The US opioid epidemic has been acknowledged by President Trump as a public health emergency. “As Americans, we cannot allow this to continue,” he said. “It is time to liberate our communities from this scourge of drug addiction.”
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The opioid epidemic has wracked havoc in the US; opioids (other than methadone) are now the main cause of drug overdose deaths in the country. This year, the odds of accidentally dying from an opioid overdose overtook those of death in a car accident for the first time.
In Australia, the problem is less pronounced, but opioid abuse is still trending heavily in the wrong direction. A report from the National Drug and Alcohol Research Centre (NDARC) said the rate of opioid induced deaths had jumped from 3.8 deaths per 100,000 Australians in 2007 to 6.6 by 2016.
The White House has promised a “tough law-and-order approach” to curb the problem.
Will cutting off international supply help reduce the opioid epidemic?
One of the big picture narratives in the opioid epidemic has been US attempts to cut off illicit supply from China. The issue was a bone of contention between the two nations during their ongoing trade talks and China recently moved to legislate against the production of all fentanyl variants earlier this year.
Trump had said such a move would be a “game changer” in curbing the opioid epidemic. “If China cracks down on this ‘horror drug,’ using the Death Penalty for distributors and pushers, the results will be incredible!” he tweeted.
While announcing the new legislation, however, Liu Yuejin, the Vice Commissioner of China’s National Narcotics Control Commission was adamant that the new legislation would do little to address the problem if US domestic policy remained the same.
“We believe that the United States itself is the main factor in the abuse of fentanyl there,” he said.
Getting China to agree to the new legislation, a goal the US been pursuing since the Obama administration, was seen as a political win. None of the experts that spoke to The CEO Magazine, however, expressed much optimism about the impact it would have.
Associate Professor Carolyn Day, a public health researcher in drugs and alcohol at the University of Sydney, says that the international supply of opioids is only part of a complex picture.
“How much that stuff (disrupting the supply from China) will impact, I don’t know,” she says.
“I probably don’t have a lot of faith that it will do a huge amount. Once there is that demand, the black market will thrive. So we need to think beyond just cutting off that supply. One needs to look to the supply source and if it’s an obvious source you can regulate, then that is really sensible. But once we’re thinking about black market supply, we need to think a bit bigger.”
Jarryd Bartle, a Lecturer at RMIT focusing on criminal law and illicit drugs, also pointed out the limitations of disrupting supply.
“Focusing too heavily on reducing supply is maybe a distraction from more effective measures,” he said.
Writing on the American Enterprise Institute’s Foreign Policy blog, Roger Bate was also skeptical how much good the new legislation would do. He said it was unclear how stringently China would police new laws it was seemingly forced to enact.
Bate also predicted that if supply of fentanyl was cut off in China, other nations could spring up to fill the production void. This concern was echoed by Foreign Affairs, which said “entrepreneurial chemists around the world will find a way to supply (the US)” even if China is obliterated as a supplier of illicit opioids.
Lawsuits against big pharma
Another recent development in the US is the increasing willingness of state and federal governments to pursue litigation against pharmaceutical companies producing prescription opioids.
The US is only of only two countries (with New Zealand) to allow product claims to be made in direct to consumer marketing by pharmaceutical firms. Many commentators have pointed the finger at these companies for exacerbating the problem with reckless and money-driven moves to push addictive opioids onto consumers who don’t need them or who haven’t been properly educated on their addictive qualities.
Two executives from Rochester Drug Company and the company itself were also recently hit with a lawsuit alleging they supplied addictive prescription opioids such as oxycodone and fentanyl to pharmacies who were known to be recklessly prescribing the drugs.
Purdue Pharma LP, maker of Oxycontin, also recently entered into a US$270 million settlement to avoid a potentially damaging (and televised) jury trial. The lawsuit, filed by the state of Oklahoma, alleged the company had engaged in deceptive marketing which had exacerbated the opioid epidemic. This was only one of around 2,000 lawsuits filed at both state and federal level against Purdue and its competitors.
Again, there was widespread skepticism about whether this new strategy will move the needle on opioid abuse.
“Prosecution of drug companies will likely not be effective for combating this steep rise in addiction numbers, nor will clamping down on illegal imports of opioids make a difference,” said Dr. Ryan Hoser, a Chiropractor and Strength Coach from Tampa, Florida.
“Yes, taking these steps may make a slight difference in the problem, but it won’t be enough.”
Day says there is “some merit” in the pharma company prosecutions but, again, it is only a partial solution at best.
“I think the more realistic solutions are probably ones that are harm reduction focused…These things are always best dealt with in a regulatory framework,” she says.
“The most sensible option would be about changing the regulation and looking at why the US has a problem that no other country in the developed world has dealt with to the same degree. I’m not opposed to them going after some of these cowboys. There is messaging there that is useful.”
