In Lessons Blog

Last month, the World Economic Forum released global statistics on life expectancy. Although most nations saw improvements in average life span, the United States experienced a decline for the second straight year.

As the media have report extensively, the opioid epidemic contributed significantly to the country’s shortened life span, killing 42,000 Americans in 2016. But who’s to blame for the opioid crisis?

So far, that question remains largely and surprisingly unanswered. When there’s a fire, a bridge collapse or a tainted food product, the public demands justice. Someone is identified and prosecuted for the preventable loss of human life. That hasn’t been the case with America’s opioid epidemic.

Understanding Opioid Addiction

From 2015 to 2016, the rate of opioid overdoses rose 28%. In states like West Virginia, 1 in 5 babies are born addicted to these dangerous narcotics and suffer painful withdrawals during the first two weeks of life. Drug overdoses are now the second leading cause of death for young adults, ages 18-30.

Many people begin their journey toward addiction with prescription medications, such as oxycodone. Once firmly in the grip of opioid dependency, some individuals find it cheaper and easier to purchase heroin, frequently cut with fentanyl or unusual agents like snake venom. As a result of growing addiction, Americans from all socioeconomic strata are dying unnecessarily. Although the consequences of addiction are finally gaining national recognition, little effort has been given to rooting out the culprits and holding them accountable.

Understanding Who’s Behind It

Year after year, drug makers, distributors, prescribers and politicians have contributed to the problem, by looking the other way and, in many cases, benefiting from the deaths that ensued. Here are some of the roles they’ve played in America’s ongoing epidemic:

  1. Drug Manufacturers. In the 1980s, physicians everywhere feared the consequences of opiate addiction and, as a result, came under fire by media and the public for under-treating chronic pain. Manufactures of these powerful narcotics seized the opportunity. They funded “educational programs” on pain management, which encouraged physicians to drastically liberalize the use of pain medications. They hired doctors to assure conference attendees that if pain is real, addiction won’t happen, and that overdosing is rarely a problem. In recent decades, manufacturers have made billions in profit as the death rate from abuse continues to rise.
  2. Drug Distributors. The middlemen who package and ship pharmaceutical products to pharmacies, hospitals and health systems include billion-dollar corporations like McKesson, Cardinal and AmerisourceBergen – known as the “Big 3.” By ignoring regulations that require them to halt suspiciously large shipments, these distributors have served as problem accelerators, pouring gasoline on the fire. In just one example, a small-town pharmacy in West Virginia received shipments of 9 million hydrocodone tablets over a two-year period. This facilitated the explosive growth of “pill mills” and abetted unscrupulous doctors in writing fraudulent prescriptions for cash. None of the distributors to this pharmacy reported any unusual activity to the FDA.
  3. Physicians. Doctors, and the overall health system, bear major responsibility for the opioid epidemic. Their prescribing habits represent a combination of fear and negligence. It is, after all, easier for doctors to prescribe increasing doses of narcotic painkillers for chronic musculoskeletal pain than it is to help their patients find safer treatment alternatives. And it is certainly more convenient to write a single prescription for 100 pills following an orthopedic procedure than it is write smaller ones while monitoring patient progress.
  4. Elected Officials. Federal and state politicians have contributed to the opioid epidemic by failing to hold drug companies accountable. Early on, many state legislatures passed mandatory pain-management courses, with curricula developed by paid consultants of opioid manufacturers. And while there has been much recent discussion in Congress about the need to address the epidemic, little has come of it. Some legislation has even worsened the problem. A 2016 bill co-authored by Congressman Tom Marino and Congresswoman Marsha Blackburn essentially stripped the DEA of its ability to stop suspicious drug shipments and enforce the Controlled Substance Act.

