The Opioid Epidemic: An Organizing Narrative

A seminal National Academy of Sciences report provides this summary about the causes of the opioid epidemic:

“Overprescribing (of opioid) was not the sole cause of the problem. While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are the root causes of the misuse of opioids and other substances. “ 56 (p1–9)

National Academies of Sciences, Engineering, and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: National Academies Press; 2017. [PubMed]

The popular narrative for understanding the Opioid Epidemic goes something like this.

The pain-opioid epidemic is killing and harming more and more Americans. The statistics are overwhelming. The personal stories are heartbreaking. The financial cost staggering. Millions of Americans are directly affected by the pain-opioid ecosystem*, and the rest are touched by the epidemic indirectly. The consequences for the individual, families, friends, communities and the nation have been devastating. Most tragically, opioid overdoses leading to the user’s death and serious morbidity have become an increasingly common experience throughout the US. In addition, the related issues of chronic pain and the consequence of the “War on Drugs” are having an ever increasing devastating impact on individuals, families, communities, nationally and globally. Rather than spending societal resources on social programs that promote individual and community well being, the drug war has left in its wake traumatized individuals and devastated impoverished communities.

According to the CDC, 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. Often, the individual suffering with Opioid Use Disorder had started their path after receiving a prescription from a medical provider, gotten it from a friend or family member, (either voluntarily or from un-secure medications at home). Interestingly, it has been suggested that the current Epidemic is partially caused by the economic and political realities confronting many of the “victims”.It is therefore not surprising that there is public outcry to address the Epidemic of Opioid Overdoses and Abuse which has emerged as a significant public health and national policy issue. The responding national efforts including the rare bipartisan CARA legislation passed by congress and signed into law by president Obama, CDC, FDA, DEA, as well as all major medical associations has been slow, with limited effectiveness. There is a growing consensus political (Globally, nationally most states, counties and cities) that there is a need to find a remedy for the consequence of opioid use.

The increase in opioid related injury and death has coincided with a dramatic increase in prescription drugs, especially opioid analgesics — a class of prescription drugs such as hydrocodone, oxycodone, morphine, Fentanyl, methadone used to treat both acute and chronic pain. International, national, state and local efforts have fallen short of providing effective solutions to this social challenge.The state and local responses have been more profound reflecting urgency of local communities coping with the devastation of the epidemic.

Often, the individual suffering with Opioid Use Disorder has started their path after receiving a prescription from a medical provider, gotten it from a friend or family member, (either voluntarily or from un-secure medications at home).

The opioid epidemic started at the turn of the century, continues to have a devastating impact on many individuals and communities throughout the United States. The statistics are overwhelming. The personal stories are heart-breaking.

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.

There is a growing number of Americans who are personally affected by The Pain-Opioid Ecosystem. The consequences for the individual, families, friends, communities and the nation have been devastating. Most tragically, opioid overdoses leading to the user's death and serious morbidity have become an increasingly common experience throughout the US.

The increase in opioid related injury and death has coincided with a dramatic increase in prescription drugs, especially opioid analgesics—a class of prescription drugs such as hydrocodone, oxycodone, morphine and methadone used to treat both acute and chronic pain. Often, the individual suffering with Opioid Use Disorder has started their path after receiving a prescription from a medical provider, gotten it from a friend or family member, (either voluntarily or from un-secure medications at home).

As more and more individuals became dependent on opioids, users seeking the drug turned to their physicians, and are on a course of chronic opioid Use. The public policy, public and media response contributed to more and more medical professionals limiting their opioid prescribing. Individuals who have become dependent on opioids who could no longer get their needed medication from “legitimate” sources turned to drug dealers. Illegal elements, especially drug cartels flooded the “street market” with cheap heroin often delivered intravenously by syringe, increasing the risk of overdose, as well as many transmittable diseases. Violence and theft accompanied the increasing market for “street” acquired opioids. Additionally, patients requiring pain medications that can improve their quality of life are denied needed care.