Keith K. Keller, a Registered Nurse and Author of The Infinite Recovery Handbook, also believes the punitive approach to curbing drug abuse has failed.
“While punishing pharmaceutical companies is appropriate, it will not be an effective remedy for addiction and its collateral damage, including unintentional fatal overdose,” he says.
“Reversing the stigma around addiction, and the policy of marginalising addicts, along with advancing the cause of recovery (a teachable skill) to the point where using drugs becomes uninteresting and inappropriate would be far more effective.”
Alternative treatments for those suffering chronic pain
In one sense, rising levels of opioid dependency can be explained by the most basic of human urges, to be free of pain. Dr. Michael Wong, a Melbourne-based Neurosurgeon and Spinal Surgeon, says the new breed of prescription opioids are more powerful painkillers than their predecessors and don’t come with the old side-effects of nausea and vomiting.
Another layer of complexity is added by increasing evidence that some people using opioids are utilising the narcotics for their ability to numb emotional rather than physical pain.
Day says that ultimately, the realistic goal should be to manage pain rather than eliminate it. She says pain management “is about people being able to function with their pain, not the pain going away. If it’s a chronic long-term management of pain, that is how success will be measured.”
Wong deals with patients suffering chronic spinal pain. Many many have endured months or years of pain and he says they need proper support.
“Those patients need longer time in terms of listening to their stories and referral to the appropriate treatment avenues,” he told The CEO Magazine. “GPs are under pressure to see more and more patients and to bulk bill. They don’t think they have the time to do those additional steps. It’s easier to just give the patient a script.”
Darren Wedge, Founder of Oska Wellness, a company making technology-driven products for those suffering chronic pain, says there needs to be more awareness and education. “People with chronic pain to be educated around the risks of becoming addicted to their prescribed pain killers and it should be the doctors in many cases, doing the warning,” he says.
“We need more stories of accidental overdoses to be reported on in mainstream media, not just the famous people such as Prince, Michael Jackson and Heath Ledger whose deaths have been attributed to accidental overdose of prescribed pain killers.”
Wong says patients are becoming more cognisant of the highly addictive nature of painkilling opioids and the availability of alternative treatments of pain, but “by and large” they are still not aware of these issues. In the area where he works, chronic spinal pain, he says “there needs to be appropriate investigation to discover what is actually the source of that pain”.
“When we know what the source of pain is, we know the appropriate treatment option. In most cases, even ongoing and severe spinal pain, can be managed through regular exercise, physiotherapy, spinal injections and, in some cases, surgery.”
In some areas, the links between illicit opioid abuse and the prescription of painkillers by the medical profession is very strong. Several studies have found the majority of heroin users started with prescription opioids. Yet heavily restricting the prescription of powerful painkillers, or completely removing them circulation, would take away options for those wracked with chronic pain.
The American Academy of Family Physicians (AAFP) has insisted that despite the opioid epidemic, painkiller opioids “still have a legitimate place in pain management and can be used safely”.
“We recognise that long-acting and extended-release opioids are powerful drugs that require oversight, but these drugs can be controlled without unduly limiting their proper use,” it says on its website.
“Creating additional prescribing barriers for primary care physicians would limit patient access when there is a legitimate need for pain relief.”
Is there political will to properly address the opioid epidemic?
Cindy Steinberg, National Director of Policy and Advocacy at the US Pain Center, recently testified to Congress on the issue. Steinberg has suffered chronic pain since being injured in a workplace accident that resulted in her being unable to stand upright for more than a couple of hours without severe pain and muscle spasms.
““In the near term, we can and must restore balance to opioid prescribing with depoliticised, rational and clear-eyed recognition of the risks and benefits of these medications,” she told Congress. “In the long term, we must invest in the discovery of new, effective, and safer options for people living with pain.”
Steinberg testified from a cot, which created a powerful visual. But are politicians interested in heeding her words?
There has been no shortage of strong rhetoric from Trump about “making a dent” in the opioid epidemic. He has vowed that there is “nothing going to stop us” from fighting opioid abuse. Experts say, however, that there is a funding shortfall of tens of billions of dollars, not to mention misguided policy directives in this area.
Speaking on illicit drug use more generally, Bartle says he has been “very disappointed” to have heard scant discussion of the issue during the ongoing national election campaign.
“The Federal government is responsible for setting Australia’s national drug strategy and I haven’t heard much from the two major parties on illicit drugs and actually improving the lives of people who use drugs,” he says.
From academics to those dealing with patients suffering chronic pain on a day-to-day basis, the consensus among experts was that there will be no quick fix to the opioid epidemic.
“It’s a really complex issue with many different problems,” Day says. “There are a lot of unanswered questions.”
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