In the last two weeks, what class of drugs was mentioned in the State of the Union address, was the subject of new guidelines proposed by the Centers for Disease Control and Prevention (CDC), was reported to kill more Americans than car accidents and whose users are 40 times more likely to abuse heroin? If you guessed opioids—these would be drugs like hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), hydromorphone (Dilaudid), codeine, and related drugs–you’re right.
It’s not clear whether this recent spate of news coverage is normal, but on the evening of January 22nd, while waiting on a delayed flight in an airport, I did a quick Google news search on the term “opioid,” not sure what to expect. I found that out of the top news postings appearing over the previous three days (Jan 19-22) there were 27 stories, from such diverse sources as the Huffington Post, WSKG news, a TV station serving the southern tier of New York and Northern Pennsylvania, the Sacramento Bee , the Central Penn Business Journal, the Boston Globe and NPR.
The key thing I gleaned from these stories was the overwhelming sense of an epidemic of such unmanageable and complicated proportions it’s hard to know where to start. According to the CDC it is estimated that in 2012 alone there were about “259 million prescriptions for opioids, [or] enough to give every U.S. adult a bottle of pills,” and the prescribing of these drugs has by some estimates quadrupled since 1999. The carnage, approaching 19,000 (2014 data) overdose deaths due to opioids, and the economic costs, pegged at more than $55 billion (in 2007 dollars), gives you some idea why these drugs continue to generate headlines.
What makes this so complex above the human stories of addiction, overdoses and deaths is the involvement of physicians genuinely interested in helping patients relieve their pain. As far as I can tell, there are three irrefutable facts about the opioid crisis:
Fact 1: There are real patients with real pain asking, sometimes begging their doctors to step up to the plate to prescribe them sufficiently strong drugs to do the job. One estimate from the Institute of Medicine says there are 100 million Americans suffering from chronic pain and somewhere between 5-8 million people who take opioids for that pain. Unfortunately opioids rarely “do the job”; even as they make people feel good in the short term, over time their effectiveness wanes and people become trapped by physical dependence on the drugs.
Fact 2: There is a very widespread problem of drug abuse, opioid-related overdoses and an increase in the use of heroin (for people who are so desperate when they can’t get their fix from the doctor). It doesn’t help that heroin is cheap and readily available. The underlying gravitas to these stories is that most people are getting these drugs not from pill mills (ie: home-based manufacturing) but from a prescribing pad.
Fact 3: This is an American problem, but also Canada and Australia have high rates of opioid use. For some drugs, the US tops the charts. For example, the per-capita ingestion of oxycodone in the US is the highest in the world, almost twice as high as the next country (Canada) and between five and ten times the rate of other developed countries (2013 data).
It’s hard to precisely apply the HealthNewsReview.org criteria to these stories as they are more like “social issue” stories than healthcare stories, yet a couple of notable points are worth mentioning.
In terms of evidence, opioids are mostly studied in short-term randomized controlled trials against placebo. After all, few patients in chronic pain are going to enroll in longer-term clinical trials because, as Janet Woodcock, head of the FDA’s Center for Drug Evaluation and Research told TIME Magazine: “It’s not practical for us to require people to go for a year on a placebo.” [Note: I couldn’t access the original TIME story].
Having said that, there are a range of other drugs for pain such as non-steroidal anti-inflammatory drugs (known as NSAIDS). Very few of the stories give any sense of comparative effectiveness of these drugs, and there is scant mention that the benefits of opioids for longer term, chronic use is scant and inconclusive.
Very few of the stories discuss the cost of opioids (which clearly can grow into multiple times the pharmacy cost when they are sold on the street to addicted people). The huge costs of opioid abuse are not just related to the effects on the patient, but also the family. An oxycodone addict might not be able to work or function well in society, have difficulty looking after him or herself and may neglect other important aspects of their lives like caring for children and other loved ones.
While the most severe adverse effects are almost always mentioned, (addiction, overdose and death) the lesser effects of opioids such as constipation, which can sometimes be severe and occasionally fatal, are not.
Nor do the stories state specifically which kind of patient would benefit from an opioid and which might not. Stories on opioids need to be more explicit in saying how much is too much (in terms of developing dependence) and what signs a person might have when they are getting addicted. These facts should not be corollaries to a story, they are must-haves.
One of the main unreported aspects of the opioid crisis is the involvement of the drug companies in this mess. There is pretty clear evidence opioid manufacturers have played a substantial hand in ramping up opioid prescribing in the world by buying patient groups, infiltrating physician education, and encouraging doctors to be more bold in prescribing these drugs to patients who are in pain, while downplaying the dangers of doing so. There was a US Senate Finance Committee investigation several years ago that looked into the links between the manufacturers of pain medications and the patient and professional groups working in pain. The conclusions, dear reader, are not pretty.
There was some good reporting in the stories I found but also some naiveté. For example the Sacramento Bee rightly noted that the conversation has changed “from one of punishment to treatment” where opioid use has become viewed more of a public health problem than a criminal problem. It quoted a study from the Annals of Internal Medicine which found that people who overdosed on opioids “still have an easy time getting prescriptions from the same doctors.” It noted, somewhat puzzlingly, that “the researchers didn’t know why doctors kept prescribing opioids to at-risk patients. We don’t either.” Hmm. Seemed like a missed opportunity to me. Couldn’t they maybe hazard a guess?
For some perspective I sent an email to Dr. David Juurlink, a Canadian expert on opioid research. He’s a physician at Sunnybrook Health Sciences Centre in Toronto and I asked him if he could map out the major issues about journalistic coverage of opioids and what is being missed. His response (which I condensed) formed a neat list:
For some original research on the reporting of opioids I found the work of Dr. Emma McGinty who examined opioid reporting up to 2012. Over a 15 year period (1998 to 2012) her team found that more than 75% of the news stories mentioned a cause of the crisis, most commonly illicit drug dealing by physicians, patients, and others (57%), followed by physician-related causes (47%), patient-related causes (32%), and pharmacy-related causes (34%). She noted that most of the news stories depicted individual abusers of opioids (2/3 of whom were involved in criminal activity).
While Dr. McGinty’s work may have suggested that “the national dialogue around opioid analgesic abuse still frames this issue predominantly as a criminal justice issue rather than as a public health problem or treatable health condition,” my assessment of my Google news search in January 2016 would show that we’ve moved past that.
I can’t conclude much else after my mini-survey of opioids in the news except to say the reporting of opioid issues continues unabated, and that much of the coverage skimps on key issues including the costs and harms of these drugs and the role of pharmaceutical companies in perpetuating this crisis. The issue is highly complex and explosive and the solutions seem as elusive as ever.
Alan Cassels is a drug policy researcher in Victoria, British Columbia and a reviewer with HealthNewsReview.org. The opinions he expresses are his own. Follow his writings on twitter @akecassels.