The US opioid crisis: the public health epidemics that never should have happened

Pain Killer:An Empire of Deceit and the Origin of America’s Opioid Epidemic
DOPESICK: Dealers, Doctors & the Drug Company that Addicted America

In 2018, an opioid epidemic that began two decades earlier with OxyContin finally seized the nation’s attention. Over 250,000 Americans had died from overdoses involving prescription painkillers. Every day, hospital emergency rooms nationwide treated 1,000 people for abusing or misusing these drugs. Prescriptions written for narcotic painkillers—and overdoses associated with the drugs—had started to slowly decline. But counterfeit versions of fentanyl were rapidly driving up the overall numbers of overdose deaths.

The more you know about it, the more you get concerned about how this tragic epidemics could have been avoided. The details explained in a book written 15 years ago, and reedited now, are horrendous.
The connection between pharma sales promotion, lobbying and an inappropriate regulation is a dramatic story that has a known outcome: 65,000 deaths a year from addiction to oxycodone and fentanyl.

The “opioid crisis” is actually two separate crises, each with its own causes and solutions. One involves illegal narcotics, such as counterfeit fentanyl, and requires the attention of law enforcement as well as compassionate treatment for those addicted to these lethal drugs. The other crisis lies in the medical use of opioids, and its solution is much easier. There is no question that opioids, particularly when used at low dosages, work for some patients who can’t otherwise find relief. But if companies value their employees, if governments want to reduce the number of people addicted to opioids, if doctors want the best for their patients, then a new approach to the treatment of pain must become a priority. Many experts believe that most types of pain can be successfully treated with methods popular before the opioid era began, such as physical therapy, exercise, behavior modification, and non-narcotic drugs. Many institutions have begun to adopt these methods, and federal officials recently recommended that doctors limit opioid dosages and switch to another type of treatment, rather than raise the dosage, if patients don’t respond. Some states have taken the more draconian step of limiting the number of opioids a doctor can initially prescribe, to just a few days’ supply.

For two decades, drug companies such as Purdue used pain patients as shields and surrogates to advance their corporate interests. For pain treatment to change, patients will need to fight to put their concerns ahead of these interests, and doctors, employers, hospitals, and other institutions have to become fierce advocates for treatments outside the flood of narcotics that has proved so profitable and expedient for drugmakers and insurers. The lesson of the past two decades is a clear one. Change is not optional. It is essential if we are to alter the cascade of death, addiction, and despair that is now a fundamental part of American life.

In another recent book, you'll find the emotional side of the loss, how mothers lost their sons and the impact. Both books illustrate a national emergency that the government has recognised now, after two decades!

PS. Latest article in FT

PS. If you want to know what's going on in our country check this report. Five years growth in publicly funded opioid drugs: 45%!!!. Public health officials and prescribing physicians should read both books before it is too late.

Opioid crisis

Deaths of Despair and the Future of Capitalism

Beyond covid crisis there is still another one in US: the opioid crisis. The most relevant book on the topic is the Case-Deaton one.

We are telling the story in the way that we uncovered it, starting with midlife deaths of all kinds. We then focused on the immediate causes, which turned out to be deaths of despair among whites plus a slowdown and reversal in deaths from heart disease, which, until then, had been a main engine of mortality decline. Unfortunately, deaths of despair are not only afflicting middle-aged whites. While the elderly have been largely exempt, there have also been rapid increases in deaths of despair—particularly from overdoses and suicides—among younger whites. For whites between the ages of forty-five and fifty-four, deaths of despair tripled from 1990 to 2017. In 2017, this midlife age-group
had the highest rate of mortality from deaths of despair. But whites in younger age-groups were also doing badly and their deaths rose even more rapidly, accelerating in the last few years.

 Drug overdoses are the single largest category of deaths of despair. They are part of a broader epidemic that includes death from alcoholism and suicide, a reflection of the social failures that we have described in this book. Yet the behavior of the pharmaceutical companies caused more deaths than would otherwise have happened, showering gasoline on smoldering despair. Stopping the drug epidemic will not eliminate the root causes of deaths of despair, but it will save many lives and should be an immediate priority. Addiction is extremely hard to treat, even with the cooperation of the addict. There appears to be wide agreement that medication-assisted treatment can be effective, but it is not available to everyone, often because of cost.

