Tuesday, January 23, 2018

Tom Petty, the opioid epidemic and changing structural inequities in the US

In October 2017, the rock musician Tom Petty died at the age of 66. Given Mr. Petty’s history of heroin addiction back to at least the 1990s and the frequency with which overdoses seem to cause the death of celebrities, there was some early assumption that it may have caused his. This was confirmed by the coroner, (NY Times, January 19 2018); however, the cause was not heroin but rather prescription opioids (oxycodone plus 3 types of fentanyl), combined with two also-addictive anti-anxiety medicines known as benzodiazepines: “The coroner, Jonathan Lucas, said that Mr. Petty’s system showed traces of the drugs fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl.” (The citalopram is an SSRI anti-depressant). According to a statement from his wife and daughter, he had many ailments including a fractured hip that caused him great pain.

Thus, Mr. Petty becomes another victim of the epidemic of prescription opioid-related deaths. His previous heroin addiction (chronic use of opiates or opioids leads to tolerance, requiring higher and higher doses for relief) and his stature as a rich and famous person (which seems to make it even easier to find doctors who will prescribe such drugs) may have increased his risk, but his death is one instance of a widespread American problem that has been the subject of academic articles, government reports, and opinion pieces from medical providers, patients, and the general range of pundits.

David Blumenthal and Shanoor Servai of the Commonwealth Foundation write in their report “To Combat the Opioid Epidemic, We Must Be Honest About All Its Causes” that “History offers only one other recent example of a large industrialized country where mortality rates rose over an extended period among working-age white adults: Russia in the decades before and after the Soviet Union’s collapse. The economic and social contexts have been eerily similar, and substance abuse has been a dominant factor in both countries: alcohol in Russia, opiates in the United States.” A major study by Princeton economists Anne Case and Angus Deaton in 2015, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century” (which I have previously cited, Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) posits opioid-related deaths as a major cause of the surprising  increase in mortality rate among white Americans. Blumenthal and Servai note that “Based on weighted estimates, 92 million, or 37.8%, of American adults used prescription opioids the prior year (2014); 11.5 million, or 4.7%, misused them; and 1.9 million, or 0.8%, had a use disorder. The epidemic is spreading so rapidly that it’s likely the numbers are higher now.”

So it’s a very big problem, with many causes, and the solutions are not simple. Doctors play a big role, since they must prescribe the opioids (whether these are taken by the designated patient or illicitly redistributed). While well-known surgeon and author Atul Gawande, in an interview with Sarah Kliff on Vox.com, says “We started it”, I don’t think that is completely true. Certainly doctors have been vehicles for its perpetration but there are other forces at work. One is the movement that began in the 1990s to adequately address patients’ pain, which was seen as insufficient by many critics. In many institutions pain was labeled the “fifth vital sign”, and staff were instructed to ask about pain relief in every interaction. While this is important, especially for acute short-lived pain (such as post-operative or post-traumatic), the use of opiates for chronic pain skyrocketed. The obvious problem is, as cited above, the more you have taken them the more you need; tolerance to opiate and opioid effects often requires increasing doses. The “high” resulting from these drugs (whether intended or not) increases their potential for abuse.

Long-acting opiates and opioids (such as extended release morphine or oxycodone, methadone, and fentanyl patches) are preferred as they can control pain with less of a “high”, but they still lead to tolerance. While addiction is not an issue for people who are dying of their cancer, it is for people with chronic diseases such as sickle-cell and chronic pain syndromes, most commonly in the US back pain. Opiates and opioids have been shown to be poor choices for long-term treatment of chronic back pain, but taking them is often easier and cheaper for patients than complicated (and often expensive) modalities such as physical therapy, and it relieves the pain more quickly and completely until higher and higher doses are needed. So patients, as well as physicians, are part of the problem, and physicians are working to try to help people, while complicating the problem.

Real villains include those who have originated and perpetuated this crisis only to make money. This includes insurance companies, who often deny more expensive treatments such as extended physical therapy or drugs such as buprenorphine, essentially pushing doctors and patients into the use of opioids. They certainly include the pharmaceutical companies who have developed and heavily marketed these drugs, notably the Sackler family who owned Purdue and made and pushed Oxy-Contin®, as documented in the New Yorker article “The family that built an empire of pain” (October 30, 2017). In brief, they acquired the rights to long-acting morphine, but because this was losing its patent protection (and thus its profitability), they developed a long-acting form of oxycodone, which was patented and thus more profitable. Counting on the negative associations that the public and even physicians associated with morphine, they pushed Oxy-Contin, which was at least as addictive and dangerous, for an ever-expanding list of chronic conditions. Back pain, of course, was the target market, and it soon seemed as almost everyone had an indication for opioids. And we have since been paying the price with their deaths.

The flaws of capitalism that directly drove and continue to drive this epidemic through the pursuit of profit should be clear enough. The structural flaws that have and continue to ruin the lives of so many Americans (not to mention people in the rest of the world) may be less obvious but are no less real. The dramatic redistribution of wealth from the vast majority of us to the already-wealthiest, with the concomitant decrease in the quality of life for so many, proceeds apace. The 1%, maybe even the 5%, are doing great, although the biggest benefit (including from the new GOP tax “reform”) law goes to the 0.1% or less. The richest 1% now owns half the world’s wealth and the 8 richest men have as much as half the world’s population!  Worldwide, it is those in the poorest countries that suffer most. In the US, it remains minorities. While the shocker in the Case and Deaton study was the fact that white mortality is increasing, the fact remains that minorities, especially African-Americans, still have far higher mortality rates.

