The Opioid Epidemic

The death of renowned actor Matthew Perry, who played the ever-sardonic and lovable Chandler Bing on the show, Friends has shocked many globally. Even more so was the discovery in his apparent memoir of his severe addiction to Vicodin. After revealing in his memoir, Friends, Lovers and the Big Terrible Thing, that he was abusing prescription medication to the point where he was taking up to 55 pills of Vicodin per day, a highly addictive and powerful opioid painkiller, it put into perspective the genuine extent of the opioid epidemic in America. Faking pain during COVID at a rehab centre in Switzerland to score 1800 milligrams of Oxycontin a day with ketamine, the addictive nature of opioids cannot be understated. 

The number of people who had died from a drug overdose in 2021 was over six times the number in 1999, with the number of drug overdose deaths increasing more than 16 per cent from 2020 to 2021, and over 75 per cent of the nearly 107,000 drug overdose deaths in 2021 involving opioids. 

Many stories have matched up to this, and these do not just include high-profile celebrities in the entertainment industry either. America has an opioid epidemic, as the fentanyl and oxycontin crisis has spiralled out of control. The root of the opioid epidemic in America goes deep and has affected millions of lives. 

But the age-old question returns, what are the exacerbating factors behind this crisis?

1. Corporate Greed: Risky and over-prescription of opioids by Big Pharma 

Oxycontin, a drug promoted by Purdue Pharma, was approved by the Food and Drug Administration (FDA). However, Purdue Pharma was later shown to have presented a fraudulent description of the drug as much less addictive than other opioids, with the firm being profit-seeking more than anything. The prescription drug was heavily marketed across the state, and its use had spread amongst residents of all ages and demographics, which triggered the first wave of deaths that were linked to the use of legal prescription opioids when the FDA had initiallyapproved it in the mid-1990s.

The manufacturer of the drug had the original responsibility to educate and advise prescribers how to evaluate and mitigate the risk of the drug in treating its chronic pain patients. However, Purdue Pharma had instead engaged in donations and lobbying to politicians in order to influence policy decisions for the continued manufacturing and the safety of the drug. The company had spent over US$1.2 million (S$1.6 million) on lobbying efforts alone, which influenced public policy on regulations related to opioids. Former United States Representative Mary Bono mentioned a deceptive campaign strategy by corporations profiting from the epidemic to portray any attempt to rein in the mass prescription of painkillers as depriving millions of Americans of legitimate treatment for chronic pain problems.

Purdue Pharma itself, had promoted the risk of its drug’s addiction as less than 1 per cent, while studies contrasted this by reporting the risk of addiction as high as 50 per cent for patients with chronic non-cancer related pain. It  had also trained their sales representatives in order to persuade pharmacists, physicians and nurses to prescribe OxyContin for common pain relief as well as sponsored clinicians to attend symposiums promoting the drug , which no doubt had exacerbated the existing drug crisis. The aggressive marketing tactics were no doubt so effective for chronic pain that Oxycontin eventually became one of the biggest blockbuster drugs in pharmaceutical history and eventually generated US$35 billion (S$45.54 billion) in revenue.

450,000 Americans have died of opioid-related overdoses in the 23 years since the pills hit the market.

2. America’s Chronic Pain Epidemic 

In the year 2021 alone, an estimated 20.9 per cent of US adults (51.6 million persons) experienced chronic pain, with 6.9 per cent (17.1 million persons) experiencing high-impact chronic pain, also known as chronic pain that results in a substantial restriction to daily activities, almost presenting a disability. 

To put that in perspective, that means that one in five Americans suffer from chronic pain. Pain treatment can cost from US$261 billion (S$347 billion) to US$300 billion (S$399 billion). Add that in together with the days of work missed, hours of work lost as well as lost wages, and the total price of pain has been researched to exceed the cost of managing heart disease and cancer combined. 

