Last week President Trump declared opioids a national public health emergency. You may know the depressing statistics. More than 183,000 opioid-related deaths in the last sixteen years, the number of heroin overdoses tripling in just a few years, 78 opioid-related deaths per day in America alone. About 1,000 people are treated by hospital emergency departments every day for using opioids in a manner not prescribed by a doctor.
On any given day about 3,900 Americans initiate the use of non-prescription opioids and 560 use heroin for the first time. Oddly, these statistics are related.
You should also know that about 650,000 opioid prescriptions are dispensed in the United States every day, and that number has increased tremendously during the last 25 years. In fact, American doctors write about 80% of the planet’s opioid prescriptions. We are apparently a country in a great deal of pain.
You know that quite often what happens is that someone will be prescribed an opiate following surgery or another medical procedure, and the prescription includes enough medication to addict the individual (I came home with a couple of bottles of pills following arm surgery but one pill was enough for me; I hated the way it made me feel). Then the doctor cuts the patient off and will not renew the prescription. The addict has two choices: She can either begin doctor shopping to find other doctors to prescribe the opiates or she can turn to a cheaper opiate called heroin. In some areas a heroin fix can be bought for about $10. So a good many folks use heroin for the first time each day because their opioid prescription ran out.
This is all depressing stuff. A while back I wrote about our son’s heroic and successful struggle with opioid abuse, so at a visceral level I understand how depressing it is. To date he has buried at least nine friends and most died from opiate overdose. The ones I knew were good kids. Really good kids.
Here is the thing: Greed and profit are a large part of this problem. Two examples should suffice.
The first example comes from this week’s The New Yorker magazine.
As explained by New Yorker, OxyContin was developed by Purdue Pharma, a company in Connecticut. OxyContin contained oxycodone, a poppy-derived drug that was already being sold as Percodan and Percocet. But OxyContin took it to the next level because it was pure oxycodone (not mixed with aspirin or acetaminophen) produced in doses of up to 160 milligrams. Just so you know…that is a lot!
When Purdue consulted doctors prior to releasing OxyContin the doctors expressed concern about the potential for higher levels of addiction but Purdue released the drug without any research on its addictive potential. The FDA allowed the release of OxyContin and even stated that the drug was less addictive because of its patented time release formula. And, by the way, the FDA administrator who released that statement left the FDA and, you guessed it, took a job with Purdue Pharma.
OxyContin was prescribed for both severe and moderate pain levels. Within five years the drug was producing a billion dollars a year for Purdue Pharma.
Within a short time some abusers began to realize that OxyContin could either be ground into a powder and snorted or added to liquid and injected, thus overriding the time release agents. This as more and more doctors prescribed the drug in large quantities leading to a black market for those selling the pills they didn’t use. Some doctors began prescribing the drug like it was M&M’s.
Rather than taking responsibility for producing a highly addictive drug and promoting its wide distribution, Purdue began a campaign blaming OxyContin addiction on the addicts. Purdue’s ads stated that the drug provided twelve-hour pain relief, but that wasn’t always the case so patients took more than prescribed. And when patients began reporting itchy feelings and other symptoms of addiction to their doctors, Purdue coined the phrase “pseudo addiction”, again blaming the patient.
When Purdue Pharma came under attack by the medical community and others because people were crushing and snorting OxyContin and because of its high addiction rates, Purdue reformulated the drug making it more difficult to crush. Good idea, right? Well…except that the patent on OxyContin was about to expire and changing the formula kept generic options of the drug from being distributed. The company profited from the formula change. And the higher price of the reformulated drug drove those who could not afford it to heroin. In fact one academic paper found that the current heroin crisis is a result of the OxyContin reformulation. The correlation between the new formulation and rising heroin deaths is almost indisputable.
The bottom line is that in spite of evidence that OxyContin was extremely addictive, the pharmaceutical company profiting from it kept producing it, aggressively marketing it, and blaming negative consequences on the consumer. Mike Moore, Mississippi’s attorney general, said it best when he stated that tobacco companies and Purdue Pharma were similar because “they’re both profiting from killing people”.
Interestingly, I stumbled upon a second example published on the CNN website yesterday. A story similar to that of OxyContin but involving Endo Pharmaceuticals and its drug, Opana ER, a very addictive pain killer.
In 2012, according to CNN, Endo actually pulled Opana ER off the market because it was so addictive and because it was being crushed and snorted and was killing people. Endo also sued the FDA to keep a generic version off the market, ostensibly for the same reason (addictive and killing people). Very altruistic, right? Well…not so much.
As you may anticipate, Endo actually reformulated Opana ER with a hard shell to make it difficult to crush and snort. The new formula also included a few other new active ingredients. Addicts figured out how to bypass the crush/snort conundrum by liquefying and injecting it with a needle.
This summer the FDA found that reformulated Opana ER was no safer and, uncharacteristically, pressured Endo to stop selling it. I wish this had a happy ending, but it doesn’t. The FDA order only impacted the reformulated drug with the hard coating, not the original crushable/snortable version. You can probably guess what Endo did. The company contracted with another company to begin producing the original formula under a generic name. So Endo will be making a profit off a drug that in 2012 it said was too dangerous for patients. And Endo will now be responsible for a generic version of Opana ER, something it sued the FDA to keep off the market.
Endo has earned between $160 million and $380 million in annual profits from Opana ER.
I’m generally in favor of economic competition. Our cars, phones, clothes, and groceries are higher quality and less expensive because we have choices. Back when Ma Bell controlled almost all the phone services and phones, for example, they were still connected to walls with wires and did nothing but, you know, make calls. Because of competition my phone does much more. The same is true of other goods and services and the competition means less government regulation is necessary (though some is still required).
Competition doesn’t work with pharmaceuticals. Greed and profit cannot determine what drugs are released onto the market. Remember Martin Shkreli increasing the cost of Danaprim from $13.50 to $750 per pill? Remember the six-fold increase in the cost of the lifesaving Epi-Pen in a ten year period? Then think about the stories I just shared.
Saving lives and managing pain should not be based entirely on profits because the temptation to sacrifice lives for money is apparently just too great for some folks and companies.
Clay County, Kentucky. Population 21,000. Prescriptions for 2.2 million doses of hydrocodone and about 617,000 doses of oxycodone filled in the 12-month period ending last September. https://www.theatlantic.com/health/archive/2017/02/kentucky-opioids/515775/