Ps. Medicaments i risc de pneumònia

 Els analgèsics opiacis causen depressió respiratòria amb la hipoventilació pulmonar resultant;
alguns d’ells (codeïna, morfina, fentanil i metadona) també tenen efectes immunosupressors.
Incrementen el risc de pneumònia i la mortalitat respiratòria en un 40 a 75%.26,27,28
L’any 2018, uns 50 milions de persones als EUA (15% de la població adulta, 25% entre els més
grans de 65 anys) reberen una mitjana de 3,4 prescripcions d’analgèsics opiacis, i 10 milions de
persones reconeixien consum exagerat d’analgèsics de prescripció mèdica.29 A Europa en els
últims anys el consum d’opiacis suaus y forts ha augmentat, sobretot entre la gent gran.30,31
Fentanil i morfina son els opiacis forts més consumits, i més recentment oxicodona. El
tramadol, que és també inhibidor de la recaptació de serotonina, és l’opiaci suau més consumit.
En dos estudis observacionals de publicació recent, el consum de tramadol, comparat amb el
d’AINE, es va associar a una mortalitat 1,6 a 2,6 vegades més alta,32,33 sobretot en pacients
amb infecció i en pacients amb malaltia respiratòria.

Pharma, Big Pharma

 White Market Drugs. BIG PHARMA AND THE HIDDEN HISTORY OF ADDICTION IN AMERICA

A book to understand the contribution to addiction over a century.

By showing how the twenty-first-century opioid crisis is only the most recent in a long history of similar crises of addiction to pharmaceuticals, Herzberg forces us to rethink our most basic ideas about drug policy and addiction itself—ideas that have been failing us catastrophically for over a century.

This is the outline:

Introduction
The First Crisis
1 Drug wars and white markets
2 “Legitimate addicts” in the first drug war
3 Preventing blockbuster opioids
The Second Crisis
4 Opioids out, barbiturates in
5 A new crisis and a new response
6 White markets, under control
The Third Crisis
7 White market apocalypse
Conclusion: Learning from the past
Appendix: White market sales and overdose rates, 1870–2015

The profits of opioid addiction epidemic (2)

Empire of Pain. THE SECRET HISTORY OF THE SACKLER DYNASTY

The winner takes it all. And the winner is: the Sackler family. They are not alone, they needed accomplices. CDC says:

In 2019, an average of 38 people died each day from overdoses involving prescription opioids, totaling more than 14,000 deaths.1  While prescription opioids were involved in over 28% of all opioid overdose deaths in 2019, there was a nearly 7% decrease in prescription opioid-involved death rates from 2018 to 2019.

 From 1999–2019, nearly 500,000 people died from an overdose involving any opioid, including prescription and illicit opioids.

This rise in opioid overdose deaths can be outlined in three distinct waves.

The first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 19993.

The second wave began in 2010, with rapid increases in overdose deaths involving heroin4.

The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl5,6,7. The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine.

And regarding synthetic opioids, you'll find many details inside this book: "The empire of pain" that explains the largest man-made epidemic nowadays.

 My intention was to tell a different kind of story, however, a saga about three generations of a family dynasty and the ways in which it changed the world, a story about ambition, philanthropy, crime and impunity, the corruption of institutions, power, and greed. As such, there are aspects of the public health crisis that this book gives scant attention to, from the science of addiction to the best strategies for treatment and abatement to the struggles of people living with an opioid use disorder. The issue of pain and appropriate pain management is enormously complex, and while this book is highly critical of the mass marketing of opioids for moderate pain, it does not explore at any length the harder question, which is currently a matter of heated debate, about the long-term therapeutic value of opioids for severe chronic pain. 

Beyond that, somebody should remember that the regulator was and is on vacation...

Highly recommended. 

Why we must not let the tech and drug industry forge the future alone

On the tech industry by Martin Wolf in FT

Selected statements on 7 reasons

What are the economics of these extraordinary valuations? The answer must be monopoly. As of September 30, the book value of Apple’s equity was $134bn, while its market valuation was close to $900bn. The difference has to reflect the expectation of enduring “super-normal” profits. This may not be the product of malign behaviour, but of innovation and economies of scale and scope, including the network externalities that lock in customers. Yet only monopoly could deliver such super-normal profits

How should we think about competition policy for businesses that benefit from such powerful monopoly positions? A question is whether these positions are temporary — as the great Austrian economist, Joseph Schumpeter, with his idea of “creative destruction”, would argue — or lasting. This suggests a host of responses, but one at least seems straightforward. Schumpeter would argue that new entries are a necessary condition for eroding such temporary monopolies. If so, the technology giants should be strongly deterred from buying up their potential competitors. That must be anti-competitive

Yet these enormously profitable businesses are parasitic on the investments in collecting information made by others. At the limit, they will become highly efficient disseminators of non-information. This links to a further point: they can, as we now know, be used by people of ill will for the deliberate dissemination of dangerous falsehoods. These facts raise huge issues.

