While traveling over the holidays I encountered something new on the side of the Pennsylvania Turnpike. Well-accustomed to seeing fast-food restaurants attached to gas stations catering to truck-driver and family vehicle alike, I was surprised to find a small emergency medical office occupying the space usually reserved for a Wendy’s or Subway.
What made the location of this particular office noticeable was what it represented. While I have no reason to doubt the professionalism or good intentions of the health care providers that occupy this roadside “doc-in-a-box,” surely, I thought, there is some distinction between harried travelers in search of sustenance at a highway rest stop and patients in search of medical care, right? Or have the two industries come to resemble each other so intimately that the distinction between patient and consumer breaks down altogether? Have Benzodiazepines functionally become Diet Coke—little more than the fuel required to keep this car full of cooped-up children and their sleep-deprived parents on the road?
This week, we bring you stories on the opioid crisis in America—when it began, who it affects, who (if anyone) is to blame, and what (if anything) can be done about it.
To get a sense of the crisis, we start with Eric Eyre’s important and revealing reporting on the opioid crisis in West Virginia for the Charleston Gazette-Mail. Published in two parts, Eyre’s investigation into the opioid supply chain begins with a seemingly obvious statement: “follow the pills and you’ll find the overdose deaths.” The results of this quest, however, are startling:
The trail of painkillers leads to West Virginia’s southern coalfields, to places like Kermit, population 392. There, out-of-state drug companies shipped nearly 9 million highly addictive—and potentially lethal—hydrocodone pills over two years to a single pharmacy in the Mingo county town…In six years, drug wholesalers showered the state with 780 million hydrocodone and oxycodone pills, while 1,728 West Virginians fatally overdosed on those two painkillers, a Sunday Gazette-Mail investigation found. The unfettered shipments amount to 433 pain pills for every man, woman and child in West Virginia.
While each stop on the opioid supply chain is regulated to some degree, Eyre’s reporting reveals negligence or corruption at every turn. Writing for the website STAT, David Armstrong uncovered important documentation showing the power of pharmaceutical companies to thwart regulation from state agencies. According to Armstrong, when West Virginia state officials noticed a striking uptick in overdose deaths in 2001, they sought to implement a statewide system where prior authorization from insurance companies for prescriptions for OxyContin in particular. While this additional step does not prevent prescription drug abuse, recent studies have shown that it does reduce the rates at which opioids are prescribed, largely because insurance providers can notice over-prescription and deny reimbursement.
Unsurprisingly, large pharmaceutical companies fought prior authorization efforts at every step. In West Virginia, they did so by hiring a “pharmacy benefits manager” who would receive large “rebates” in exchange for successfully keeping co-pays low on particular drugs tied and prior authorization initiatives at bay. Details of this effort came out in a suit against OxyContin maker Purdue Pharma. As Armstrong reports:
“Contrary to the picture of helpfulness and cooperation Purdue attempts to paint, Purdue’s employees were actively and secretly trying to prevent West Virginia from imposing any control on the sale of OxyContin,” the state claimed. The case with Purdue was settled in 2004 when the company paid $10 million to West Virginia. Portions of the case file, including documents about marketing of the drug and Purdue’s attempts to ward off limits on prescribing, remained sealed until STAT filed a motion in May to open the records.
The results of these breakdowns in West Virginia alone are catastrophic. As a state, West Virginia has the highest per capita drug overdose rate in the country. And nationally, the CDC reports that “more persons died from drug overdoses in the United States in 2014 than during any previous year on record,” a rate that has tripled since 2000. By comparison, in 2014, drug overdoses accounted for one and a half times more deaths than automobile accidents.
In a new book, Drug Dealer, MD, Stanford Psychiatrist Anna Lembke argues that this crisis originates with the merger of “Big Pharma” and big medicine. As she recounts in an interview with Terry Gross for NPR’s Fresh Air, the kind of lobbying and regulatory policy work Armstrong describes is itself a response to laws intended to reduce direct appeals from pharmaceutical companies to physicians themselves. Rather than bringing coffee and doughnuts to a doctor’s office, to take one common example, pharmaceutical companies successfully sponsored research and policy initiatives downplaying the addictive qualities of prescription opioids and promoting extended periods of pain management as scientifically grounded medicine.
What we’ve come to call our “opioid crisis” has at least two dimensions in need of sustained attention. In the first place, there are very real and pressing policy questions regarding the flow of powerful drugs, the incentives of medical professionals, and the means by which we treat pain. Concerted efforts to drive up sales of powerful drugs have led to a reconfiguration of the relationship between medical providers and patients. Given the emergent nature of these challenges and the depth of the crisis in particular communities, we should not be surprised if the lion’s share of our attention goes here. However, even if the structural elements of the crisis improves and real people with real addictions get real help, our ambivalence about the moral status of pain endures. As Lembke makes plain, the notion that pain can be salutary or—at the very, least tolerable—has largely been replaced with a wholesale imperative to relieve all pain by any means necessary, even if greater and greater doses of more and more powerful drugs are required. And it is this dimension of the problem that seems most contested and vexing.