Over the last year, 64,000 Americans have died as a result of opioid overuse.
After a 21% increase in opioid overdoses in 2016, Donald Trump has declared the addiction crisis a national emergency. Powerful prescription painkillers such as Oxycontin and Percocet are seen as a common thread in the countless stories of ordinary Americans falling into lifelong and often fatal patterns of addiction.
As a result, the US government is looking into pharmaceutical companies’ responsibilities when it comes to transparent marketing of these dangerous drugs. While those who have lost loved ones to the epidemic are rallying for opioid-based painkillers to be removed from the market altogether, government officials and healthcare professionals are considering how the drugs can be responsibly prescribed, minimising the chance of addiction and overdose.
From prescription to addiction
There are two types of pain that affect the human nervous system. Nociceptive pain is the sensation of actual damage to the body - for example, a pin prick or a burn. The mind’s ongoing perception of the injury, however, is known as neuropathic pain.
When an injury occurs, the skin senses pain and passes a signal to to be central nervous system via electrical pulses, directing the body to respond both actively, such as snatching a hand away from a hot stove, and passively, such as the release of stress-relieving hormones and endorphins.
Endorphins are a naturally-occurring opioid, inhibiting neuropathic pain by stopping electrical pulses from travelling to the central nervous system. In cases of chronic pain, however, neurological pathways become overloaded and natural endorphins aren’t enough. This is when doctors prescribe painkillers.
Opioid-based painkillers, however, affect far more than just pain pathways. The receptors that process opioids slow respiration, lower blood pressure, and decrease alertness, as well as shutting off the neurons that process pain and pleasure.
This floods the brain’s pleasure circuits with dopamine, which relieves stress and triggers a temporary wave of happiness, leading to an intense craving for more once the effects have worn off. It is this craving that forms the basis for addiction.
Addiction in America
According to the National Institute of Health, 21-29% of patients prescribed opioids give into this craving, exceeding recommended dosages and otherwise misusing medications. Meanwhile, a staggering 80% of heroin users in the USA began by misusing prescription opioids, moving onto stronger and more readily available illegal opiates.
These statistics have caused national outrage, and condemnation of the pharmaceutical industry itself. Ohio Attorney General Mike DeWine went as far as to file a suit against the industry for its malfeasance, citing “grossly misleading information about the risks and benefits of these drugs”.
The State of New Hampshire was hot on DeWine’s heels, filing suit against the creators of OxyContin, criticising the commercial way in which the drug was sold. “The company allegedly maintained a state sales force of four to six representatives who were each given the goal by the company of seeing six to seven prescribers per day,” the state reported.
With the government holding pharmaceutical companies in ever-closer scrutiny and the families of addicts freely voicing their devastation, the industry has a responsibility to reassure patients, stakeholders and the general public, offering transparent information about the risks and benefits of medications, and recommending opioid-free alternatives wherever possible.
Stemming the flow
Americans are now asking what their government will do to de-escalate the ongoing pandemic, and to ensure that it can’t happen again.
While Trump has stated that “This country and, frankly, the world has a drug problem … and we’re going to something about it,” experts are calling for definitive action, such as forcing down the cost of anti-opiate drug naloxone, funding medication-assisted treatment, and mandating thorough training on the dangers of opiates for all doctors and dentists.
The FDA is taking action to withdraw medications from the market wherever there is doubt that the benefits outweigh the risks. This June, Endo Pharmaceuticals were asked to remove an opioid painkiller from the market due to concerns over addiction.
Companies such as MAP Health Management and IBM Watson Health are turning to big data to address substance abuse, algorithmically building patient risk models and calculating how likely a user is to misuse opioids or relapse into previous addictive behaviours. By using platforms such as this one, providers can better anticipate and prevent further epidemics.
Similarly, the Massachusetts Department of Public Health has released a multi-state database that allows doctors to check a patient’s prescription history before prescribing a new drug, helping to curb individual use of opioids and contribute toward decreasing addiction nationwide.
Educating the public
Another crucial movement toward transparent, fully informed pharmaceutical marketing is Express Scripts’ Advanced Opioid Management program, which offers information and outreach to all patients who are prescribed an opioid painkiller for the first time.
So far the initiative has seen a 38% reduction in hospitalisation and a 40% reduction in ED visits during a pilot study of 100,000 patients. Consisting of an educational letter and a counseling call from a specialist pharmacist, the initiative helps patients to monitor and manage their own usage, and provides an outlet for concerns over addictive behaviours.
Over six months of follow up, patients who received both a letter and a counselling phonecall experienced a 19% decrease in opioid use over six months of follow-up.
A longer-term approach to the problem involves lessening the need for opioids by changing the way we think about pain. Rather than promoting a reliance on opioid painkillers, clinicians are being encouraged to recommend alternatives wherever possible.
While patients in the USA have come to expect the quick and instant relief provided by opioid medications, physicians can foster a more sympathetic approach to pain by prescribing more targeted medications, which address the cause of the pain rather than the neurological symptom.
The Colorado Hospital Association has launched an opioid safety pilot that encourages condition-specific medications for pain caused by kidney stones, migraines, back spasms and more on a case-by-case basis. Not only does this approach lessen the ongoing need for opioids - it also gives patients a greater opportunity to understand the conditions behind their pain.
The current pilot program is primarily to gather data, establish best practices and determine the efficacy of different opioid alternatives. However, it is already yielding promising results, pointing to a future where opioids are all but redundant.
Reinstating honest pharma
The idea of a future without any opioid medication is appealing - particularly to those who have lost loved ones to addiction and overdose - in reality, however the situation is more complex. Debilitating chronic pain can lead to a significant decrease in mental health and suicidal thoughts, and where there are no other options available, strong painkillers such as Oxycontin could be the difference between life and death.
Furthermore, a sudden move away from opioids could cause patients who are reliant on them to feel afraid of withdrawal and abandoned by their physicians. Tapering off a medication is a long, uncomfortable process in any case, and individual differences between patients need to be taken into account. We owe it to current opioid patients to avoid a culture in which taking strong painkiller is stigmatised.
However, as far as possible it is the duty of clinicians to prescribe responsibly, and of pharmaceutical companies to market drugs honestly. Patients should enter any opioid-based therapy with a rich and nuanced understanding of the risks and benefits, and how it will affect them as a person rather than a statistic.
They should work with their physicians to form an “exit strategy” from the very beginning of their therapy. This will ensure that patients are aware of the fact that tapering off medication will be a difficult process, but will also reinforce the idea that opioids are not a long-term solution.
Meanwhile, the pharmaceutical industry needs to come together to speak out against misuse of prescription drugs, to promote transparent marketing of painkillers, and to research alternative options for the next generation of chronic pain sufferers.
Only by opening the dialogue about opioids to include pharma companies, physicians and patients themselves can we work together to reduce the potential for lifelong harm done by addictive painkillers.
What do you think the pharma industry’s responsibility to opioid patients should be? Join the debate on LinkedIn.