tag:theconversation.com,2011:/id/topics/opioid-epidemic-26182/articlesOpioid epidemic – The Conversation2024-03-15T12:09:55Ztag:theconversation.com,2011:article/2256382024-03-15T12:09:55Z2024-03-15T12:09:55ZHow meth became an epidemic in America, and what’s happening now that it’s faded from the headlines<figure><img src="https://images.theconversation.com/files/582056/original/file-20240314-20-ipf1yd.jpg?ixlib=rb-1.1.0&rect=163%2C92%2C4570%2C3009&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Police detectives sort through evidence after raiding a suspected meth lab. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/UrbanMeth/62442edc986247c08ccfff109e7b07e0/photo?Query=meth%20AND%20rural&mediaType=photo&sortBy=creationdatetime:desc&dateRange=Anytime&totalCount=7&currentItemNo=6">AP Photo/Jeff Roberson</a></span></figcaption></figure><p><em>Rural America has long suffered from an <a href="https://theconversation.com/when-hes-not-on-drugs-hes-a-good-person-one-communitys-story-of-meth-use-and-domestic-violence-176069">epidemic of methamphetamine use</a>, which accounts for <a href="https://news.illinois.edu/view/6367/548454463">thousands of drug overdoses and deaths every year</a>.</em></p>
<p><em>William Garriott, an anthropologist at Drake University, explored meth’s impact on communities and everyday life in the U.S. in his 2011 book “<a href="https://nyupress.org/9780814732403/policing-methamphetamine/">Policing Methamphetamine: Narcopolitics in Rural America</a>.” Since then, the problem has only gotten worse.</em></p>
<p><em>The rural news site <a href="https://dailyyonder.com">the Daily Yonder</a> spoke with Garriott about what has been driving the <a href="https://www.nih.gov/news-events/nih-research-matters/trends-us-methamphetamine-use-associated-deaths">surge in meth use in recent decades</a> and what prompted him to focus on meth in his work. The Conversation has collaborated with The Daily Yonder to share the interview with you.</em></p>
<p><strong>How’d you get interested in methamphetamine as an academic subject?</strong></p>
<p>When I started my Ph.D in anthropology in 2003, I knew I wanted to focus on the Appalachian region of the United States. At the time, I was curious about religious life in the region and its contribution to the growth of Pentecostalism and evangelicalism around the world.</p>
<p>But I had also just taken a course with medical anthropologist Arthur Kleinman. He says that we should seek to understand “<a href="https://tannerlectures.utah.edu/_resources/documents/a-to-z/k/Kleinman99.pdf">what’s at stake</a>” or “<a href="https://global.oup.com/academic/product/what-really-matters-9780195331325?cc=us&lang=en&">what really matters</a>” for people in their everyday lives.</p>
<p>And what really mattered to people in places like eastern Kentucky at the time was drugs. We now know we were at the beginning of the opioid epidemic. OxyContin was already taking a toll on local communities, and there was little national concern because it was seen as an isolated regional problem (the derogatory term “hillbilly heroin” was <a href="https://www.theguardian.com/world/2001/jun/25/usa.julianborger">getting thrown around a lot</a> at the time).</p>
<p>When I started my dissertation research, methamphetamine had become the primary concern, both regionally and nationally. When the <a href="https://www.justice.gov/archive/ll/highlights.htm#%22%22">Patriot Act</a> was reauthorized in 2005, the only significant addition was anti-meth legislation called the <a href="https://www.deadiversion.usdoj.gov/meth/cma2005.html">Combat Meth Epidemic Act</a>.</p>
<p><strong>In what sense was the meth surge of the ’90s and early 2000s a rural phenomenon?</strong></p>
<p>Lots of ways. The internet gave people access to meth recipes, and meth cooks tended to be located in rural areas. It was easier to hide and access key ingredients like <a href="https://www.justice.gov/archive/ndic/pubs13/13853/product.htm">anhydrous ammonia</a>. In fact, the number of meth labs grew so quickly that huge swaths of the rural U.S. were labeled <a href="https://www.jstor.org/stable/10.5816/anthropologynow.5.1.0027">High Intensity Drug Trafficking Areas</a> – something that had only been applied to cities like New York and Los Angeles before.</p>
<p>The rural economy was also changing. Jobs weren’t paying as well or were going away altogether. Meth found a niche as a kind of performance enhancement drug for people working long hours at physically demanding jobs – something <a href="https://nyupress.org/9780814732403/policing-methamphetamine/">I saw</a> in the poultry industry in West Virginia, journalist <a href="https://www.bloomsbury.com/us/methland-9781608192076/">Nick Reding</a> found in the pork industry in Iowa, and anthropologist <a href="https://www.upress.umn.edu/book-division/books/the-alchemy-of-meth">Jason Pine</a> found in general in Missouri. Eventually some folks just left these jobs to work in the meth economy full time.</p>