It costs the nation of upwards US$635 billion (S$844) each year in medical treatment as well as lost productivity. Pain management strategies are also often inaccessible and inadequate. Chronic pain is more than just a disability, it is agonising, and a terrible thing to endure when prolonged. The desperation to relieve such pain is often the key factor to opioid abuse, which binds to receptors in an individual’s brain or body in order to reduce the intensity of brain signals reaching the brain. Strong opioids tend to provide good pain control in around 75 per cent of patients in one randomised trial that compared Morphine with Oxycodone in patients with cancer pain. While they can effectively reduce pain, they are highly addictive. Tolerance can be built, especially if the dosage is increased, and this, compounded with exacerbating factors like economic insecurity, and a global pandemic, can lead to worsened medical symptoms. Any global crisis is enough to traumatise  many to the detriments of chronic pain. It is not just the result of car accidents and workplace injuries, but also linked to troubled childhoods, loneliness, job insecurity as well as a hundred other pressures on working families.

This means that unfavourable socioeconomic factors such as low income and low schooling can often be predictors of the development of chronic pain, and with global crises causing widespread economic insecurity, this situation can often be exacerbated. Individuals living with chronic pain are often at heightened risk for mental health problems, including depression, anxiety as well as substance abuse disorders. It can also affect sleep, increase stress levels as well contribute to the onset of depression, with an estimated 35  to 45 per cent of people with chronic pain experiencing depression. The resultant debilitation can evoke the desperation required to start abusing prescription drugs. 

In order to resolve this, it is necessary to address the perils of financial insecurity, before holding pharmaceutical companies accountable for the role that they play in exacerbating this crisis. Boundaries are required to be drawn regarding the distribution of painkillers to patients with chronic pain problems, and other alternative treatments could be recommended, ranging from osteopathy, acupuncture, biofeedback, and electrical stimulation to even medical marijuana, which has a substantially lower addiction rate as compared to opioids. The risk of fatal overdose of marijuana use as compared to opioid use is also substantially lower, in fact, fatal overdose with cannabis has never actually been documented and has been thought to be remotely impossible. 

A singular accident can often be the catalyst for someone’s chronic pain problem and thereby economic downfall, and as individuals become hooked on prescription painkillers, the transition to cheaper as well as more accessible illegal opioids like heroin and synthetic opioids like fentanyl on the streets become much more alarmingly common. The war on drugs has also severely disadvantaged patients dealing with chronic pain.

“There are almost no chronic conditions I can think of where you look at medical maintenance and say, ‘When are you going to get off it?’ We don’t ask diabetic patients when they’re going to get off their insulin. We reevaluate the need for those medicines at regular intervals and employ every tool we have to treat the underlying causes.”

• Alicia Agnoli, University of California, Davis researcher 

By reigning in opioid supply and prescriptions, policymakers are only ensuring that patient suffering from chronic pain get their supply from street narcotics, which might then be laced with other, more dangerous substances, such as fentanyl, which is responsible for the deaths of over a quarter of a million Americans since the year 2018. Many countries have then instead opted for the ‘safe supply’ movement, which aims to curb drug-related deaths linked to the opioid crisis. These are narcotics that people can be certain are not laced with deadly fentanyl. It has also become clear that all attempts to control overdoses by reining in opioid supply and prescriptions have been abject failures, based on the government’s own data, collected from the Centers for Disease Control and Prevention and the National Survey on Drug Use and Health, show no association between the volume of opioid prescriptions and the nonmedical use or addiction in persons over the age of 12. This brings up the problem of how lawmakers are supposed to address America’s opioid epidemic in a way that prioritises harm reduction.

Addressing America’s opioid epidemic requires a multi-faceted approach which encompasses healthcare reform, addiction treatment as well as community support. 

1. Healthcare reform 

There is a need to address the overprescription of addictive medication, starting with the overprescription of benzodiazepines and opioids. It is well known that improper or long-term use of benzodiazepines like Xanax or Ativan can often lead to tolerance as well as psychological as well as physical dependence. 

Medical professionals are often well advised to not prescribe a benzodiazepine for more than two weeks. However, that standard has not always been followed, with doctors even increasing the dosage after a couple of weeks. Benzodiazepines are a significant contributor to opioid-related fatalities and are involved in almost a third of fatal overdoses. Inappropriate benzodiazepine prescription must be addressed, with a more appropriate understanding of the associated risks, their highly addictive nature, as well as their situational cost-benefit ratio. 

The overprescription of opioids are a significant contributor to this public health crisis, with 29 per cent of prescribed opioids exceeding the recommended morphine equivalents for the appropriate management of acute pain. 

