Opioids and the ‘Right’ to Pain-Free Living

(from  NeuroPerspective June 2014, focused on Pain)

Two California counties (Santa Clara and Orange) have filed suit against the pharmaceutical companies with the largest stakes in opioid analgesics (Actavis, Endo, Janssen/JNJ, Purdue Pharma,  Teva Pharma), claiming that they deliberately understated the addictive risks of their products, overstated their safety, and in so doing have not only greatly accelerated prescription drug abuse, but also spurred an upsurge in heroin addiction. There are a few issues here that warrant comment:
1) We do not know what each of these companies provided physicians in terms of information regarding abuse/addiction risk for their products. But we do know that Purdue Pharmaceuticals pled guilty in 2007 to having ‘misbranded’ OxyContin as presenting less abuse risk. Purdue paid $635 million in the settlement, three Purdue executives were also fined $34.5 million.
2) The plaintiffs’ argument falls short in linking the marketing of these abusable prescription opioids to the recent increase in heroin abuse, which has been accompanied by a high-profile increase in deaths from heroin overdose. The fallacy is indicated by figures from the NIH: Their estimates of the number of individuals in the US regularly using heroin (‘in the past month’) was around 160,000 in 1982, decreasing to under 50,000 by 1990. However, the 1990s saw a dramatic resurgence, the number reached 216,000 in 1996, the year OxyContin was introduced. The number blipped up to 325,000 in 1997, but was down to 130,000 by 2000, 123,000 in 2001. It is clear that heroin use, which had been down since the 1970s, was escalating even before OxyContin was launched, and indeed decreased thereafter–one might actually wonder if the availability of prescription opioids and the growth of heroin use may be negatively correlated. By 2002, after a change in the sampling protocol that elevated the reported rates of drug abuse, the number of current heroin users was still under the 1996 level, at 166,000. Other than an anomalous rise to 339,000 in 2006, followed by 161,000 in 2007, this rate of current use did not reach the 1996, pre-OxyContin level again until 2010, when concern regarding prescription opioids had mounted, and abuse-resistant Oxycontin was launched. Indeed, from 1997-2007, during which time the total amount of prescription opioids sold in the US increased by 149%, the NIH figures showed a decrease of 50% in the number of ‘current’ heroin abusers. The number of heroin users has been steadily increasing since then (335,000 in 2012), as public attention to prescription drug misuse increased. Our faith in these numbers is tempered by the fact that these statistics are extrapolated from small datasets and the sampling system changed in 2002. But even with that caveat, the figures do not point to a positive correlation between prescription opioid use/abuse and heroin usage. If anything, the former may substitute for the latter, a reminder that when it comes to drug abuse, the forty-year legacy of the ‘War on drugs’ has been akin to a game of molecular Whack-a-Mole, or as The Economist referred to it recently:”Press down, pop up.”
3) In looking at the shift of opioid prescribing towards what does appear to be an overly expansive pattern of utilization for less-than-severe pain, one might also consider the societal context, particularly in the United States, which has been Ground Zero for prescription opioid use and abuse. From ‘pain-free dentistry’ to ‘trigger warnings’ to an ever-burgeoning emphasis upon political correctness and a reluctance to pay for infrastructure utilized and entitlements received, there seems to be a simmering belief in a right to life with as close to zero personal pain and sacrifice as possible. There is something of an emerging ethos in the US that phenomenological pain, be it physical, emotional, or a combination of the two, should be medicated, adjudicated, or legislated out of existence. This is an unattainable aspiration, and while genuine maltreatment, malfeasance, and misconduct require a response, opioid overuse is a symptom that also speaks to social dynamics that go far beyond the prescription pad.

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