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The Opioid Epidemic: Who’s to Blame — Doctors or Big Pharma?

Today, nearly every adult in the U.S. has been affected in some way by the opioid epidemic.
Almost everyone knows someone — a friend, a family member, an acquaintance — who has struggled with an opioid addiction or even died of an overdose. Many have seen opioid addiction ravage their community, tear families apart, and turn kind people on a road to desperation, addiction, and despair.
The widespread impact of the opioid problem has shattered some aspects of the stigma attached to drug addiction and substance use. No longer can those struggling with addiction be cast aside as nameless “addicts” or criminals on the outer edges of society. They are sons and daughters, parents, and neighbors — proof that addiction knows no bounds and can affect people of all ages, upbringings, and socioeconomic levels.
This has allowed for a further understanding of — and a more honest discussion about — addiction and recovery. Rather than hide their child or spouse’s substance problem, people may be more likely to seek help and support from others in similar situations or from a treatment center.

As more people recognize the seriousness of the problem and try to put an end to the epidemic, offering support to individuals and families dealing with an opioid addiction, many in communities across the country are left wondering how we got here.

When it comes to who is to blame for the opioid crisis, the public is often split. Some think the big pharmaceutical companies who pushed their opioid drugs bear the blame, while others blame the doctors who prescribed these drugs to patients looking for relief.

Past Drug Epidemics in the U.S.

The U.S. has experienced many drug epidemics in its time — a heroin epidemic in the 1980s, a cocaine and crack epidemic in the 1980s and 1990s, and a methamphetamine epidemic that began in the 1990s and is now perhaps getting worse.

The U.S. is currently experiencing an ongoing opioid epidemic. In the late 19th century, it’s estimated that over 300,000 people were addicted to injected morphine or smoked opium.

The country has never experienced anything quite like the current opioid crisis. It is already the deadliest drug epidemic in American history, killing tens of thousands of people every year.

Understanding Opioids

Opioids are a class of drug that produces a variety of effects in the brain. They are believed to block pain signals from the brain to the body.

Opioids can be prescription drugs (usually called painkillers) or street drugs, like heroin. In addition to affecting pain signals, opioids makes users feel high and relaxed. Users quickly develop a tolerance to and physical dependence on opioids, making them highly addictive.

The most commonly used opioids are prescription opioids (painkillers like Oxycontin and Vicodin), the street drug heroin, and fentanyl (an incredibly strong and dangerous illegal synthetic drug that’s 50 to 100 times more potent than morphine).

A Brief History of Today’s Opioid Epidemic

The opioid problem in America is huge and complex. There were many factors that contributed to it becoming the deadliest drug epidemic in American history. Some events surely shaped the crisis and help to explain how the situation spiraled out of control.

1995

Purdue Pharma receives FDA approval for OxyContin, a potent opioid prescription painkiller.

1991–2011

Prescriptions for opioid painkillers triple in this time period, likely in part due to doctors overprescribing these drugs and addicted patients “doctor shopping” (getting multiple prescriptions from different doctors).

1999–2003

The number of people who admit to using OxyContin for nonmedical purposes rose dramatically during this time period, from 400,000 in 1999 to 1.9 million in 2002. It spiked to up to 2.8 million in 2003.

2007

Purdue Pharma pays a $634 million dollar fine for “misbranding” OxyContin and falsely marketing it as a safer and less abuse-prone painkiller option, as well as misleading doctors, regulators, and patients about its high abuse potential and risk of addiction.

2009

During this year, approximately 1.2 million hospital emergency room visits were related to misuse or abuse of pharmaceutical drugs. This number is larger than the number of hospital emergency room visits related to illicit street drugs, and it reflects a 98 percent increase since 2004. The most prominent drugs involved in the emergency room visits were opioid painkillers, particularly OxyContin.

2010

Purdue Pharma releases a more abuse-resistant form of Oxycontin. If a user tries to inject or snort the drug, it becomes a gummy hard-to-use substance.

2011

The FDA supports the The White House Office of National Drug Control Policy’s report “Epidemic: Responding to America’s Prescription Drug Abuse Crisis,” which outlines comprehensive plans to battle the ongoing opioid prescription drug epidemic.

2015

Opioid prescriptions fall 18 percent from a 2010 peak, according to the Centers for Disease Control and Prevention.

2008–2014

A Washington University School of Medicine study that involved opioid users over a seven-year period found that the number of those who used only prescription medications declined by 6.1 percent, while the number of those who used prescription opioids and heroin increased by 10.3 percent. The number of those who began using only heroin rose by 14.1 percent.

2019

Despite a reduction in opioid prescription drug prescriptions, the number of opioid-related deaths continues to rise. Many opioid prescription drug users have switched to more accessible street drugs, including heroin and fentanyl.
To date, 48 states have sued Purdue Pharma in relation to OxyContin. Accusations include lying about the drug, exaggerating its benefits and safety, and downplaying its dangers and high addiction rate.


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Are Doctors to Blame for the Opioid Crisis?

opioid pills spilling out of bottle onto table

According to a 2019 AP-NORC poll, approximately 46 percent of participants blame doctors and dentists for the current opioid crisis.

