The US opioid epidemic

Opioid Map

The United States is in the midst of an escalating epidemic of opioid-related drug addiction and overdose-related deaths. Between 2000-2015, more than 500,000 mostly white working-class people, in small towns and rural communities, died prematurely from both illegal and legal opioid drug use. But legal prescription opioids now kill more people than both heroin and cocaine combined. The responsibility for this lies with criminal pharmaceutical companies which manufactured the opioids, bribed doctors to prescribe them, and, playing down the risks, pushed them onto the public in the pursuit of profit. There is no end of the epidemic in sight, and it is having devastating consequences.

Racist drug war

Prescription opioids are medication developed specifically to treat severe pain, for instance, in cancer patients. The bald facts are that between 1999 and 2016, more than 200,000 people died in the US from overdoses related to prescription opioids. In 2016, more people (34,572) died after overdosing on prescription synthetic opioids such as fentanyl (20,145 deaths), or natural and semi-synthetic opioids such as oxycodone (14,427 deaths), than died from illegal heroin usage (15,446 deaths), cocaine (10,619 deaths) and methadone (3,314 deaths) (US Centers for Disease Control and Prevention (CDC) September 2017). This followed 2015 when more than half the 52,404 deaths resulting from drug overdose were the result of prescription opioid use, 27,176 in all. Opioids such as fentanyl are 50-150 times more potent than morphine, and have been criminally but legally prescribed for people who have no clinical need for such medication. Even those who have died from illegal opioid use such as heroin often first became addicted to legal synthetic prescription opioids.

Although President Donald Trump declared the opioid epidemic a National Health Emergency in October 2017, the focus remains on punitive criminalisation of illegal drug usage, rather than on treatment of addiction. There has been no let-up in the drug war against poor and black people despite efforts to decriminalise or legalise banned substances like marijuana by anti-prohibitionists. In October 2016, the FBI reported marijuana-related arrests of more than 600,000 people in 2015, mostly for possession rather than for sale or cultivation. Arrests for illicit drug use in the US reached 1.57 million in 2015. Black people comprise 13% of the population and 13% of illegal drug users, but make up 29% of drug arrests and 35% of drug state prisoners.

Prescription opioids

Overall, the opioid epidemic is costing an estimated $504bn annually in health care expenditure, lost wages, sick days and criminal justice costs. The scale of use is phenomenal: in 2014, 245 million prescriptions for opioids were issued; by June 2016, more than 650,000 opioid prescriptions were being dispensed daily. Opioids are widely passed on and misused, and the major source of diverted opioids is doctor’s prescriptions. Although people of varying class, ethnic and age backgrounds have been affected, the majority of victims have been young, teenage, white working-class people in neglected post-industrial rural regions of the US. A 2016 study found that the vast majority of children and adolescents under 19 years of age who overdosed on prescription opioids were white (73.5%). Between 1999 and 2014, overdose rates were highest among people aged 25-54 years, and higher among the  non-Hispanic white and American Indian or Alaskan Native populations, compared to non-Hispanic blacks and Hispanic communities.

On 23 January 2018, a member of Trump's Commission on Combating Drug Addiction and the Opioid Crisis, Patrick Kennedy, called the work of the commission a ‘sham’ and ‘charade’. The emergency declaration ‘has accomplished little because there's no funding behind it’. Of the 11.5 million US citizens estimated to have misused prescription opioids, including 969,000 children aged 12-17, three million young adults aged 18-25, and the 2.6 million people diagnosed with opioid-use disorder (OUD) in 2015, only 1.1 million people received treatment. In 2015, opioid poisoning claimed the lives of 51 children under the age of five (CDC).  

Big Pharma bribes

Behind the crisis lies the privatised US health care system. Doctors and nurses have benefited materially from prescribing opioids and have been bribed by pharmaceutical companies to ‘keep them rolling’. Hundreds of ‘sham’ speaking programmes and ‘educational’ events for doctors have been held at upscale restaurants. One New Jersey doctor received $136,768 in payments from Insys Therapeutics. Insys spent $1.32m on speaking fees to doctors in 2016. In December 2016, several Insys executives and managers were arrested and charged with a ‘nationwide conspiracy to bribe medical practitioners [many of whom operated pain clinics] to unnecessarily prescribe a fentanyl-based pain medication [Subsys] and defraud health care insurers’ (US Department of Justice).

Subsys is a potent and addictive narcotic intended to treat cancer patients suffering intense episodes of breakthrough pain. But in exchange for bribes and kickbacks, the doctors wrote large numbers of prescriptions for patients most of whom were not cancer sufferers. Insys marketed the drug ‘off-label’ – ie for other types of pain for which it wasn’t approved. Furthermore, Insys targeted doctors they knew were not cancer doctors. More than 80% of Subsys scripts were off-label by 2015. One Insys salesperson’s motto for patients was to ‘start them high and hope they don’t die’. In 2016, 631,000 doctors received $2.8bn directly from Big Pharma, for meals, travel, consulting, speaking fees and so on.