<p>I think it’s also important to mention how meth was being portrayed in national media as the drug of choice for <a href="https://pubmed.ncbi.nlm.nih.gov/29733233/">poor white people</a>. From there, it doesn’t take much to connect it to rural communities, given how those communities are often thought of as predominantly white and poor in the public imagination.</p>
<p>Anti-meth programs like the <a href="https://montanameth.org/">Montana Meth Project</a> and <a href="https://www.oregonlive.com/pacific-northwest-news/2004/12/the_faces_of_meth.html">Faces of Meth</a> played a big part in this. They were very visual campaigns that focused on the damage meth does to the body. All of the people they pictured appeared to be white. They had sores, scars and sunken eyes. They also were often missing teeth. All of that invokes a lot of stereotypes. Sociologists Travis Linnemann and Tyler Wall have a great <a href="https://journals.sagepub.com/doi/10.1177/1362480612468934">journal article on this</a>.</p>
<p>With all of that said, it is important to keep in mind that meth is just as much an urban and suburban problem as a rural one, particularly now. Sociologist <a href="https://www.rutgersuniversitypress.org/women-on-ice/9780813554594/">Miriam Boeri</a> has made this point really clearly. Also, something to keep in mind about Faces of Meth: It was created by a jail deputy in Oregon who used mugshots of people booked into the county jail. The jail is in Portland, so the folks featured probably weren’t living in rural communities at the time.</p>
<p><strong>Your book was called “Policing Methamphetamine.” I’m curious – what made you zero in on that element of meth culture, its policing?</strong></p>
<p>When I began my research, I thought my focus would be on the treatment experiences of people who use methamphetamine. But what I quickly found was that those experiences couldn’t be understood outside of the criminal justice system. Many people only got treatment after an arrest, and often as a condition of probation. One officer told me that people came up to him on the street and asked to be taken to jail so they could stop using drugs. Community members also often channeled their concerns into calls for increased enforcement.</p>
<p>In retrospect, none of this should have been surprising. U.S. drug policy has long focused on <a href="https://www.britannica.com/topic/war-on-drugs">enforcement</a>. This puts police and the criminal justice system on the front lines whenever and wherever a new drug problem emerges. There is no exception to this dynamic for rural communities. What’s more, the justice system is likely to be the most visible and well-resourced state institution in the community (which is not to say it is sufficiently resourced).</p>
<p><strong>What are the questions you still have about meth in American life?</strong></p>
<p>Today, the most pressing question from my perspective is how meth and opioids are converging. One of the more unfortunate developments is that people have started <a href="https://www.health.state.mn.us/communities/opioids/basics/intravenous.html">injecting meth</a>. There is also the broad contamination of the drug supply with fentanyl.</p>
<p>All of this creates additional public health challenges, particularly in rural communities.</p>
<p>Something else I’m thinking about a lot is what happens when drugs like meth stop making headlines and get replaced by the next drug scourge. Today, people are much more likely to <a href="https://www.texastribune.org/2023/06/19/texas-fentanyl-drugs/">talk about fentanyl than meth</a>. This is understandable given the overdose risks, as well as the way news media works. But what are the consequences of this for the communities where meth is still a major concern?</p>
<p>Bigger picture, I’m thinking about meth in the broader context of U.S. drug policy. My next book is about marijuana legalization and justice reform. It’s been interesting because the conversation around cannabis is so different from the conversation around meth. One of the big questions I have is if the kinds of reforms that are following cannabis legalization will do anything to change the conversation around the broader punitive approach to drugs. <a href="https://www.opb.org/article/2024/03/04/oregon-drug-misdemeanor-new-convictions-arrests/">The debate happening right now in Oregon over Measure 110</a> is something I’m watching very closely. It’s a major test case for whether or not a different, less punitive approach to drugs is possible.</p>
<p><em><a href="https://dailyyonder.com">The Daily Yonder</a> provides news, commentary and analysis about and for rural America. The interview accompanies a five-part series on its <a href="https://open.spotify.com/show/41tCRxV4af8cl7CuJi6NsN?si=868e20efc47142e4">Rural Remix podcast</a>.</em></p><img src="https://counter.theconversation.com/content/225638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Will Garriott received funding for his meth research from the National Science Foundation. His current work on marijuana legalization and cannabis policy reform has been funded by the Wenner Gren Foundation, Drake University, and the Center for the Humanities at Drake University.
