The current opioid crisis is a national emergency. As a nation, we are no longer able to consider it a problem contained in a certain demographic or community, it is truly affecting everyone. In May of this year, two teenage boys who were childhood friends died of an opioid overdose within half a mile of each other on the same morning. One of the boys, Joseph Abraham, was introduced to opioids around the start of middle school when he had his wisdom teeth removed, and again when he was injured playing sports. These sound like normal circumstances for a person to receive a short term prescription to painkillers. However, this quickly developed into an addiction, which ultimately led to his death at age 19 from the synthetic opioid fentanyl.
There are countless stories of seemingly normal American lives torn apart by the disease of addiction fueling the examination of patterns and history surrounding the opioid epidemic in order to find answers. In the substance abuse and behavioral health industry, we are in the business of saving lives and finding solutions. So, while these types of stories are hard to hear, they’ve become so commonplace that it forces us to take a hard look upstream from where the addiction initially manifested and the sheer number of fatalities occurred in order to find solutions. This means examining prescribing practices of physicians, the manufacturing and distribution of legal painkillers, and the reasons patients shift from routine medical recovery to full blown opioid addiction.
In our previous article we discussed President Trump’s announcement that the opioid epidemic is a national health crisis and the implications of that declaration. Better policy and funding from the federal government will certainly help curb the opioid crisis. However, in order to truly solve the opioid epidemic, it is important to have a greater understanding of:
- The underlying systemic causes, aspects, and issues at play
- How doctors and medical practitioners contribute to causing the crisis in the first place
- How doctors and medical practitioners can help solve the crisis through education and prevention
- The other players involved in creating the crisis
- How we can collectively create greater outcomes for everyone affected, especially those whose lives are at risk from their opioid addiction
The Genesis of An Opioid Addiction
When engaged in discussions about the opioid epidemic, it’s important to remember that not all people who are prescribed opioid based medications develop addictions. Additionally, most doctors who prescribe opioids for pain relief are not contributing to nor creating an opioid dependency in individuals they treat.
There are several factors that contribute to opioid dependence. One common path leading someone to develop an opioid dependency is suffering a debilitating or painful injury. In an effort to alleviate pain and suffering, an initial prescription is given to the patient by a physician. However, there are several factors the physician might not know or account for upon prescribing the medication including:
- If a prescription will be properly used by the patient
- If a patient will develop a dependency to an opioid based medication that could manifest in addiction
- If the patient has a personal history of dependency or addiction to other substances
- If a patient will sell or distribute medication they don’t use themselves
- If the patient will return once they have finished their initial prescription for a follow up, or go to another physician for additional prescriptions
Compounding the complexity of this issue is the prevalence of co-occurring mental disorders in those suffering from any type of addiction or dependency. For example, according to the 2015 National Survey on Drug Use and Health (NSDUH), of the 20.8 million people, aged 12 or older, who had a substance use disorder during the past year, 41.2 percent also had a mental illness. When dealing with this particular subset of the population, this greatly increases the burden of a primary care physician to account for several factors during what might otherwise seem to be a routine visit to the doctor.
There are some formal assessments and also professional experiences physicians utilize to recognize a dependency issue beginning to form, and in this case ordinarily they will limit or deny the patient’s access to the prescription medication. It’s in this latter scenario where we see many addictions manifest, as patients are forced to pursue alternate methods of obtaining the painkillers they have developed a dependency on. There are those who “doctor shop” to obtain multiple prescriptions for otherwise legal substances. Additionally, there are those who turn to street drugs which are most often “off brand” or generic versions of the medication they’ve become addicted to.
Some medical professionals contend the opioids that are at the root of the epidemic are actually the more generic ones, not the brand names. These generic and synthetic opioids are far cheaper, and harder to track prevalence rates on due to the wide array of legal and illegal manufacturers. However, when these generic opioids aren’t available, or become too expensive, the patient is forced to seek out a more illicit painkiller: heroin.
Unfortunately, an individual who has already developed an opioid dependency can save a lot of money by switching from generic forms of OxyContin, oxycodone, and other opioid based medications to heroin. In today’s epidemic, we see even more lethal forms of heroin that are laced with volatile substances like fentanyl. This creates a dangerous dependency funnel for those afflicted that many times results in death.
