Opioids are getting national attention. In August, the President announced that Opioids are a National Emergency. There are a fair few national emergencies unfrotunately. CNN reports that we currently have 29 national emergencies on the list. One dates to the Carter administration (some may not remember, he was the President before Reagan. Everyone remembers Reagan as the President the last time the Kentucky Wildcats beat Florida at football).
Suffice it to say that declaration of an emergency is likely "a" good step in addressing the death and destruction that surrounds Opioids. However, the declaration itself is not "the" solution. Note that on the CNN list, narcotic traffickers were targeted as a national emergency over 20 years ago (1995). There are other long-standing issues on that list, indicating that the attention of an emergency declaration may not be sufficient alone to solve a problem.
The President is not alone. ABC News reports that Florida's Governor declared a Public Health Emergency in May. The Governor recognized in his Executive Order that
opioid abuse "Poses a severe threat to the State of Florida and requires that measures are taken to protect the communities and general welfare of this State."
ABC reports that the Governor will announce more efforts today.
I have made no secret about my concerns regarding Opioids. I was curious about More Powerful Opioids in 2013, and remained curious about them as they were in the news, protested by Attorneys General, and in the news again, and yet again. As stronger Opioids were brought to market, I struggled with several questions such as why do we need stronger Opioids, and why do we need any Opioids that lack abuse precautions. Those blog posts generated some interesting conversations, and through them I met some very interesting people who share an interest in better medicine and the bigger questions of our Opioid epidemic.
I have made no secret about my concerns regarding Opioids. I was curious about More Powerful Opioids in 2013, and remained curious about them as they were in the news, protested by Attorneys General, and in the news again, and yet again. As stronger Opioids were brought to market, I struggled with several questions such as why do we need stronger Opioids, and why do we need any Opioids that lack abuse precautions. Those blog posts generated some interesting conversations, and through them I met some very interesting people who share an interest in better medicine and the bigger questions of our Opioid epidemic.
In 2015, I started to perceive similarities between our headlong 1990s rush to Opioids, and the groundswell of "medical marijuana." States that are free to ignore federal law regarding marijuana are nonetheless constrained in their abilities to constrain Opioids, addressed in A Study in Federalism. There are some interesting questions about marijuana that perhaps merit our attention, but more on that in a moment.
Opioids are causing damage in America. At the risk of sounding like a Broken Record, people are dying from ingesting these substances. The New York Times reported last summer that Opioid deaths for 2016 were likely more than 59,000 in America. The story was updated later to claim it was over 64,000. In the entire span of the Vietnam conflict, American casualties total 58,220, according to the National Archives.
Digest that for a moment, more Americans died in one year, 2016, from Opioids than were killed in the long, bloody conflict that was Vietnam. America is suffering a Vietnam every year, right here at home. And, whether we want to look in that mirror or not, the fact is that we are all likely to blame in some degree. Can you imagine us building a memorial each year to list the names of all the Opioid fallen?
How did this happen? That very question is stated in the National Institute of Drug Abuse site, and answered thus:
In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates.
Producers assured doctors that there was no harm. Doctors began to prescribe more often. Doctors believed that "patients would not become addicted." Some advocate not blaming the addicts, but instead those who manufacture and market these drugs. An interesting Guardian article takes this approach. This perspective blames the manufacturers, their lobbyists, and their marketing. And, perhaps, the doctors (experts) that went along?
Anyone who lived through the 1970s likely remembers the news reports of heroin. Heroin is an Opioid, and was identified as a problem in the 1970s. The death and destruction it instigated led to President Nixon to declare war on heroin (Nixon was the one before Ford, who was before Carter, whose emergency declaration mentioned above lingers yet). I might suggest that there is nothing new about the troubling nature of Opioids. Anyone exclaiming "they're addictive" has all the credibility of the "Barney Fife" policeman in Casablanca.
courtesy giphy.com
The deaths are troubling. The destroyed lives of non-users are as troubling or more so. I know I sound like a Broken Record, but it is not just the users who are affected. Each of those dead from Opioid abuse had someone that loved them (well, we all at least have someone that likes us). What is the human toll on those people left behind by the addictive behavior and death?
How many people are affected? The Centers for Disease Control (CDC) says that men are more affected than women, but equality is coming. The highest rates are among those 25 to 54. Might that age group also be presumed to be the most predominant age of working Americans? The CDC statistics are troubling
In 2014, almost 2 million Americans abused or were dependent on prescription opioids.
As many as 1 in 4 people who receive prescription opioids long term for noncancer pain in primary care settings struggles with addiction.
Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.
All this from substances that we were assured by science were not addictive. All this from substances that the experts, medical doctors, prescribed. These experts, and their knowledge, and their experience, missed the boat. They wrote the prescriptions and people actually did become addicted. People actually died.
As the fallacy of their failure came to light, doctors became reluctant about Opioids. There were efforts to curtail prescribing. The great "pill mills" were raided, shuttered, and banned. Recognizing the dangers and the false propaganda, the experts began to be introspective and analytical about Opioids. Less were prescribed, less were diverted, and less were available on the streets. But those who were addicted to them remained.
Nature abhors a vacuum, and so other substances entered the market. Heroin, the scourge of the 1970s returned in force according to the CDC. A synthetic Opioid called Fentanyl entered our lexicon and deaths from it made the news. It turns out that there are people who wanted Opioids badly enough to buy or steal or connive prescriptions for pills. Later deprived of that source by the doctors and Attorneys General, those same people were apparently just as willing to turn to street dealers and street drugs.
Despite the Guardian's point regarding the contribution of pharmaceutical manufacturers and expert physicians, the fact seems to remain that there are people who engage in drug-seeking behavior without resort to prescriptions. In short, there are people who are drawn to the siren's call of drug use. They seek it or it is thrust upon them. They engage, they partake, and too often they succumb.
And that returns me to the current rush to the arms of yet another panacea for the new century. Marijuana is said by the National Institute on Drug Abuse to be addictive. But others, like the New York Times reassure us about Marijuana. Though the Times concedes that Marijuana can "produce a serious dependency" and could "interfere with job and school performance," it poses "little or no risk for healthy people."
The Times assures us that the "science" should reassure us. It says that "the clear consensus of science (is) that Marijuana is far less harmful to human health than most other banned drugs and is less dangerous than . . . alcohol and tobacco." Science, per the Times, has spoken. And yet, no one asks whether this is the same or better science than told us that Opioids would not be addictive. How soon we seem to forget.
On Friday, September 29, 2017 at noon, I will be privileged to participate in a discussion on Opioids, Marijuana and pharmacy formularies. The program is called the "Hot Seat," and this inaugural program will feature Mark Pew and Ryan Brannan. They will provide their perspectives and thoughts on the issues we face with these substances, the costs they pose for society generally, and our American workforce. It promises to be an interesting and unscripted discussion.
Are we blindly following science into another debacle? Are we irrationally resisting legalization of a benign substance? Are we making the point or missing the point? This discussion may provide answers or pose more intriguing questions. Register today and join us for the conversation.
UPDATED 09.27.17 - On Tuesday, September 26, 2017, Governor Scott unveiled a proposal to limit Opioid prescriptions to a three day supply, investment of $50 million in drug treatment, and described other proposed changes. The details were published in multiple publications, the Palm Beach Post among them.
