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The Narratives of the Opioid Epidemic    

 

The Opioid Epidemic and its Narratives  series of articles and tools, are a central aspect of the effort to better understand the challenges of the opioid epidemic as a symptom of pathology at the core of American democracy. The goal, consistent with The James Madison Project and Citizenism,  is to reclaim the role of the citizen within American democracy. This series of articles identifies the multiple narratives that have shaped the public conversation about the opioid -pain epidemic. These narratives are used to frame the complex nature of the opioid epidemic within the US body politic, and set the stage for a more in depth exploration of the ecosystems and stakeholders that have been central to the  current state of the opioid crisis. The narratives presented are not comprehensive, they are used to highlight specific aspects of the way the opioid challenge has been portrayed and to use it as a basis for case example for a more citizen oriented approach to understand and engage with the relevant stakeholders and provide a framework for addressing other social - political challenges. These narratives are at various stages of “completeness” and are occasionally updated. Elsewhere I outline the challenges and opportunities of the opioid epidemic that are consistent with The Pain Opioid Project, and explain in more detail The Medical Case Presentation general and more specifically The Pain Opioid Case Presentation.

The prevailing  popular narrative for understanding the opioid epidemic, driven by a well orchestrated public opinion campaign that was part of the strategy to impact the outcome of the case brought against Johnson & Johnson for creating a public nuisance, is limited and targeted for the financial outcome to abate the damage by the companies negligence.  The narrative summarized by Oklahoma Attorney General Mike Hunter in opening statements in the case against Johnson & Johnson that led to a guilty verdict in May 2019. 

"Many people wonder, “how did we get into so much trouble with opioids?”  

 

"How did this happened? At the end of the day, your honor, I have a short, one-word answer: greed."

 

The attorney general said evidence will show that drug companies "in their zeal to provide a magic drug ... ignored centuries of experienced, well-documented scientific histories of deadly addiction epidemics."

 

"Judge, money may not be the root of all evil, but I've learned this. ... Money can make people and businesses do very bad things."

It is clear that a different, more comprehensive  narrative and approach to the problem of opioid use disorder is necessary. A narrative that recognizes the various stakeholders and processes that actively and passively played and continue to play a part. Most importantly, a narrative that recognizes and explores the social, economic and political setting in late 20th century United States and the continued challenges facing the nation in the first two decades of the 21st Century.  The powerful socio-economic forces shaping our communities in the era of increasing globalization and financialization. The political elites that ushered in the era of neoliberalism, neglecting to assess the consequences of policies on increasing number of communities and populations.

After presenting a number of “personal” narratives, we present the prevailing narrative that has emerged in the media and the courts litigating the causes and consequences of the opioid epidemic. This narrative has been carefully woven to support the recently concluded Oklahoma vs. Johnson and Johnson case and the  current legal status of the multi-state and communities court case in progress in a federal court in Ohio. Building on a citizen oriented focus, we than provide a number of narratives that more accurately capture the causes and provide for potential "treatment" for the "epidemic". 

 

More specifically the narratives will explore some of the following areas and more:

 

  • The company that created and marketed opioids as non addictive medications, targeting vulnerable communities. 

  • The failure of the regulatory institutions to address the expected challenges associated with opioids. 

  • The failure of congress and state agencies to perform their function of oversight 

  • The failure of the medical community to accept responsibility that comes with the ability to prescribe dangerous drugs and their reluctance to engage in addressing social challenges that contribute to patient’s well being. 

  • The inadequacy of the media to provide the public deep, contextualized information that can impact the course of the epidemic, often resorting to sensationalization of the victims of epidemic. 

  • The failure to respond to changing economic conditions in increasing number of communities and the social forces causing  growing desperation, alienation, marginalization and hopelessness. 

  • Role of evidence based policy and legislation. 

  • Race inspired policing and  criminal justice responses leading to mass incarceration. 

 

 

We are also developing supporting content that includes:

  • The history and timeline for the current situation. 

  • Resources including congressional hearings, NAM,  strategic plans, legislation, reports from academic, non profit organizations, books,  and other related material.

  • For specific topics such as the media narrative we provide links to selective newspaper, magazines, social media,  and TV shows 

List of articles at various stage of development for The Narratives of the Opioid Epidemic..


 

The Opportunity of the Opioid Crisis

In many ways the opioid epidemic has come to highlight and act as a symptoms for many underlying challenges faced by the body politic of the United States. It is symbolic of the symptoms of the  social and political pathology in the US if not a major symptom. The many explanations for the initiation and continued use of opioids for each individual victim of the epidemic, the general forces contributing to the epidemic as well as the barriers to effectively addressing the challenges  reflect the personal, social, political dynamics that shape our politics.