 

* Reader Survey: Who Do You Think Is Responsible For The Opioid Epidemic? *

 

Holding Leaders Accountable For The Solution

We may not be able to fully reverse opioid addiction, nor can we bring back those who have died from it. However, there are things we can do to (a) prevent future opioid dependence, (b) help those currently struggling with addiction, and (c) hold powerful individuals and companies responsible for America’s decline in life expectancy:

  1. Punish Drug Makers and Distributors. We should not expect powerful/profitable manufacturers and distributors to be part of the solution. Therefore, elected officials should pass legislation holding leaders in the drug industry personally responsible when they knowingly harm patients and negatively impact American health. In 2002, Congress passed the Sarbanes-Oxley Act (SOX) to protect investors and the general public from the fraudulent activities perpetrated by companies like Enron and WorldCom. We now need policy makers to step up and protect patients against America’s growing opioid addiction. By enacting legislation that prevents healthcare entities from making money off of addiction, healthcare CEOs would think twice before putting such profits ahead of patients.
  2. Curb Physician Prescribing Habits. Physicians should limit the supply of new opioid prescriptions to a five- to seven-day window. Emergency departments should dispense pills to patients for no more than 72 hours after discharge. All refills should be issued by the patient’s primary physician to prevent so-called “doctor shopping.” Pain management expertise and assistance should be provided before refills are written for any patient whose pain continues for more than two to three weeks without a specific cause. High-dose narcotics for patients with musculoskeletal problems should be avoided per widely accepted best practices. Finally, physicians should make a concerted effort to safely taper the total dose of narcotics over time for patients currently on opiods, and help them explore the use of alternative pain relief treatment.
  3. Pass Meaningful Legislation And Provide Public Services. Serious consideration should be given to repealing the Marino Act, thus restoring the DEA’s ability to enforce the laws and protect communities from self-serving individuals. Further, the expansion of social services is essential for addicted individuals, their families and their children. Many communities and schools provide education and support, but we need a more comprehensive effort to curb addiction. Some states already require drug testing as part of an initial driver’s license application. This enables officials to identify high school students with problems, allow treatment and provide services in a non-punitive fashion for those already addicted.

As Michael Bloomberg recently wrote, “real success requires much bolder leadership – and a far greater sense of urgency – from both elected officials and industry leaders.”

Simply put, the 42,000 annual deaths from opioids last year reflect the failures of the American healthcare system and its leaders.

Leadership is about doing the right thing, despite the appeal of the alternative. Those responsible for this epidemic should step forward, take responsibility and change their actions. But since we know that won’t happen, I hope elected officials will have the courage to pass legislation that punishes the perpetrators of this epidemic. If nothing is done, the problem will only get worse, and tens of thousands more will die each year.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD.

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Showing 3 comments
  • George Mathew
    Reply

    Robert – fully agree with this very succinct but accurate piece. If I may add, we seem to forget the “silent hands” of hospital administrators influencing physicians in order to get better CAHPS scores, and insurers who may use patient generated ratings as a means to compensate and/or influence reimbursement. These are rarely spoken of, and neither group almost never held responsible for poor consequences, but both strongly affect care, and I believe played roles in creating the Opioid Crisis

  • Jose Chavez
    Reply

    Dr. Pearl, PCPs should not be refilling narcotics because the vast majority of us have not had training in pain management. The medical groups need to invest in pain medicine specialists to treat this population.

  • Michael Kamen
    Reply

    Dear Robbie, all your points are so well taken, and obviously you cannot cover every nuance in a single article. I would only want to add that Low Back Pain is a symptom complex contributing to a significant slice of opioid use. Physicians, from Orthopedists, to Sports Medicine docs, to PCPs, seem at a loss to offer successful interventions to address these problems, and resort to opioids (especially under the pressures you have discussed).

    Dr. Stuart McGill, Professor of Spine Bio-mechanics at Waterloo University in Ontario, Canada, has for the past 35 years been doing world class research and patient care. Yet, even our physical therapists seem to be unaware of his work and continue to prescribe standard sets of unscientific exercises, many of which are causing further damage to patient’s already compromised lumbar spines. Please read his research, and use your influence to promote scientific, evidence-based medicine (readily available but apparently routinely ignored by the profession) in this critical area.

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