John Oliver is a brilliant comedian with a large platform, and he has been using it of late to demonize the pharmaceutical companies that produce opioids. Major targets of his attack are Purdue Pharma and its Sackler family principals, developers of OxyContin, which, until around 2010 was a drug of choice for non-medical users.
Like the tobacco companies in the 1990s, it is understandable to focus indignation at companies, driven by the profit motive, that purvey products that can cause harm and even death. It is reasonable to question and criticize their marketing ethics and aggressiveness.
But at the end of the day, extracting a pound of flesh from the Sacklers won’t stop the overdose rate from climbing. That’s because the standard narrative that overprescribing of opioids caused the overdose crisis is based upon misinformation — as is the belief that opioids have a high overdose and addiction potential.
Data from the National Survey on Drug Use and Health, as well as the Centers for Disease Control and Prevention, clearly show no correlationbetween the number of opioid prescriptions dispensed and “past month non-medical use” or “pain reliever use disorder” among adults over age 12. As high-dose opioid prescriptions dropped 58 percent from 2008 to 2017 and overall prescriptions dropped 29 percent in that time period, the overdose rate continued to climb. Decreasing the availability of prescription pain relievers for diversion into the black market only drives non-medical users to more dangerous heroin and fentanyl.
In 2017, heroin and fentanyl comprised 75 percent of opioid-related overdose deaths. Deaths from prescription pain pills also involved drugs like cocaine, heroin, fentanyl, alcohol and benzodiazepines 68 percent of the time. Less than 10 percent of overdoses from prescription pain pills in 2017 did not involve other drugs.
Opioids prescribed in the medical setting have been repeatedly shown to be safe. Researchers following over 2 million North Carolina patients prescribed opioids noted an overdose rate of 0.022 percent, and nearly two-thirds of those deaths had multiple other drugs in their system. A 2011 study of chronic pain patients treated in the Veterans Affairs system found an overdose rate of 0.04 percent. A larger population study found an overdose rate of 0.01 percent.
Researchers at Harvard and Johns Hopkins universities recently found a total misuse rate of 0.6 percent in over 560,000 patients prescribed opioids for acute and post-op pain between 2008 and 2016. Cochrane studies, highly regarded for their rigor, found addiction rates in chronic pain patients on opioids of roughly 1 percent.
People often mistakenly equate physical dependency with addiction. Physical dependency is seen with a variety of drugs, including antidepressants, anti-epileptics, and beta blockers. A person can be slowly weaned off these drugs. But addiction is a compulsive behavioral disorder with a genetic component featuring repeated use despite self-destructive consequences. The director of the National Institute on Drug Abuse points out in a 2016 paper that true opioid addiction “occurs in only a small percentage of persons who are exposed to opioids — even in those with pre-existing vulnerabilities.”
As researchers at the University of Pittsburgh recently demonstrated, non-medical use has been on a steady exponential increase at least since the mid-1970s and shows no signs of slowing down. The only things that have changed over the years are the drugs in vogue for non-medical use. It seems sociocultural factors are at play. In fact, young people seem more willing to engage in risky drug use than their predecessors. A 2017 study showed 33.3 percent of heroin users initiated with heroin.
At the end of the day, the drug overdose problem is the result of sociocultural dynamics intersecting with drug prohibition — and all the dangers that a black market in drugs present. Prohibition also presents powerful incentivesto corrupt doctors, pharmacists and pharmaceutical representatives who seek the profits offered by the underground trade.
When Portugal decriminalized all drugs in 2001, it saw a 75 percent drop in its population of heroin addicts by 2015, and now has the lowest overdose rate in Europe, at 6 per million population (compared to 312 per million in the United States). Along with Portugal, most of the developed world has put an emphasis on harm reduction strategies over restrictionist, prohibitionist approaches, one reason they have lower death rates than the United States. These strategies include medication-assisted treatment with drugs like methadone and buprenorphine; safe injection facilities; needle-exchange programs; and making the overdose antidote naloxone more available.
None of this is meant to defend the conduct of a few pharmaceutical companies or those who work for them. It is meant to refocus energy and anger where it belongs.
The real villain is the war on drugs. Yet it’s getting off scot-free.
This article appeared in the UPI on April 24.
Dr. Jeffrey A. Singer is a general surgeon in Phoenix and a senior fellow at the Cato Institute.