The Doctor’s Role in the Opioid Epidemic
An upstream approach to the opioid epidemic is an attempt to examine the conditions and aspects that lead to an individual manifesting with the disease of opioid addiction. The doctor only plays one part in this problem, so the blame does not fall solely on them. However, the fact remains that primary care physicians who prescribe patients opioid based medications are often part of the path that leads to addiction.
It’s like a flooding of the market. The more prescribed opioids there are out there, the higher the probability that somebody will abuse them. As the prevalence of abuse increases, the probability that somebody will become addicted to an opioid based medication also increases. In turn, this increases the likelihood that at some point an individual might not be able to obtain the medication, and then switch to heroin use.
Are Doctors Being Paid to Prescribe?
Some people attribute the source of the epidemic to doctors who receive money from pharmaceutical companies to prescribe their brands of opioid based medication. After discussing this issue with several medical professionals, here's the consensus of their opinion: most physicians do not receive any “kickbacks” for prescribing. It’s actually illegal for pharmaceutical companies to directly pay doctors to prescribe their brands of painkillers.
However, there are indirect ways in which doctors and physicians are “encouraged” to prescribe these brands. These “kickbacks” from the manufacturers come in a grey area, a doctor might:
- Receive compensation to talk about the research related to a drug
- Receive consulting fees
- Be compensated through business travel, meals, and other similar gifts
Additionally, the Sunshine Act was put in place in order to make public such compensations that physicians receive. All types of transactions are to be reported on both sides to a public database. There are steep penalties for transactions occurring outside of this. A recent study showed that one in twelve physicians -- and nearly one in five family medicine physicians -- received payments related to opioid based medications from manufacturers. While statistically that is not a large number of practicing physicians, this is a problem for a couple of reasons:
- Any primary care physician that is influenced by a third party that's not the direct payer is damaging the whole workflow of pursuing better outcomes for this patient population
- Creating incentives for doctors to prescribe a medication that could eventually harm a patient is questionable from a medical ethics perspective
A ProPublica analysis has shown that “kickbacks” do sway doctors to prescribe a particular brand-name medication. The analysis showed that doctors who received money from drug and device makers prescribed a higher percentage of brand-name drugs overall than doctors who didn't. This doesn’t conclusively tie these “kickbacks” to fueling the opioid epidemic, however it does provide some evidence that this practice is certainly not helping the situation.
The Doctor’s Duty
A doctor’s first priority is to help their patient. They want to control and eliminate the pain their patients are experiencing. Before the opioid epidemic rose to such prominence, an argument of ignorance could be made on the part of some doctors. Some medical professionals, especially those in pain management, considered the strength and risk of opioid based painkillers like oxycodone and hydrocodone to be minimal in comparison to something like morphine.
In order to relieve the level of pain they were seeing in their patients, this discrepancy in relative painkiller strength made physicians view prescribing these medications as no different from using Tylenol for a headache. The operative question becomes: is the doctor responsible if an addiction develops from that prescription?
These doctors were not, and many still are not, fully educated and aware of how the intricacies of addiction overlap into their own practice. They were, and some still remain, unaware of the power of these medications to induce addiction, or at least have it manifest in the subset of the population that's particularly vulnerable.
Additionally, even though many physicians write prescriptions appropriately, they didn’t, and some still don’t, know that once the prescription is finished those suffering from addiction would do whatever they needed to find the drug, even if that means purchasing it illegally. This includes cheaper, generic brands on the street or illicit drugs like heroin.
Heroin: The Cheap Alternative to OxyContin
As mentioned above, the allure of heroin can be directly attributed to its price. As with most addictive substances, as an individual increases the frequency of their use they develop a tolerance, and will need stronger or more frequent doses as time goes on. This kind of pattern can get incredibly expensive. A breakdown of the price comparison between heroin and OxyContin paints a clear picture of how OxyContin prescriptions can lead to heroin addiction.
It’s impossible to get a precise breakdown of the street price of illicit substances, but studies show that when legally sold a 10 mg tablet of OxyContin will cost $1.25, and an 80 mg tablet will cost $6. When illegally sold the 10 mg tablet of OxyContin can cost between $5 to $10 and the 80 mg tablet can cost between $65 to $80. That is an incredible price increase to obtain it illegally. By contrast, a multi-dose supply of heroin costs $45 to $60. It may sound insensitive, but put simply the economic incentive for a person suffering from opioid addiction to use heroin is quite clear in this regard.