In many ways the opioid epidemic has come to highlight the pathology of our current political moment and represents the many underlying challenges faced by the body politic of the United states. I have come to realize that without a comprehensive understanding of the interconnected and complex bio-psycho-socio-political challenges of opioid use/ abuse and the related complex factors that fermented and now maintain this epidemic, the pathology within our body politic, the current efforts stemming from the SUPPORT Act and the implementation of recommendations made by the President’s Commission on Combating Drug Addiction and the Opioid Crisis, including funding allocations by the federal and state governments, the billions of dollars that states and local governments stand to “win” to help “fight” the epidemic, the promises made by presidential candidates, will have similar outcomes to all the trillions in taxpayer dollars that has been “spent” over the past 2 decades with continued OD death and destruction in communities.

It is therefore not surprising that there is public outcry to address the Epidemic of Opioid Overdoses and Abuse which has emerged as a significant public health and national policy issue. The responding national efforts including the rare bipartisan CARA legislation passed by congress and signed into law by president Obama, CDC, FDA, DEA, as well as all major medical associations has been slow, with limited effectiveness. There is a growing consensus political (Globally, nationally most states, counties and cities) that there is a need to find a remedy for the consequence of opioid use. There have been however, multiple initiatives by a host of stakeholders that have shown to be effective in targeting a limited aspect of the Pain-Opioid Ecosystem. Although encouraging the current approaches suffer from the constraints of the political and social structures and terms of deliberation that exist and lack a framework for comprehensive approach that can be implemented effectively within the pain opioid ecosystem.

Efforts to stem the epidemic have failed to change the number of fatalities and related morbidity. The politician, medical community and other stakeholders have failed to provide effective solutions to this societal challenge. The government's response has been ineffective to date. Efforts to stem the opioid epidemic through government action is costly. Efforts underway to treat the epidemic are a positive step however limited. Policies implemented have had unintended consequences.The increase in opioid related injury and death has coincided with a dramatic increase in prescription drugs, especially opioid analgesics — a class of prescription drugs such as hydrocodone, oxycodone, morphine, Fentanyl, methadone used to treat both acute and chronic pain. International, national, state and local efforts have fallen short of providing effective solutions to this social challenge.

The state and local responses have been more profound reflecting urgency of local communities coping with the devastation of the epidemic. Citizen groups seeking to address the need for adequate pain treatment, as well as those focused on decreasing the supply of opioids as well as treatment of addiction have grown substantially. During this period trends, public policy regulations have fluctuated between addressing pain (fifth vital sign) the growth of the addiction industry have failed to stem what has come (again) to be recognized as an epidemic.. ). The law enforcement/ criminal justice approach of the declared “war on drugs” other than costing wasted tax dollars, questionable techniques that impact civil liberties and collateral strategies. An issue that has garnered bipartisan collaboration at a time of highly polarized political environment. Passage of legislation, organizations, public events. Yet, the devastation of opioid overdoses continue, individual suffering with pain have a more difficult time accessing quality care.

The company that created and marketed the medication, the companies that distributed the medications, the insurance companies that paid for it, the governmental agencies that approved the medication, yet (failure) of government (federal, state and local) to regulate potentially dangerous substances, or to provide a framework to minimize their harm. the physicians that prescribed the medication, the patients who took the medications, the medication plans and PBM’s that distributed the medIcation, the people who stole the medication, the government agencies that didn’t regulate and prevent diversion, the congressional and executive branch for not monitoring, the media for not holding the stakeholders accountable.

The medical profession, including physicians, nurses, dentists, podiatrists have been challenged by the obligation to treat their patient’s pain conditions and the concern for side effects and the possibility of diversion. In the 1990’s, responding to the challenge of inadequate pain management for patients suffering with severe pain, the medical profession, supported by specialized professional associations guidelines, national regulatory organizations and public policy initiatives treated pain complaints with pharmaceutical agents aggressively promoted by drug manufacturers who earned billions of dollars from the expanded use of their products. Unscrupulous medical professional driven by greed opened “pill mills”, essentially selling drugs to drug dealers and opioid dependent individuals.

The story of the Fifth Vital Sign

In 1996, the president of the American Pain Society, Dr. James Campbell, said in a speech that “if pain were assessed with the same zeal as other signs (vital) are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign”. From this, the idea took hold that America was under-treating pain. This was viewed as an unnecessary epidemic, for medicine now had the tools to treat it…new formulas of opioids.

Efforts to regulate opioid prescription on the federal, state and local levels wee med by fierce opposition from well organized and announced lobby groups on behalf of the pharmaceutical industry. The Washington Legal Foundation, a nonprofit that litigates to defend “free-market principles,” threatened the CDC with legal action if the agency moved forward with the proposed opioid guidelines.

