Who Is Responsible for the Opioid Epidemic?

April 2, 2018

By Mencken's Ghost

The opioid epidemic has killed tens of thousands of Americans and devastated families and communities, yet no one is responsible for it. 

Or more correctly, no institution has accepted responsibility for it—not the Republican Party, not the Democrat Party, not the medical profession, not Big Pharma, not the media, and certainly not government bureaucrats.

Maybe the Russians are responsible for it.

For sure, libertarians don't take responsibility for the epidemic.  They say it wouldn't have happened if it were not for drug prohibition and the War on Drugs.  But it's difficult for even this libertarian to follow their thinking, since such opiates as OxyContin are legal drugs.

The epidemic is a great example of how people cover their tracks instead of taking responsibility for problems that they've caused, especially when the truth would go against their ideology, financial interest, reputation, or ego.

There is one notable exception, however.  That would be Dr. Hershel Jick.  He should get a Nobel Prize for being the one honest man in a world of dishonesty.

Jick would later admit that a study he had done in the late 1970s while at Boston University on the effects of painkillers was instrumental in triggering the epidemic.  The study concluded that it was rare for prescribed opiates to result in addiction.  He and an assistant sent a letter to this effect to the New England Journal of Medicine, which in turn published the letter—which in turn set off an avalanche of the over-prescribing of opiates.

The medical profession thought it had found the Holy Grail of pain management.  Opiates could be given to patients with little worry about addiction, not only for the pain of surgeries but also for chronic pain, such as pain from debilitating back ailments.  The finding quickly spread among medical associations, consumer advocates, and other organizations devoted to the commendable cause of helping people live pain-free.  From there, it spread to the government and to such programs as Medicare and Medicaid.

But as Jick would say, his study was not a peer-reviewed study.  Not only that, but it was based on the experience of hospitals, where opiates were prescribed in measured dosages and patients were monitored closely.  That is a much different situation than the largely uncontrolled environment of patients being given prescriptions for opiates to consume at home.  

Those who were already drug addicts, and those who were prone to addiction, quickly figured out how to feed their addiction with prescription opiates.  They went shopping for doctors who would write additional prescriptions for them, they crushed the pills for injection, they removed the time-release coating to get a hit all at once, and they mixed the prescription opiates with illegal drugs.  A black market quickly developed for the pills.  In one scam, pills were obtained cheaply through Medicare and Medicaid and then resold at considerable profit.  

It was easy to find customers in towns with methadone treatment centers, because the junkies at those centers would become customers themselves or know of potential customers. (Black heroin was also marketed this way.)

The problem became particularly acute among towns and people hardest hit by the loss of highly-paid manufacturing jobs.

At the same time, pill mills masquerading as clinics sprang up.  Disreputable doctors would write prescriptions for opiates without even a cursory examination of patients.  Customers would line up in the parking lots of the phony clinics to wait their turn to pay $200 or so for a prescription.  These weren't the cream of society.  Some waited in their pajamas.  Some ate fast food while waiting.  Some were obviously strung out.  Fights would break out.  Neighbors knew that something funny was going on, but law enforcement turned a blind eye to the problem. 

It's easy to theorize about drug legalization, but imagine living next door to something like this.

The problem was fueled by Purdue Pharma, the maker of OxyContin.  Referring to Dr. Jick's study, the company developed a bogus advertising message that an addiction develops in less than one percent of patients who are prescribed opiates.   Using this message, it undertook an aggressive sales and marketing campaign targeted at doctors.  It feted doctors at conferences held at swank resorts, it funded an estimated 20,000 continuing medical education seminars for doctors, and it hired one thousand sales reps to call on doctors, showering them with coupons for free pills and giving them and their staffs free lunch and other gifts.

Other pharmaceutical companies began copying Purdue's tactics.  As a result, the number of drug sales reps in the United States increased from 35,000 in 1995 to 110,000 a decade later.  (Disclosure:  My wife used to work for a drug company in the heart of the pharmaceutical industry in New Jersey, but not as a sales rep.  The sales reps we knew made six-figure incomes.)

Some government regulators and some ethicists from the medical profession warned about such practices, but nothing was done until the abuse of opioids and other opiates became an epidemic.

The silver lining in all of this is that the epidemic has caused people to rethink their political positions on substance abuse.  There is now more support for needle exchange programs to stop the transmittal of disease from one addict to another, and for rehabilitation instead of punishment.  These have been longstanding libertarian positions.

What is the learning here?  To me, the learning is twofold:  first, how easy it is for a misleading study to trigger an avalanche of unintended consequences; and second, how those who accept a misleading study without doing their homework aren't about to admit it, especially if they have benefited financially or reputationally from the study. 

The Iraq war is another example of unintended consequences and the disavowal of responsibility.  So are the dietary guidelines issued by the government and medical profession over the years that have since been shown to cause more harm than good. 

Chances are, it will be found out years from now that the projections of climate change were hyperbole.

Thank goodness I'm never wrong.  Just ask my wife.  Oh, wait, on second thought, don't ask her.