An epidemic of opiate abuse and addiction continues to ravage communities throughout the United States. Approximately 183,000 Americans succumbed to opiate overdoses between 1999 and 2015, and countless more have suffered the ancillary effects of addiction that include the loss of employment, shattered relationships, chronic and debilitating health conditions, and encounters with law enforcement officials and the criminal justice system, to cite but a few (U.S. Senate Homeland Security & Governmental Affairs Committee Report, 2018). By some accounts, this scourge is partially responsible for recent decreases in average life expectancy – the first of such decreases recorded in decades (Carroll, 2019). The opiate abuse epidemic is surely not the first of its type nor is it likely to be the last, however. But it is particularly insidious insofar as its origins may be traced to our medical and pharmaceutical industries. Tragically, the industries charged to heal and to promote population health have been repeatedly found culpable in the proliferation of drugs whose use should be limited to select health conditions accompanied by severe and intractable pain.
In his testimony before the U.S. Senate, Dr. Andrew Kolodny, a preeminent authority in addiction medicine, described an unmistakable correlation between a rise in “legitimate” prescriptions for opiate medications and the incidence of addiction and overdose events (Kolodny, 2018). This trend began in the 1990s and rose unabated until quite recently. Dr. Kolodny attributes this to multiple agents including drug company sales representatives, professional societies, hospital and healthcare accreditation organizations such as the Joint Commission (formerly The Joint Commission on Accreditation of Healthcare Organizations), and medical boards, among others. By his account, all were complicit in the reversal of a longstanding tradition that had discouraged the administration of opiate medications in all but the rarest of circumstances.
In 2001, The Joint Commission issued revised standards for the assessment and management of pain that, by many accounts, revolutionized the healthcare establishment’s orientation toward pain and the use of opiate medications for its relief. It would be unfair, however, to attribute the ensuing epidemic of opiate drug abuse and addiction solely to The Joint Commission standards. Several years before they were released, aggressive marketing campaigns by pharmaceutical industry representatives produced an unprecedented increase in opiate drug prescriptions. For instance, Purdue Pharma’s promotion of OxyContin, an opiate-based analgesic, generated a near exponential rise in sales of the drug during the five-year period that preceded the release of The Joint Commission standards (Van Zee, 2009). Purdue’s “success” was not merely a product of astute marketing tactics, however. It followed a campaign that dissembled and deceived the public and the many healthcare practitioners on which it depends for accurate and reliable information. This campaign repeatedly minimized the risk of iatrogenic addiction, a tactic that led many providers to prescribe the drug more liberally than they would if they possessed a more sober appraisal of its risks. Purdue regularly employed other measures of dubious legality but undisputed efficacy that yielded bloated balance sheets and satisfied shareholders. In these respects, Purdue was not unlike other pharmaceutical companies whose misdeeds have been thoroughly publicized in recent years. A Senate investigation of Insys Therapeutics revealed systematic manipulation of insurers and pharmacy benefit managers that enabled it to circumvent prior authorization procedures designed to limit prescriptions of Subsys, a fentanyl-based product patented by Insys for the treatment of breakthrough cancer pain (U.S. Senate Homeland Security & Governmental Affairs Committee Report, 2018). Insys representatives repeatedly defrauded insurers and pharmacy benefit managers by impersonating healthcare providers or falsely claiming they were operating on providers’ behalf. The McKesson Corporation, Cardinal Health, Janssen Pharmaceuticals (a subsidiary of Johnson & Johnson), and other manufacturers have recently endured heightened scrutiny (and countless legal and civil claims) for their roles in perpetuating this epidemic.
The events of the past 30 years portray a cautionary tale of an unholy alliance between our pharmaceutical industry and medical establishment. This alliance elevates pecuniary interests above clinical considerations and continues to pervade healthcare practices. It has played a particularly sinister role in the opiate abuse epidemic, but its influence is surely not limited to this crisis. It is both embedded in and a byproduct of a capitalist system that necessitates the continual generation of profits for investors, shareholders, and other financial stakeholders. Such a system, when applied to public goods such has healthcare, is bound to produce egregious conflicts of interest and other failures at the expense of our population health. More than 50 years ago, Nobel Laureate Kenneth Arrow offered a detailed explanation of the inapplicability of free markets to healthcare, and the opiate abuse epidemic is merely one manifestation of its misapplication (McKee & Stuckler, 2012). By Arrow’s account, in order for free markets to succeed in this domain they must transform healthcare into a commodity to be regularly sold to prospective buyers irrespective of buyers’ actual needs or resources (Arrow, 1963). For instance, older individuals and those with chronic or comorbid health conditions often have the greatest need for healthcare but few resources with which to purchase it. Thus, as markets cannot profit from the provision of healthcare to our most vulnerable citizens, they must rely on other populations to provide returns on investment. Such prima facie evidence of the free market’s failure to meet our population health needs warrants a radical reevaluation of our healthcare financing and delivery systems.
Recent developments suggest the opiate drug abuse epidemic will eventually abate, like the many others that preceded it. The Department of Health (DOH) recently announced opiate overdose deaths declined 15.9 percent in 2018 compared to 2017 (outside of New York City), the first decrease in 10 years (New York State Department of Health, 2019). This may be attributed to several factors including the increased availability of Medication Assisted Treatment (MAT) for individuals with substance use disorder and the development of additional resources that more readily meet the needs of those in crisis (e.g., open access centers, mobile and telehealth services, etc.). This is welcome news, and it suggests the foregoing measures and others recommended by the New York State Heroin and Opioid Task Force are beginning to produce their desired effects. Nevertheless, this achievement was 10 years in the making and required nothing less than the collective will of the government, healthcare providers, individuals, families, and many other stakeholders. It would be naïve, however, to expect these efforts to continue to persevere in the face of countervailing pressures exerted by actors with seemingly unlimited resources and an economic system that facilitates their exploits.
The author may be reached at (914) 428-5600 (x9228) and by email at abrody@searchforchange.org.