Of course, many doctors dispute this logic, insisting that they were also unaware of the dangers of prescription opioid painkillers like OxyContin. They claim that they were misled by the pharmaceutical companies, particularly Purdue Pharma who marketed OxyContin as a safer alternative to many other types of painkillers.

Some doctors also point to the pain-related patient advocacy movement in the 1990s that called for more aggressive pain treatment and pain relief standards. The advocates for this movement — which perhaps began with a 1990 editorial in Annals of Editorial Medicine by Dr. Mitchell Max, the President of the American Pain Society — expressed disappointment in the medical community’s lack of progress or focus on pain management. Advocates for aggressive pain management asked that pain be treated as a “fifth vital sign.”

Within a year, the American Pain Society had issued guidelines for pain management and related bills passed in Congress. By 2000 (well after OxyContin’s release), mandatory pain scales were used in certain areas of health care, sometimes requiring an “acceptable” pain score for release. The standards suggested using a numerical scale based on patients’ self-reported pain.

Many doctors claim this movement put them in conflict. Some feared their patients would become too dependent on opioids, but they were at risk of violating pain guidelines or patients’ rights if they were to try to limit access to painkillers.

While these explanations may sound reasonable, there are other aspects and statistics relating to doctors’ roles in the opioid crisis that raise more questions.

  • A 2019 study found that there was a direct association between OxyContin marketing and payment to doctors, and opioid overdoses. The study found that counties in which OxyContin was heavily marketed to doctors, with doctors receiving payment, later experienced higher overdose rates, even when researchers controlled for other influences.
  • The study also found nearly 475,00 payments totaling $39.7 million to 67,507 physicians — roughly 1 in every 12 doctors. About one in five family doctors had received this type of “marketing” (payments).
  • While there’s been an overall reduction in opioid prescriptions in the country, the prescription rate remains triple what it was in 1999. Prescription rates have not dropped as sharply in communities already dealing with high levels of opioid-related overdoses.
  • Particularly during the peak period of opioid overprescription, “pill mills” (doctors and medical practices that were prescribing opioid painkillers for a fee without qualifying patients pain problems, often knowing they were writing illegal prescriptions for addicts) became a well-known problem and a symbol of doctors’ corruption in the opioid crisis.
  • On average, doctors whose volume of opioid prescriptions were in the top 5 percent nationally received about twice as much from opioid companies as doctors who were in the median area of prescriptions. The top 1 percent of opioid prescribers made approximately five times as much as a typical doctor.

Are Drug Companies to Blame for the Opioid Crisis?

The 2019 AP-NORC poll found that a majority of Americans (63 percent) placed blame on the pharmaceutical companies for the opioid epidemic. According to a 2019 poll from National Public Radio (NPR), about 70 percent of respondents feel that pharmaceutical companies should cover the cost of addiction treatment as well as the costs for the drug naloxone, which is used to revive individuals after an opioid overdose.

It’s not hard to see why. As discussed above, drug companies — particularly Purdue Pharma, makers of OxyContin — have paid out millions in “marketing” to doctors. Purdue Pharma has already paid hundreds of millions for fines relating to lying and misleading the public, patients, and doctors about their drug. In 2007, the company and its top executives pleaded guilty to a felony related to the false marketing of OxyContin, even confessing to directing their sales team to tell doctors that the drug was less addictive than other opioids.

There is further evidence of the pharmaceutical company’s role in the opioid epidemic.

  • A sealed court document obtained by the press in early 2019 revealed that top Purdue Pharma executives made the decision not to correct the false impression among doctors that OxyContin was weaker than morphine. It also revealed that the executive supported decisions on the sales team to indicate that OxyContin produced “less of a buzz” or less euphoria than other painkillers. A top executive was revealed to have said of the drug’s early success: “Clearly this strategy has outperformed our expectations, market research and fondest dreams.”
  • The document also revealed that top executives at Purdue discussed plans to persuade German officials to classify OxyContin as an uncontrolled substance, which would make it easily obtainable without the need to see a doctor. A top executive hoped this method would help to weaken OxyContin-related regulation throughout the European Union.
  • Even as the opioid epidemic continues in the U.S., pharmaceutical companies are looking to go global with opioid painkillers. In 2016, a Los Angeles Times article covered this shift, highlighting a pro-opioid consultant speaker who travels globally and has been paid over $1 million from drug companies (including Purdue Pharma) since 2013.
  • Records show that Purdue Pharma spent over $8 million dollars on a website venture called “Partners Against Pain,” which served to connect patients to doctors (likely doctors known to prescribe OxyContin).
  • In a Massachusetts lawsuit against Purdue Pharma, claims against the pharmaceutical company include that it tried to blame patients for soaring addiction rates, tried to market to older people without disclosing the full risks, and pushed doctors to prescribe higher doses, particularly the 80-mg tablet, which was very profitable for the company.
  • Another marketing program involved convincing a Tufts University program to include two pro-opioid, unbranded courses. In 1999, top Purdue executives established, after a donation, the university’s master-level class in pain research and policy.
  • According to New Jersey’s complaint against Purdue Pharma, when a top Purdue official was emailed by a sales executive to alert the company that OxyContin was being marketed to an illegal drug ring operating as a “pill mill,” the company chose not to act for over two years. At that point, the pill mill doctor had already been arrested.
  • Despite marketing the drug as a safer and less addictive opioid, prosecutors claim that the terms snort, street value, and crush were found in 117 internal notes made by Purdue Pharma sales representatives while recording their visits to doctors and health facilities. No action was taken by the drug company although they were told of the drug’s abuse.
  • Purdue Pharma and other drug companies recently (and possibly currently) continued to fund nonprofit groups advocating for access to pain management tools and research. Government watch groups question whether this involvement is yet another sales tactic to market opioid painkillers to the public.