Questions Associated with the Opioid Epidemic 

The opioid pain  epidemic raises multiple questions that are fundamental to our political environment. In addition the opioid epidemic raises can inform us of the challenges the epidemic presents for individuals, communities, organizations and the nation. The epidemic raises multiple questions that are fundamental to our political environment. Attempting to answer these questions, can guide us with  a citizen oriented framework to develop strategies and policies that address the needs of individuals suffering with pain, opioid use disorder, families devastated by the multigenerational impact of the disorder, communities devastated by responding to the epidemic. More importantly, the process can shed light on the complex interconnected stakeholders and processes that contribute to and maintain the epidemic. Framing and answering the questions can set us on a path to examine our body politic and to develop strategies to more effectively engage with- as citizens.

My Path to the Opioid Epidemic Project

During  the three decades I have practiced as a psychiatrist the most difficult and challenging individuals I encountered suffered with intractable chronic pain, opioid substance use disorders and people who have lost a child, sibling, parent or friend to opioid overdose. As a physician I have encountered parents who lost children to unintentional opioid overdoses, I have treated individuals who become suicidal due to persistent excruciating chronic pain. Additionally, I have seen the suffering of people who experience chronic pain and require opioid medications but must now face increasing obstacles to increasing scrutiny and regulations. Individuals who got embroiled in the legal system for experimenting or using drugs with substances.

The Opioid Epidemic Who is to Blame?

This article will explore the “culprits” that over the past few decades contributed to the Opioid Crisis faced by the US. The goal is to provide an in depth view for exploring the pathology of the US body politic and to provide a treatment plan that reflects a healthier approach to the function of government, the responsibility of the business sector, and the potential for citizen engagement. It will utilize systems thinking as a way to clearly illustrate the complex ecosystem of the pain opioid epidemic and to  highlight the various stakeholders, their roles and dynamics. 

Macklemore, Kevin and I: Confessions of a Drug Dealer  

A number of years ago I came across  Macklemore (Ben Haggerty) , a rapper from Seattle who has millions of dedicated fans, including former president Obama. My initial exposure to Macklemore was during the American Music Awards when he and Leon Bridges sang the song, Kevin. The song is dedicated to Macklemore's friend who died of an opioid overdose. The powerful song seems to provide an overview on the view of the public about the opioid crisis, in particular the role of the medical profession.

The Federal Government and its Narrative

The federal government has been a central player in the opioid epidemic. Shortly after being elected, President Trump declared the opioid epidemic a national emergency and tasked a presidential commission with addressing its cause and propose a direction for the nation. The report offers a narrative of the causes of the current state of the epidemic. After reviewing past epidemics, the report concludes that, “over 30 years ago, a sequence of events eroded fears of opioids, and the medical community once again relapsed into liberal use of medicinal opioids. Triggered by excessive prescribing of opioids since 1999, the current crisis is being fueled by several factors that did not exist in the 19th century: the advent of large scale production and distribution of pure, potent, orally effective and addictive opioids; the widespread availability of inexpensive and purer illicit heroin; the influx of highly potent fentanyl/fentanyl analogs; the transition of prescription opioid misusers into use of heroin and fentanyl; and the production of illicit opioid pills containing deadly fentanyl(s) made by authentic pill presses. Prescription opioids now affect a wide age range, families both well-off and financially disadvantaged, urban and rural, and all ethnic and racial groups. Historical precedent demonstrated that this crisis can be fought with effective medical education, voluntary or involuntary changes in prescribing practices, and a strong regulatory and enforcement environment. The recommendations of the Commission are grounded in this reality, and benefit from modern systematic epidemiological and large data analytics, evidence-based treatments, and medications to assist in recovery or rescue of an overdose crisis”.

The Opioid Epidemic and its Narratives Pharma

The masters of persuasion and deception, the Sackler family, with their army of well paid force of “drug dealers” were able to convince enough uninformed, physicians and dentists to prescribe opioids to their patients and thus unleashed the worst public health disaster in American history. In the past two decades, the actions by Purdue, the drug company privately owned by the family, has made billions pushing prescription pills with predatory marketing techniques, contributing to the death of more than 400,000 American of opioid related overdoses and millions are dependent on opioids and suffer from opioid use disorder. The products manufactured and marketed by the company, violated  “the state’s public nuisance law, creating a substantial health harm”, and as such the company and its owners should be found responsible for the damaged product and be held to pay for the abatement of the devastation it had caused in the various states.

The Un-epidemic and its Narratives 

We will be remiss if we didn’t explore the experts who haven’t bought into the Opioid epidemic narrative. 

The current opioid overdose crisis is actually part of a 40-year trend that is still headed upward, and current efforts to fight it may not be anywhere near enough, researchers said Thursday.