Finally, the activities in which the technology industry is now engaged — what Andrew McAfee and Erik Brynjolfsson call “machine, platform, crowd” — are going to have a huge impact on our labour markets and, if artificial intelligence continues to advance, on our very place in the world.

What are the implications? They are that our futures are too important to be left to the mercies of the technology industry alone. It has done magical things. Yet nobody elected it master of the universe. Policymakers must get an intellectual grip on what is happening. The time to begin such an effort is now

On a particular drug company, in Project Syndicate:  The Opiate of the Bosses

Business ethics are again making headlines. This time, the focus is on the rapidly escalating opioid crisis that is destroying lives across the United States. While there is plenty of blame to go around, the largest share of the guilt belongs squarely on the shoulders of the major drug companies – Big Pharma.

The cynicism with which pharmaceutical firms have encouraged opioid drug use is appalling. Providing far too little analysis and oversight, they distribute opiates widely, alongside misinformation about how addictive the drugs truly are. Then they entice doctors with inducements and giveaways – including trips, toys, fishing hats, and, in one case, a music CD called “Get in the Swing with OxyContin” (one of the most popular opioids) – to prescribe them.

In 2007, several executives of the parent company of Purdue Pharma, which markets OxyContin, pleaded guilty to misleading doctors, regulators, and patients about the risk of addiction associated with the drug. The company was hit with some $600 million in fines and penalties.

An opioid epidemic documentary and the worrying situation in France and Catalonia

 Mort amb recepta (catalan version)

Annual report on Drugs in Catalonia (p.152)

Oxicodone in Catalonia: from  879.775 DDD in 2014 to 1.003.355 in 2019, a 14% increase. Tramadol: from 11.790.547  DDD in 2014 to 17.038.936 in 2019, a 69% INCREASE in 5 YEARS (p.152) 

Daily Dose per Inhabitant (DDH)Tramadol: from 4,27 to  6,16 a 44,2% INCREASE in 5 YEARS

Documental

A worrying  french situation

The documentary: Etats-Unis, la mort sur ordonnance

Nan Goldin denounces: Who profits form the opioid crisis?

La geopolítica dels opioides sintètics

 Why America Is Struggling to Stop the Fentanyl Epidemic. The New Geopolitics of Synthetic Opioids

THE ECONOMIC TOLL OF THE OPIOID CRISIS REACHED NEARLY $1.5 TRILLION IN 2020

Hi ha dos tipus d'epidèmies les naturals i les artificials. Aquesta classificació no la trobareu als llibres d'epidemiologia. Les artificials són les que crea l'home amb l'objectiu de destruir la humanitat, i que generalment persegueixen poder i diners.

Hi ha una epidèmia artificial que ha agafat molta volada des de fa més de dues dècades als USA, es tracta de l'epidèmia dels opioides sintètics, del fentanil. Em refereixo a l'ús recreatiu del fentanil, és clar. L'ús mèdic està ben definit i l'efectivitat desmostrada. He escrit repetidament a aquest blog sobre aquesta qüestió.

Llegeixo els articles destacats de l'any a Foreign Affairs i en trobo un que m'interessa especialment i va sobre la geopolítica dels opioides sintètics. Als USA hi ha hagut 73.654 morts el 2022 fruit de sobredosi de fentanil. La suma va creixent any rera any.

L'article explica que tot el fentanil que circula als USA prové de la Xina i Mèxic i es pregunta del perquè del fracàs de la lluita contra la distribució d'aquesta droga i del que caldria fer. Tot el que s'ha fet fins ara no ha assolit el que pretenia i assenyala una estratègia geopolítica a endegar.

El cost que representa aquesta epidèmia als USA ha estat quantificat en 1.500.000.000.000$, és a dir un bilió i mig durant l'any 2020. Aquesta és una xifra descomunal, 6 vegades el PIB de Catalunya. Em fa dubtar del seu càlcul, però és una estimació oficial amb metodologia contrastada.

Aquesta setmana ja sabem que la droga ha arribat al mercat i·lícit a Mallorca. Fa uns mesos es va presentar el documental sobre la petjada del fentanil a Catalunya, on es diu que no s'ha decomissat encara però tot assenyalaria que ja circula. Motius més que suficients com per la preocupació i la necessitat de reacció immediata. El que cal fer segons l'OCDE és això.

Carry Mae Weems a Foto Colectania

The profits of opioid epidemic (3)

 The Hard Sell. Crime and Punishment at an Opioid Startup

An absolute public health crisis, a crime without punishment. The outrageous behavior of an obscure drug company, Insys Therapeutics.

Opioid epidemic as a crime (3)

 Unsettled. How the Purdue Pharma Bankruptcy Failed the Victims of the American Overdose Crisis