Conclusion

There is overwhelming evidence that drug companies, particularly Purdue Pharma, repeatedly and knowingly lied to doctors, patients, and the public about the dangers of their most profitable drugs in order to boost sales, even as it became clear that a deadly epidemic was underway. Because of this, it’s hard not to conclude that these pharmaceutical companies are perhaps more to blame that anyone for today’s deadly opioid epidemic.

However, when looking at the amount of money doctors received from these drug companies — and the direct connection between the number of opioid prescriptions written by a doctor and the amount of “marketing” payments received from the opioid manufacturers — it’s clear that some doctors also bear a large portion of the blame.

It’s particularly bleak when considering the trust many have in their doctors, who have taken an oath to serve their patients, not their bank accounts or a drug company. Even if they were misled by the drug companies, could they not see the levels of addiction rising? One has to wonder whether their marketing payments from drug companies helped them to turn a blind eye.

Perhaps the larger question here is, why are drug companies like Purdue Pharma allowed to market dangerous drugs to doctors using payments? Are payments really marketing? Or are they payoffs? Should a doctor be deciding what drugs to prescribe based on marketing payments from a drug company?

Based on what we’ve seen during the devastating opioid epidemic, there needs to be a reassessment of how opioids are prescribed and how pharmaceutical companies motivate doctors to choose their meds.

SOURCES

(August 2018) A Brief History of The Opioid Epidemic. American Council on Science and Health. Retrieved August 2019 from https://www.acsh.org/news/2018/08/22/brief-history-opioid-epidemic-13346

(April 2018) An Opioid Crisis Foretold. The New York Times. Retrieved August 2019 from https://www.nytimes.com/2018/04/21/opinion/an-opioid-crisis-foretold.html

(February 2018) Meth, the Forgotten Killer, Is Back. And It’s Everywhere. The New York Times. Retrieved August 2019 from https://www.nytimes.com/2018/02/13/us/meth-crystal-drug.html

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(May 2007) In Guilty Plea, OxyContin Maker to Pay $600 Million. The New York Times. Retrieved August 2019 from https://www.nytimes.com/2007/05/10/business/11drug-web.html

(2011) Epidemic: Responding to America’s Prescription Drug Abuse Crisis. White House Office of National Drug Control Policy. Retrieved August 2019 from http://publications.iowa.gov/12965/1/NationalRxAbusePlan2011.pdf

(2018) Timeline of Selected FDA Activities and Significant Events Addressing Opioid Misuse and Abuse. Food and Drug Administration (FDA). Retrieved August 2019 from https://www.fda.gov/media/106638/download

(April 2018) Opioid Crackdown Has Patients Struggling to Get Their Meds. The Wall Street Journal. Retrieved August 2019 from https://www.wsj.com/articles/opioid-crackdown-has-patients-struggling-to-get-their-meds-1524744001

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(March 2017) The Opioid Epidemic: It’s Time to Place Blame Where It Belongs. Missouri Medicine. Retrieved August 2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140023/

(August 2018) Purdue Pharma’s Sales Pitch Downplayed Risks of Opioid Addiction. Kaiser Health News. Retrieved August 2019 from https://www.healthleadersmedia.com/clinical-care/purdue-pharmas-sales-pitch-downplayed-risks-opioid-addiction

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(January 2019) Drug Company Payments to Doctors May Influence Opioid Overdose Deaths, Study Finds. Washington Post. Retrieved August 2019 from https://www.washingtonpost.com/national/health-science/drug-company-payments-to-doctors-may-influence-opioid-overdose-deaths/2019/01/18/f265ade0-1aa0-11e9-9ebf-c5fed1b7a081_story.html?noredirect=on

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(February 2019) Sackler Embraced Plan to Conceal OxyContin’s Strength from Doctors, Sealed Testimony Shows. ProPublica/ Stat News. Retrieved August 2019 from https://www.propublica.org/article/richard-sackler-oxycontin-oxycodone-strength-conceal-from-doctors-sealed-testimony

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(February 2018) Senate Report Probes Purdue Pharma Donations to Nonprofits. Stamford Advocate. Retrieved August 2019 from https://www.stamfordadvocate.com/business/article/Senate-report-probes-Purdue-Pharma-donations-to-12703659.php

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