Numerous US cities, counties and states have sued various makers of opioid painkillers for promoting  the epidemic, downplaying the risks of the drugs and turning a blind eye to the opioid diversion. Endo, Johnson & Johnson's Janssen, Teva, Allergan and Purdue Pharma have all been named in an opioid marketing investigation by attorneys general from 39 US states. Major drug distributors in the US such as Mallinckrodt, Cardinal Health, AmerisourceBergen and McKesson have paid fines to avoid further legal action. Mallinckrodt is one of the largest manufacturers of oxycodone, and in 2016 posted $3.4bn in revenue and a $489m profit. 500 million of Mallinckrodt's oxycodone pills ended up in Florida between 2008 and 2012 — 66% of all oxycodone sold in the state. Yet the US government has taken no legal action against Mallinckrodt. Instead, the company agreed to pay federal prosecutors a $35m fine and admit no wrongdoing. Mallinckrodt held that the DEA has never required manufacturers to know their customers’ customers and that the agency provided the company with conflicting advice about its responsibilities under the law. The DEA did not act to reduce the amount of narcotics the company was permitted to sell, nor provide guidance on how to track suspicious orders. For a company the size of Mallinckrodt, a $35m fine is ‘chump change’. The DEA, FDA and FBI have allowed the $13bn-a-year opioid industry to get away with misleading marketing and the aggressive, profit-pursuing distribution of opioids. All these drugs – their manufacture, sale and addiction warnings – were approved by the FDA, a key defence cited by Big Pharma.

Possible solutions

A person taking a relatively low dose of prescribed opioids is 15 times as likely to develop an opioid-use disorder (OUD) as a person who has not been prescribed any opioids. There is no safe level of semi-synthetic opioids. They should immediately be removed from the market and restricted to treating severe pain from life-limiting illnesses. Many opioids are available in ultra-high dosages that exceed the CDC’s own safe limits: ‘Even relatively low dosages (20-50 morphine milligram equivalents (MME) per day) increase risk of overdose and death.’

Immediate release (IR) and extended release (ER) hydromorphone, IR and ER morphine, IR and ER oxymorphone, ER hydrocodone, methadone, and IR transmucosal fentanyl are also available in ultra-high, dangerous doses of up to 240 MME in a single tablet or dose. Higher doses do not reduce pain over the long-term, so the only beneficiaries are the criminal pharmaceutical corporations, drug distributors and opioid pushers such as McKesson. The FDA has already been petitioned to remove these drugs from the market by Alaska Department of Health & Social Services, the National Safety Council, Physicians for Responsible Opioid Prescribing, the American College of Medical Toxicology and FED UP! Coalition to End the Opioid Epidemic.

In addition, the current practice of rewarding drug sales representatives with large bonuses based on the number of drugs they sell should be abolished, as should direct lobbying of doctors by Big Pharma. Education of medical personnel and the public should be increased on the lack of evidence supporting the long-term use of opioids for non-cancer related pain, their toxicity, potential fatal interactions between opioids and other drugs (including alcohol), and the lack of clinical trials comparing opioids to other alternative forms of pain relief, such as paracetamol and NSAIDS (non-steroidal anti-inflammatory drugs) such as aspirin and ibuprofen.

Trump’s efforts to repeal Obamacare and strip funding from Medicaid will adversely affect any fight against the opioid epidemic. The public health emergency to combat the opioid crisis should be superseded by a national disaster declaration. The difference is in the scale, speed and scope of funding to tackle the crisis. Medication such as buprenorphine and clinically-administered methadone, one of the best ways to treat opioid addiction and proven to lower overdose rates, are out of reach geographically and economically (sublocade containing buprenorphine is $1,580 per monthly dose) for addicts living in the more rural parts of the US. People need cheap, affordable treatment, not racist, thuggish arrests. Finally, the CEOs of Purdue Pharma, Janssen, Teva, Allergan, Mylan, Endo, Mallinckrodt, Cardinal Health, AmerisourceBergen and McKesson should be arrested and charged with manslaughter. Not just fined – charged.

That an opioid epidemic can be solved was proved by the Chinese Revolution. In 1949, 50 million of China’s 400 million population were drug addicts, a legacy of Britain’s Opium Wars on the Chinese people. By 1974, drug addiction was a memory (Monthly Review Online, 17 January 2017). That was because the socialist state put the welfare of the people first. In countries like the US and Britain where neoliberalism rules, the interests of working class people do not feature at all. And we should  be worried, as the opioid problem is growing  here: in England, the number of patients admitted to hospital for overdosing on opioid painkillers doubled over the decade to 2016 to 11,660 people, and according to NHS Digital, the number of opioid prescriptions also doubled, to 24 million in 2016. Since December 2016, 88 deaths in Britain have been linked to fentanyl, which killed the singer Prince. There are already 330,445 high-risk opioid users in the UK, the highest number in the EU (Europe Drug Report, 2015). These alarming figures underline the need to fight to defend the NHS.