdue was a small New York City pharmaceutical firm when brothers Mortimer and Raymond Sackler, both psychiatrists, bought it in 1952. The spectacular success of OxyContin has generated tens of billions of dollars in revenue over the last two decades and made the Sacklers one of the nation’s wealthiest families. Three generations of the family now help oversee the Purdue and Mundipharma corporations. The family is known for giving tens of millions of dollars through its foundations to such renowned arts institutions as the Victoria and Albert Museum in London, the Dia Art Foundation and the Solomon R. Guggenheim Museum in New York.”
And, as the Washington Post summarized of this study: “Doctors who ate a single meal on a drug company’s tab had a higher likelihood of writing a prescription for the name-brand drug that was being promoted instead of equivalent drugs that were cheaper. … And the more meals — or the more expensive the meals — the greater the rate of prescribing the pitched drug.”
The New Yorker, referring to investigations by the Los Angeles Times and others, as well as its own reporting, also found that Purdue for years paid doctors speaker and other fees to get them to convince medical peers that OxyContin should be prescribed widely for many different types of pain. The company also made a claim, later shown to be unsupported, that its drug’s effects lasted longer and so required fewer pills to be taken. But documents later were forced out, showing that many patients did not get the promised durational pain relief, causing them to abuse the drug instead.
Company employees also blew the whistle on purported pain doctors who were prescribing big shares of the tidal wave of oxycodone (sold under the brand names OxyContin and Percocet) and hydrocodone (Vicodin and Lortab) washing over the poor, rural area.
A Washington Post investigation may provide insight why: The paper says that since 2005, when the DEA began to attack illicit sales of painkillers like oxycodone, Big Pharma has targeted the drug cops’ top echelons, recruiting and hiring away 42 of the agency’s brass. The DEA division that seeks to curb illegal medication sales got picked clean by Big Pharma of 31 of its leaders, the Post says, detailing how the agency’s aggressive attack on prescription painkillers slowed as it leadership ranks thinned.
There’s a challenging path forward to end this lethal public health scourge
As more Americans see sons and daughters, fathers and mothers, nieces, nephews and countless friends struggle with opioid addiction, the cry for concerted action grows. To deal with this crisis will require a range of actions, some small, many global.
Positive signs can be detected. As mentioned, public opprobrium, criminal prosecutions, and hefty losses in lawsuits have led some Big Pharma players to curtail their unceasing hype for prescription painkillers. Alas, this might not curb makers from peddling their destructive wares overseas.
To be sure, opioid addiction can be addressed. It isn’t easy, quick, or cheap. It comes with its own controversies. Fraudsters have leaped into the field, opening exploitative facilities that purport to help users of drugs, especially opioids, get clean. As part of the lucrative industry that has burgeoned around addiction treatment, urine testing for drugs itself has become an enterprise worth $8.5 billion — more than the budget for the federal Environmental Protection Agency.
Amid all the noise about treating opioid users, some important points can get lost. A key takeaway might be this one: These are real people with a major medical problem that cannot be ignored. In the Curtis suit, my firm was pleased that the jury found Dr. Highfill responsible, but we plan to appeal the amount of damages, which we believe was inadequate, because the jury was not allowed to hear from a key witness. That was an expert in addiction medicine who was prepared to explain to the jury how oxycodone addicts its users but how addiction can be overcome with treatment.
The opioid crisis, of course, also should force us as a nation to confront social determinants that can be detrimental to our health. We must stop demonizing and stigmatizing mental illness, and provide much greater support and resources for mental health. We need to recognize and to deal better with how poverty, income inequality, poor housing, racism, loneliness, and a dearth of good jobs can grind Americans down, fostering alienation, hopelessness, and despair that can be breeding grounds for drug abuse and addiction. We cannot allow Big Pharma profiteering to destroy lives and communities. We need lawmakers, policy experts, medical researchers, regulators, doctors, and hospitals to step up to improve our care, not just to hook us on risky drugs. We need to demand that our doctors, especially, stop reflexively reaching for their script pads and erase from their practice the pill-first mentality that was drummed into them from the earliest days of hazing-like medical training.
As individuals, besides holding others and institutions accountable, we need to reach out more to help our loved ones, family members, friends, and co-workers when they struggle with major medical events, especially if they’re burdened with pain and challenges with care-giving and potential isolation. For the sake of our young folks, we also need to become models in how we get medical care and how we treat ourselves. Translation: We all need to think hard about the myriad pills we’re prescribed and that we gulp down with so little thought.
Here’s another thought: May you be so healthy and happy that you can stay away from doctors, hospitals, and pills of any kind!
Graphic materials from: The federal CDC, U.S. Health and Human Services Department
IN THIS ISSUE
Big Pharma and doctors got this epidemic started
There’s a challenging path forward to end this lethal public health scourge
Reasons for concern about anti-anxiety drugs, too
Fentanyl: a lab-produced pain reliever turned potent killer
“Prescriptions for benzodiazepines increased by 67 percent between 1996 and 2013, from 8.1 million to 13.5 million. The quantities of drugs obtained with these prescriptions more than tripled during that same period. … As a result, more people are becoming addicted to benzodiazepines and falling victim to overdose. Overdoses involving the drugs multiplied sevenfold between 1999 and 2015, increasing from 1,135 to 8,791 deaths.”
Federal authorities already have issued a stern warning that benzos must not be mixed with alcohol or opioid painkillers because the results can be deadly.
Researchers say the nation must do much more to document and deal with the harms of these drugs, which, like opioids, are starting to show up more often in illicit manufacture and sale.
Drugs like Xanax and Valium should be given for short periods of a few weeks and should not be used long-term, the experts have advised, writing:
“Other risks associated with benzodiazepines include cognitive decline, accidental injuries and falls, and increased rates of hospital admission and emergency department visits. Fortunately, there are safer treatment alternatives for anxiety and insomnia, including selective serotonin-reuptake inhibitors and behavioral interventions. Just as with opioids, some patients benefit from long-term use of benzodiazepines. But even in low-risk patients, it is best to avoid daily dosing to mitigate the development of tolerance, dependence, and withdrawal.”
Fentanyl: a lab-produced pain reliever turned potent killer
As prescription painkiller abuse became more common and widespread, fentanyl, a synthetic opioid developed in the late 1950s, burst into public notoriety.
As the CDC says of the drug: “Pharmaceutical fentanyl is a synthetic opioid pain reliever, approved for treating severe pain, typically advanced cancer pain. It is 50 to 100 times more potent than morphine. It is prescribed in the form of transdermal patches or lozenges and can be diverted for misuse and abuse in the United States.”