If we wish to decrease this excess mortality, it certainly will be important to address the opioid crisis, by physicians becoming more reticent to prescribe long-term opioids for chronic conditions, patients to accept alternative treatments, and insurers being willing to pay for those treatments. It will also be important to address other chronic addictions, like alcohol (Blumenthal and Seervai observe that while “11.5 million, or 4.7%, misused them [opioids and opiates]; and 1.9 million, or 0.8%, had a use disorder…By comparison, there are 17.1 million heavy alcohol users among adults over 18.” Legal does not mean safer, whether we are talking alcohol abuse or “legitimized” (by prescription) opioid abuse. It most often reflects the relative power of the industries that financially benefit.

The core problem is in the unfair, unjustifiable, and oppressive structural inequities in our society. These are so deeply seated that we often assume they are inevitable, and that there is no other way. There is. We may not be able to eliminate inequality, but if we are to seriously address the epidemic of unnecessary deaths, we need to do more than treat the symptoms; we must grapple head-on with and change our society’s structure. 


Jon Katz said...

Nice job Josh. I was moved by his death because we were at his show about three weeks before he died here in the Bay Area. He had a visible tremor during the first half of the show, but not the second, which makes me think he medicated at some point.

You hit the nail on the head with this one. “Real villains include those who have originated and perpetuated this crisis only to make money. This includes insurance companies, who often deny more expensive treatments such as extended physical therapy or drugs such as buprenorphine, essentially pushing doctors and patients into the use of opioids.”

I am in a space these days where I am much more open to directly pointing a finger at doctors (for everything actually). It’s not so much that we were told to “measure” a pain vital sign, or that cost incentives favor procedural medicine so patients get surgeries. It also is not about just the pills. It’s actually that doctors are horrid diagnosticians who cannot recognize pain syndromes or addiction. They just miss it. Every single one of these charts (from the perspective of a tertiary/quartenary MD in SF) shows that doctors simply fail to recognize these two issues. And, as you note, even if they can make a diagnosis, who do you refer to? Every “pain clinic” around here has been usurped by high dollar nonsense that aims to do procedures. These clinics lack expertise for even managing pain, as the anesthesiologists and surgeons who run them are incapable of actually caring for these patients. Many of them need a diagnosis and people who can just start a discussion. They don’t exist. The only step is to send someone to an inpatient rehab center, which is essentially another money operation.

Josh Freeman said...

I would add this, brought up by a friend and completely correct. We have had a race-based rhetorical shift, from a "War on Drugs", where the users were addicts (minorities), to a "Opiate epidemic", where the users are now seen as victims (white).
As part of a strategy for addressing the structural inequities that are not only economic but racial, decriminalization of possession of opiates is a necessary part.

donburke said...

Don Burke comments ...

The opioid epidemic is just the latest manifestation of a continuous overdose epidemic that has been growing exponentially for at least four decades.

See "Exponential growth of the USA overdose epidemic"

The exponential growth process began in the late 70's, well before the massive expansion of opioid prescribing. This suggests deeper causal factors, such as income disparities, social immobility (a growing caste system), and lack of a sense of purpose.


Ken Rosenberg said...

I believe that Sam Quinones, in “Dreamland: The True Tale of America’s Opiate Epidemic” documents the role of Purdue Pharma in making pain “the fifth vital sign.” Purdue had their marketing agents (“detail men”) aggressively promote the lie that there was evidence that oxycodone was not addictive if taken by post-operative patients. There has been limited criminal prosecution of Purdue and its leadership.

The press and the medical community have largely ignored the failure to adequately fund medication assisted treatment. They have also largely ignored harm reduction efforts like safe spaces for injection.

The public health community has not acquitted themselves well. Failure of the FDA to regulate Purdue’s oxycodone marketing led to increased opioid addiction. The public health response has largely been to try to decrease overprescribing by physicians. Whatever its shortcomings, oxycodone (as a pill) is less harmful than intravenous use heroin. Decreased supply of oxycodone has led many addicts to use heroin – which is now often laced with fentanyl (which is more powerful than heroin and is causing many of the opioid deaths now).

P.S. The New York Times ran a story on January 14, 2018 (“Opioid Addiction Knows No Color, but Its Treatment Does”) about racial segregation in medication assisted treatment: people of color attend methadone maintenance programs daily but white addicts can get multiple doses of buprenorphine from their physicians at a single visit. (At: https://www.nytimes.com/2018/01/12/nyregion/opioid-addiction-knows-no-color-but-its-treatment-does.html)

Jamie Cooke said...

Excellent article, completely agree with your points. The problems being seen with drugs are symptoms of the underlying cause - inequality and injustice. If we want to reduce the impact the epidemic is having then we need to explore innovative medical responses (such as here in Glasgow where we are exploring ideas for safe injecting spaces, albeit with resistance); but more importantly it will require economic, legal and societal changes. One of the areas I am working on most just now is Basic Income, which has picked up a lot of traction across the globe. One of the attacks made against it is that giving people money would see them spend it on drugs and drink - I would strongly counter this (and evidence to date supports my stance) that by investing in people, trusting them and removing the hopelessness and insecurity which many people live with we will empower them to make different choices, and will then (and possibly only then) see a significant breakthrough in this epidemic. Look forward to reading more of your work.

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