The U.S. Chamber of Commerce, a corporate lobbying group that represents opioid manufacturers, including Johnson & Johnson, issued a press release masquerading as a news story criticizing the CDC guidelines. (The U.S. Chamber operates a public relations effort dressed up as a bona fide media outlet called Legal Newsline, which it uses to disseminate stories that support the political priorities of its member companies.) At the time, The Intercept, reported on the organizations funded to attack reform of the opioid prescribing guidelines:

The Washington Legal Foundation, a nonprofit that litigates to defend “free-market principles,” threatened the CDC with legal action if the agency moved forward with the proposed opioid guidelines.

The Pain Care Forum is funded through contributions by Purdue Pharma, as well as major opioid manufacturers Cephalon, Endo, and Janssen, a subsidiary of Johnson & Johnson.

The Power of Pain Foundation, a group funded by Purdue Pharma, asked supporters to contact the CDC in opposition to the guidelines, claiming that “taking away pain medication and making providers afraid to prescribe due to your guidelines is only going to make more abusers, increase suicides, and tear apart the lives of millions.

The addiction industry flourished as well. However, for those that could afford this treatment, there were no clear guidelines or quality information about the facilities.

The government response anchored with the “war on drugs” approach focusing on criminal justice and law enforcement options has failed to “solve” the problems associated with opioid use. In the past few years federal efforts have focused more on limiting the supply of opioids through military and policing efforts, regulating opioid prescription, coordinating the multiple stakeholders, efforts to provide insurance coverage for opioid dependency medical and health services. In addition, efforts to create guidelines to assist in effective pain management has been initiated.

As more individuals, especially white middle class individuals, were being introduced to the legal system and the prison system becoming more costly, efforts have been made to address the challenge with a “public health” approach. Many states and local communities have developed programs to address aspects of the Opioid Ecosystem...including prevention efforts, targeting the supply of opioids, addressing the addiction and preventing death occurring due to overdose.

The public conversation has evolved during this period however has been limited in its scope, missing a valuable opportunity for meaningful political activity. Although there are many citizen and advocacy groups that have filled the social- political pace focusing on addiction, pain, restorative justice, few have leveraged the epidemic as a way to address the underlying political challenges in a comprehensive manner, informed by the complexity of the various aspects.

There have been however, multiple initiatives by a host of stakeholders that have shown to be effective in targeting a limited aspect of the Pain-Opioid Ecosystem. Although encouraging the current approaches suffer from the constraints of the political and social structures and terms of deliberation that exist and lack a framework for comprehensive approach that can be implemented effectively within the pain opioid ecosystem.Efforts to stem the epidemic have failed to change the number of fatalities and related morbidity. The politician, medical community and other stakeholders have failed to provide effective solutions to this societal challenge. The government's response has been ineffective to date. Efforts to stem the opioid epidemic through government action is costly. Efforts underway to treat the epidemic are a positive step however limited. Policies implemented have had unintended consequences.

Citizen groups seeking to address the need for adequate pain treatment, as well as those focused on decreasing the supply of opioids as well as treatment of addiction have grown substantially. During this period trends, public policy regulations have fluctuated between addressing pain (fifth vital sign) the growth of the addiction industry have failed to stem what has come (again) to be recognized as an epidemic.. ). The law enforcement/ criminal justice approach of the declared “war on drugs” other than costing wasted tax dollars, questionable techniques that impact civil liberties and collateral strategies. An issue that has garnered bipartisan collaboration at a time of highly polarized political environment. Passage of legislation, Organizations, public events. Yet, the devastation of opioid overdoses continue, individual suffering with pain have a more difficult time accessing quality care.

It is clear that a different narrative and approach to the problem of opioid use disorder is necessary. A narrative that recognizes the various stakeholders 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.

For example:

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

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. Opioids are the Opium of the People (Masses). Role of evidence based policy and legislation.

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

Questions associated with the opioid epidemic narrative:

Why focus on the pain opioid epidemic as an experiment in civic engagement?

What can we learn from the current opioid epidemic? And what can we do about it?

What can the opioid epidemic teach us about the challenges facing American Democracy, and more importantly provide an approach and tools for citizen engagement?