The Road to Hell is Paved with Good Intentions . . . and with the Influence of Big Pharma
The opioid epidemic is a special problem among those with mental disorders. Of 115 million opioid prescriptions distributed annually in the US, more than half were received by the 16% of Americans with mental disorders (Davis et. al 2017). The Austen Riggs Center doesn’t offer primary addiction treatment, but about half our patients, like Karen*, have a substance use disorder as part of a complicated clinical picture and have often been prescribed opioids unnecessarily.
When Karen first contacted Riggs for treatment we learned that, along with her struggles with depression, eating, post traumatic and personality disorders, she was receiving high doses of oxycodone for low back pain. Before we would consider admitting her we clarified from her referring treaters that there was in fact no real indication for a powerful opioid, and made it clear to them and to her that we were concerned she was treating emotional pain with drugs for severe physical pain. She would have to agree to come off the drug to be in treatment at Riggs.
As we try to address the problem and help people like Karen recover lives tangled in a web of addiction, we need to pay attention to lessons learned about how we got into this predicament so that we can hope to avoid future epidemics of this kind.
Simply put, the opioid epidemic is the naïve iatrogenic (i.e., caused by doctors) result of false medical “advances” that became institutionalized by regulatory bureaucracies corrupted by the undue influence of money from Big Pharma.
A 1986 study in Pain claimed that for non-cancer pain “narcotics can be safely and effectively prescribed to selected patients with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” Following this, pharmaceutical companies like Purdue and Johnson & Johnson began aggressive opioid marketing to doctors, while falsely claiming the risk of addiction was less than 1%. Big Pharma also began to fund organizations that would make pain elimination a priority. In 2001 the Joint Commission—the leading hospital accreditation agency and a recipient of pharma money to fund a pain management educational program—began to define attention to pain as the fifth vital sign and to require as a condition of hospital accreditation that all patients have pain management plans. In 2013 the US Government Accountability Office suggested the Joint Commission pain management education program was facilitating needless use of opioids.
In 1998 the Federation of State Medical Boards (FSMB), also a recipient of pharma money to develop favorable prescribing guidelines, released a policy reassuring doctors that they would not face adverse consequences for prescribing even large amounts of narcotics. In 2004 the FSMB, which by then had received more than $2 million from opioid manufacturers, issued a policy developed by people with links to opioid manufacturers, calling on state medical boards to sanction doctors who provided inadequate pain treatment to patients.
In 2007 Purdue Pharmaceuticals executives pleaded guilty to purposefully misleading and improperly educating doctors and patients, but by then the damage was done. By 2012, 259 million opioid prescriptions had been written, with annual sales in excess of $9 billion. And by 2013, overdose deaths surpassed auto accident deaths for the first time—a four-fold increase.
It’s no wonder that patients like Karen wound up on opioids without real indications. She did come off oxycodone with some difficulty, and began facing her emotional pain while in treatment at Riggs. Others are not so fortunate.
It is crucial that we learn from the opioid crisis to avoid repeating such needless problems on a societal level. For example, several states, including Massachusetts, are now legalizing recreational use of marijuana. Where might this lead us? Psychiatric research shows us that marijuana doubles the 1% baseline risk of developing the full syndrome of schizophrenia (Sewel et. al 2009), with some marijuana users developing other psychotic disorders or symptoms. So, if 50 million people across the country begin using legalized recreational marijuana, we might expect 500,000 new onset cases of schizophrenia, plus other new onset psychotic disorders. Are we ready for this?
*Karen is a fictional patient who is a composite of numerous others