Regulation is a Limited Solution
There are those who believe that the “be-all-end-all” solution is to put legal restrictions on the manufacturing, prescribing, and use of opioids. This measure alone will not work effectively. We've seen historically that criminalization doesn't work. In 1971, President Nixon declared the “war on drugs” and our nation saw an increase in cocaine use that peaked in the 1980s under zero tolerance policies set in place by President Carter the decade before. Additionally, prison populations boomed after the 1986 and 1988 mandatory sentencing laws were passed by Congress.
Let’s take a look at the groups that can be regulated, and why this falls short as a standalone solution:
Manufacturers: If you restrict a manufacturer, legal or illegal, other manufacturers emerge. If there is a demand, someone will fill the supply because more people begin to manufacture. Simply slapping regulations, fines, or punishments on individual organizations, and expecting that to solve the problem on it’s own, becomes like a game of whack-a-mole. That is not to say that these organizations should not be regulated more effectively, or punished if they break (or stretch) the law, because they should.
Doctors: Most doctors are simply trying to provide a positive outcome for their patients. In fact, most people who are prescribed pain medications don't become addicted to them, nor does it create a problem in their life. In 2010, roughly 4.8% of adults over the age of 12 used nonmedical opioids vs. the 210 million people prescribed opioids that year. Prescription opioids are a temporary solution to get through serious injury, complicated surgery, chronic pain, and other short term conditions that make everyday life very difficult. Regulating a doctor’s ability to prescribe an effective medication severely limits their ability to provide a positive outcome for their patients.
Illegal sellers: Similar to the issue with manufacturers, this solution on it’s own fails from the outset. If those who sell the drugs illegally on the streets are jailed then other individuals will fill the gap and begin to sell illegally. It’s simple supply and demand theory: if there is a demand, there will always be somebody to sell, no matter how many people you put in jail. Again, this is not to say that individuals who break the law shouldn’t be punished, but this alone will not solve the opioid epidemic.
Patients: The real problem with a patient who is addicted to opioids isn’t their means of obtaining them -- it’s their underlying addiction that needs to be treated. The development of the disease and treatment of addiction is very complicated due to unique biological, psychological, and social factors that change for each individual. Additionally, placing too many restrictions on obtaining medicine, at a state or federal level, in an effort to combat the opioid epidemic could fuel social resentment for the portion of the population afflicted with addiction. That is certainly not something that we want in any way, shape, or form.
To be clear the suggestion is not that regulations and criminal punishments shouldn't be in place, but that they need to be altered and adjusted based on their efficacy to solve the issue. Put simply, when used alone in an attempt to solve the problem those measures -- and the various forms in which they've been implemented in the past -- seem to make the problem worse not better. This is why we have to go beyond just trying to regulate, legislate, and punish this problem away. We have to look upstream to find a collaborative solution.
A systemic solution to a systemic problem
No one party is to blame for the epidemic -- this is very much a systemic problem demanding a systemic solution. We can’t simply regulate one or more parties to solve the issue. We must look at the entire landscape and reshape it in order to combat the opioid epidemic effectively. To do this we must use a mixed modality approach to the issue:
- Upstream prevention: In upstream prevention, the focus is on educating those who prescribe pain medications about the symptoms of addiction. This early detection allows for appropriate intervention for people to be assessed and treated before irreparable damage is done.
- Shifting focus from criminality to recovery: Just as the cause of opioid addiction doesn’t come from a single source, the solution doesn’t either. The efficacy of an upstream solution is further strengthened by a shift in the justice system away from severe punitive measures and simply criminalizing addiction patients. The justice system ideally would move toward providing addiction patients with better access to effective treatment and long term support through multiple individualized pathways of recovery.
- Policy changes: Policies provide resources. President Trump declaring the opioid epidemic as a national health crisis is a great start. However, the more important part of this process is developing the policies that will inform how the emergency is addressed and solved on a long-term basis. This type of emphasis from the federal government on the crisis also educates people about addiction and recovery, which further breaks down the stigma and myths surrounding them.
There are likely other aspects to the solution that are not addressed above, but this is a start to examining and approaching a solution in a realistic and effective way. We need to collectively work for immediate and long-term solutions to the opioid epidemic. Hindsight is 20/20, but the evidence is clear that a systemic problem exists and an upstream solution can prevent downstream casualties.
This means education, detection, and prevention before a dependency or addiction begins to manifest. In the past, we could blame a lack of understanding of the power of these medicines and the complexity of addiction, but those days are behind us. We must face the situation we are currently in with open eyes, and find solutions that work across the care continuum.