You might have thought the opioid crisis was petering out. In fact, the opposite is true: it's the worst it's ever been.
With public attention steadfastly attuned to the coronavirus pandemic, little has been made of the ongoing opioid crisis that predates it. But between June 2019 and June 2020, the US recorded its highest ever number of overdose deaths in a twelve-month period: 81,003. Yet that figure scarcely made the papers. In this dire situation, has society failed addicts?
What are opioids?
Opioids are essentially powerful painkillers derived from the opium poppy plant. They bind to receptors in the brain, changing the way it interprets pain and depressing the central nervous system. In high enough dosages, opioids can produce a feeling of euphoria and intense relaxation, and these feelings have resulted in opioid use for recreational purposes.
Opiates refer specifically to natural compounds such as heroin, morphine and codeine, while opioids denote the wider family of synthetic and semi-synthetic drugs such as fentanyl. Often though, the terms are used interchangeably.
How did the opioid crisis start?
Opioid usage dates back thousands of years, with Sumerian clay tablets offering the earliest recorded example of its medical prescription. Fast forward to the 20th century, and the seeds for the current US crisis were sown 35 years ago. In 1986, scientists Russell Portenoy and Kathy Foley stated that opiate-based medication was not “inherently addictive”. Few could have anticipated how seismic the impact of this statement would be. At around the same time, doctors were lauding the effectiveness of MS Contin (a strong-release painkiller containing opiates) in treating end-of-life cancer pain.
Purdue Pharma, the brainchild of brothers Arthur, Mortimer, and Raymond Sackler, capitalised on the burgeoning shift in pain management with brutal efficiency. Arthur, the oldest brother, was a pioneer of medical advertising. A highly skilled copywriter and doctor, he “recognised that selling new drugs requires a seduction of not just the patient but the doctor who writes the prescription”. In the 1960s, he made a fortune by marketing Librium and Valium – highly addictive tranquillisers – to calm the nerves of incoming college freshmen.
By 1973, more than 100 million tranquilliser prescriptions were being written every year. Arthur’s grim legacy extends beyond the architecture of two drug crises - he brought about a sea change in how Americans understand the concept of pain. That is, as a wrong to be righted; a personal slight not to be tolerated; something that is eminently and urgently fixable.
It is against this backdrop that OxyContin, “the flagship drug of the pain management movement”, must be understood. Chiefly composed of oxycodone, an opiate similar to heroin and morphine, the effects of OxyContin only last for up to twelve hours, and so Purdue claimed the abuse potential for this new drug was low. As Barry Meier, author of Pain Killer: A Wonder Drug’s Trail of Addiction and Death published in 2003, accurately attests: “Essentially, they take an equivocal claim, and they turn it into an absolute”.
After its legal approval in 1995, what followed was a marketing campaign that was extraordinary in both scope and effectiveness. Doctors were flown to all-expenses-paid conferences in California and Florida and trained for Purdue’s national speaker bureau”. They were inundated with OxyContin-branded fishing hats, tote bags, clocks, stuffed toys and CDs. Data was analysed to locate and target trigger-happy physicians, and promotional material was thus dispatched to them en masse. Most grotesquely of all, patients themselves were offered coupons for a free seven to 30 day supply. By 2001, over 34,000 coupons had been redeemed nationwide. Purdue Pharma initially targeted their crusade at rural areas. With agrarian economies largely built on manual labour, residents were susceptible to injuries and chronic pain. Sales of OxyContin exploded – from $48 million in 1996 to over $1 billion in 2000. The Virginias, the Carolinas, Tennessee and Kentucky – broadly comprising Appalachia (a mountainous area known for its poverty and white-working-class citizenry) – were ground zero. Before long, the twin pillars of poverty and isolation, catalysed by these new addictive painkillers, triggered a groundswell of misuse, addiction and suffering.
By 2004, OxyContin had become a major street drug across America. Heroin trafficking and powerful synthetic derivatives, such as fentanyl, made a grave situation infinitely worse – prescription medication is a gateway drug for around 80% of heroin users. Midway through President Obama’s tenure, in 2011, the Office of National Drug Control Policy acknowledged, for the first time, that the crisis had grown to epidemic proportions. Nonetheless, prescription rates climbed inexorably, and overdose actually became the leading cause of death for Americans under 50. Under President Trump, the situation hardly improved. While deaths dropped 4% in 2018, emergency department visits rose by 30% in the two years prior. The widening availability of naloxone, a type of medicine that reverses the effects of an overdose, is in fact to thank for the small but important mitigation in the number of deaths over that period.
Where are we today?
The current situation is grim, as is the outlook for the future. Early data estimates that overdose deaths may have exceeded 90,000 in 2020, up from 70,630 the year before – the largest single-year percentage increase in the past two decades. Last year, funding for state and local level support all but dried up, as addicts were forced to reckon with unprecedented levels of isolation and stress, which are two of the main risk factors associated with use and relapse. Group meetings went online, leaving those with no internet access in the lurch, while medical treatment became more inaccessible due to the pandemic’s impact. Moreover, the disruption to the opioid supply chain has led to a saturation of fentanyl - one of the most dangerous opiate-based painkillers - on the illicit market.
In every conceivable way, the pandemic has been catastrophic to those at risk or struggling with opioid abuse disorder. Coronavirus has ruthlessly exposed how inadequately the US is set up to deal with an opioid crisis. Infrastructure is too fragile and when placed under pressure there is no contingency plan. That state governments have slashed millions from their treatment budgets this year; in Oregon, this was by a whopping $69m. The truth is quite simple: at no point in its history has the opioid crisis been treated with the requisite level of care or attention. This neglect has resulted in the crisis, ravaging entire communities across the country, and killing in huge numbers.
What is the solution?
With the Biden administration in its infancy, it is hard to draw too many conclusions from how this government intends to resolve an issue that has been swerved by its four predecessors. However, the early signs are worrying. The President has already rescinded guidelines making it easier for physicians to provide Buprenorphine, a type of opioid treatment medication. In addition, a recent Office of National Drug Control Policy report bears many similarities to the ineffectual approach adopted by Trump, emphasising medication-assisted treatment and a crackdown on illegal drug supply. As is widely documented, the war on drugs is among the greatest domestic policy failures in American history.
The inclusion of ‘harm reduction’ in a list of drug policy priorities is more promising. Essentially, ‘harm reduction’ refers to making drug use safer rather than trying to put a stop to it. One potential method involves the introduction of supervised injection sites. During his presidency, Trump fought tooth-and-nail to block such sites from opening, and plans for a centre in Philadelphia were met with widespread opposition last year. It should be noted that no one in the Biden administration has specified supervised injection centres - yet. Of course, the roots of the problem run deep.
US drug policy has a history of racism, as outlined in MBR article Constructing the Ghetto, and addiction, globally, has always affected the most vulnerable in societies. America is no different: at every level of society, addicts find themselves marginalised. This attitude, shared by swathes of the public and politicians, must change in order for victims of this crisis to receive medical treatment. Over three decades, the government has continually failed Americans by allowing the legal opioid market to boom and lethal drugs to be prescribed in excess. Now, they are indebted to the millions of Americans who have suffered the consequences.