A new analysis of drug overdose deaths shows that while the drug of choice may change, and the kinds of people affected may change, the trend is clear: The number of Americans dying of drug overdoses has gone up exponentially for decades.

 

Media and the Opioid Epidemic

Media outlets coverage of the opioid epidemic illustrate the challenges and opportunities for the media in reporting and covering  complex social issues. As the shapers of public opinion, the media plays a crucial role within the pain opioid ecosystem. When complete this section will include the latest articles, social media, lectures and related information relevant to the Pain Opioid Epidemic Case.

Social Determinants  and the Opioid Epidemic  

As a psychiatrist I often encounter patients that suffer from symptoms and medical conditions that are the result of the interaction of biological, psychological, social, spiritual and  political factors. Current conceptualization of medical conditions is limited and is informed by the medical model that builds on pathogenesis, the examination of bio-psycho-social pathology While adequate for many of the clinical interactions, the complexity of the opioid crisis requires an approach beyond the medical, legislative, behavioral, educational, and legal changes, and it requires that these changes be made in coordination with each other, at the same time.   Leveraging my training as a physician and specialty in psychiatry, this article will expand on the “social determinants” that contribute to the opioid epidemic and provide a more comprehensive, holistic approach. Elsewhere I describe the public health focus  that highlights the social determinants — as opposed to a strictly medical and or law enforcement focus — that emphasizes the treatment and recovery needs of addicted patients. 

The Political Narrative:  The Oxy Electorate

The Banker’s Club is a term used by Gerald Epstein, University of Massachusetts, Amherst to describe the stakeholders that impact on the political, social, economic aspects of the ecosystem to the benefit of monied interests. 

 

“And when we have a financial system that gives priority to certain groups and not others, that is a mechanism for acquiring assets and realizing capital gains and appreciation with these assets. So these are legal and market processes. But undergirding all of these, and just we talked this morning about, is a political process, whereby wealth generates political power, which enables both rewriting private and public rules and furthering this wealth and income inequality. And there are many groups within society that contribute to this kind of political power that increase inequality, from elected officials who get campaign financing, from the financial sector from bankers, to independent central banks that maintain low inflation and give bailouts and access to bailouts to some and not to others, economists who rationalize these processes through theories such as shareholder value maximization and efficient markets, to regulatory authorities at the SEC and elsewhere. And we heard this morning about to lawyers who do the bidding of these elites to try to rewrite the rules. So I call this group of people that does all these things the Bankers' Club.

The Opioid Epidemic:  An Organizing Narrative 

Deaths from drug overdose have risen steadily over the past two decades and have become a leading cause of injury and death in the United States.  According to the CDC, between 1999 and 2017 more than 400,000 people have died from a drug overdose, becoming a leading cause of injury and death in the United States. In 2017, around 68% of the more than 70,200 drug overdose deaths involved an opioid. Countless more individuals have suffered severe medical, social, psychological and legal problems associated with opioid use.  In addition to the toll on individuals, the opioid epidemic has impacted rural, suburban and urban communities, rich and poor, republican and democratic, all racial groupings. In the same period, the “War on Drugs,” waged against illegal drug users has had devastating consequences on individuals, their families and communities. Efforts by government to stem drug use has militarized local police forces, and has introduced more vehicles for government intrusion into the private life of citizens. Individuals suffering with pain, have been forced to forgo treatment that has helped them function. Most tragically, many of the opioid overdoses leading to the user’s death and serious morbidity are preventable. Many of the social consequences were predictable and avoidable.  And perhaps most importantly, the political, social and economic conditions that contribute to the epidemic rarely addressed.  

 

“Death of Despair” and the Case for a Salutogenesis Approach to the Opioid Crisis​

Leveraging my training as a physician and specialty in psychiatry, this article will focus on the “social determinants” that contribute to the opioid epidemic. In particular I will utilize the concept of Salutogenesis, originally developed by Aaron Antonovsky (1979, 1987) to contextualize the epidemic as a biopsychosocial political spiritual process and provide suggestions for a holistic approach to address the challenges it presents. In the broadest sense, salutogenesis refers to a scholarly orientation focusing attention on the study of the origins of health, instead of the origins of disease. In essence, unlike pathogenesis the framing paradigm of allopathic medicine which focuses of disease creation and removal of pathology, salutogenesis is concerned with positive health, creating coherent living environments, strengthening socio-ecological health resources as well as strengthening the sense of coherence of individuals and groups. Viewed with a Salutogenic lens, the opioid epidemic provides a case study and framework to study other challenges confronting our society. For example, understanding the social and political issues associated with the epidemic, examining  the current healthcare system with a goal of identifying correctable challenges that can benefit patients, consumers and citizens.

 

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