2. Decreased Narcotic Fear-mongering 

Research has shown that fear is not at all effective in the prevention of narcotic use. In fact, the scare tactic media campaigns used around methamphetamine use, the Montana Meth Project in 2005 which launched a multimedia blitz of grotesque advertisements featuring emaciated, thieving, unhinged youths whose bodies were marred by lesions and whose mouths were full of crumbling teeth had been studied to have done little or nothing to reduce or prevent methamphetamine usage. The entire media campaign might have actually even piqued the youth’s curiosity regarding methamphetamine usage as well as the acceptability of the drug. So, not only is it not effective, it might actually do more harm than good, with the ‘War on Drugs’, headed by President Nixon as a campaign to target minorities and drive moral panic, rather than actually attempting to resolve the issue. Exploiting fear instead of advocating for the truth —his was used as a political strategy by Nixon to achieve his political agendas. 

In fact, Nixon’s aide himelf had said, “You want to know what this [war on drugs] was really all about? The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying?”

We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. 

“Did we know we were lying about the drugs? Of course we did.”

• John Ehrlichman, Assistant to the President for Domestic Affairs under President Richard Nixon

The war on drugs eventually resulted in mass criminalisation and punitive sentencing policies that disproportionately impacted minority groups. The hyperbolic, oversimplification and the fear-mongering way media campaigns often portray addiction also add to the already growing epidemic of opioid abuse. Addiction is a complex, multifaceted problem and cannot be oversimplified into a vacuum. The fundamental understanding that sobriety is the opposite of addiction is inaccurate, considering the statistic that the 400,000 American soldiers who were addicted to heroin in Vietnam should not have been able to drop their addictions immediately upon returning home, but they were. In truth, there are multiple tenets that contribute to the path of addiction, ranging from genetic to environmental factors, and this fear-mongering and misinformation of narcotic use can actually contribute to more harm by hindering access to harm-reduction treatment, shaping prohibitionist policy as well as exacerbate the consequences of criminalization, and make drug use and substance use disorders much more dangerous. In practice, proper education and awareness of   narcotic use and proper harm-reduction strategies are the keys to combating the epidemic. 

    3. Environmental Factors

The “Rat Park” study, conducted by Canadian psychologist Bruce K. Alexander, was a series of studies regarding drug addiction with his colleagues at Simon Fraser University in British Columbia. 

Research explored the self-administration of morphine in animals and often used small, solitary metal cages. Professor Alexander hypothesised that the conditions may have been responsible for the exacerbation of the self-administration of morphine. In order to test this hypothesis, Professor Alexander and his colleagues had built Rat Park — a large housing colony 200 times the floor area of a standard laboratory cage, with 16-20 rats of both sexes in residence, with water, food, balls and wheels for play, as well as enough space for mating. The rats with entertainment outlets had eventually stayed away from the water laced with morphine, as compared to the rats with little to no entertainment outlets.  The results of the experiment eventually appeared to support his hypothesis that housing conditions affect the consumption of morphine, together with our biological need for healthy relationships and connections as a countervailing force to addiction.

This also goes to properly show the importance of environmental factors in countervailing addiction, particularly for individuals living in poverty with fewer outlets of entertainment, who may then be more vulnerable to addictive forces. 

4. Expand access to evidence-based treatment and recovery services

All in all, it is absolutely crucial to expand access to evidence-based treatment and recovery services in order to reduce opioid overdose. These include access to naloxone, a life-saving medication that can reverse an overdose of opioids, which research has proven can help prevent a significant amount of overdoses. This can also include fentanyl test strips as well as medication-assisted treatment (MAT), which includes medications along with counselling as well as behavioural therapy in order to treat opioid use disorders as well as “good Samaritan” laws that provide limited immunity from drug-related criminal charges for victims and/or bystanders who call first responders for an overdose. 

The addiction to and abuse of opioids is certainly a prevailing problem that has resulted in not only a significant loss of life, but also severe economic and socio-political consequences. It is definitively easy to treat the multifaceted and complex problem of addiction with derision and a dismissive attitude, but even harder to engage in empathy for what we can now define as a modern epidemic of opioid addiction.