</span></em></p>An anthropologist who wrote a book exploring meth’s impact on rural communities explains what drove the epidemic and how it’s changed.William Garriott, Professor of Law, Politics, and Society, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2173602024-02-27T12:33:24Z2024-02-27T12:33:24ZHundreds of thousands of US infants every year pay the consequences of prenatal exposure to drugs, a growing crisis particularly in rural America<figure><img src="https://images.theconversation.com/files/567417/original/file-20231228-29-57e4ok.jpg?ixlib=rb-1.1.0&rect=50%2C10%2C6659%2C4456&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Substance use during pregnancy can lead to a broad array of harmful effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/adorable-newborn-baby-with-pacifier-and-toy-in-royalty-free-image/1407722363?phrase=baby">Liudmila Chernetska/iStock via Getty Images Plus</a></span></figcaption></figure><p>Nearly 1 in 12 newborns in the United States in 2020 – <a href="https://www.samhsa.gov/data/sites/default/files/reports/slides-2020-nsduh/2020NSDUHWomenSlides072522.pdf">or about 300,000 infants</a> – were exposed to alcohol, opioids, marijuana or cocaine before they were born. Exposure to these substances <a href="https://www.cdc.gov/reproductivehealth/maternalinfanthealth/substance-abuse/substance-abuse-during-pregnancy.htm">puts these newborns at a higher risk</a> for premature birth, low birth weight and a variety of physical and mental disabilities. </p>
<p>These substances can have <a href="https://doi.org/10.1038/npp.2014.147">direct and indirect consequences on fetal development</a>. By crossing the placental barrier directly, they can cause abnormal development. And by affecting the mother’s organs, they can reduce blood flow to the placenta and damage the health of the growing fetus.</p>
<p>Considerable <a href="https://doi.org/10.1111/j.1521-0391.2010.00079.x">sociodemographic and geographic disparities</a> exist in the U.S. regarding the rates of prenatal substance exposure. This includes in West Virginia, where I live, a rural Appalachian state struggling with extraordinary rates of substance use and an opioid crisis. </p>
<p><a href="https://directory.hsc.wvu.edu/Profile/47295">As an epidemiologist</a>, I study the relationship between substance use during pregnancy and infant health outcomes. I am a member of the <a href="https://www.wvdhhr.org/birthscore/">Project WATCH</a> team, which is a long-standing, state-mandated surveillance and referral system in West Virginia funded by the <a href="https://dhhr.wv.gov/Pages/default.aspx">West Virginia Department of Health</a>. The surveillance system expanded in 2020 to include substance exposure data from all births in the state. </p>
<h2>Staggering numbers</h2>
<p>Our research work showed that between 2020 and 2022, prenatal substance exposure in West Virginia was <a href="https://doi.org/10.1111/jrh.12752">nearly 50% higher, at 124 per 1,000 births</a>, than the national rate of 80 per 1,000 births. This means that nearly 1 in 8 infants born in the state had exposure to substances during pregnancy. </p>
<p>We found that the <a href="https://doi.org/10.1016/j.jpeds.2022.11.040">rate of prenatal cannabis exposure</a> in West Virginia was 80 per 1,000 births, similar to the national rate. However, the rates of opioid exposure, 44 per 1,000 births, and stimulant exposure, 21 per 1,000 births, during pregnancy were nearly 10 times higher than national rates. Additionally, 1 in 5 women in the study smoked, and 64% of the infants exposed to substances were also exposed to smoking during pregnancy. </p>
<p>There are many reasons why the numbers in West Virginia are staggering. <a href="https://doi.org/10.3390/healthcare11081182">Economic challenges</a>, including poverty, low education and limited job opportunities, contribute to chronic stress, a known risk factor for substance use. Moreover, nearly half the population lives in rural areas with a <a href="https://www.marchofdimes.org/maternity-care-deserts-report">limited number of hospitals and clinics</a>. The geographic isolation <a href="https://doi.org/10.1186/s12954-023-00795-w">limits access</a> to health care and substance use treatment services. Finally, <a href="https://doi.org/10.1016/j.mhp.2019.01.010">stigma and judgment</a> within close-knit rural communities may discourage these mothers from seeking help.</p>
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<figcaption><span class="caption">Substances that can affect a developing embryo include alcohol, tobacco, cannabis and prescribed drugs such as methadone.</span></figcaption>
</figure>
<h2>Substance exposure and infant outcomes</h2>
<p>Our earlier work demonstrated that <a href="https://doi.org/10.1038%2Fs41390-019-0731-y">alcohol consumption during pregnancy</a> was associated with preterm birth, which is when a baby is born before the 37th week of pregnancy, and low birth weight, defined as babies born weighing less than 5 pounds, 8 ounces (2,500 grams).</p>
<p>Our more recent study has shown that <a href="https://doi.org/10.1016/j.jpeds.2022.11.040">prenatal opioid exposure</a> is also associated with low birth weight, while stimulant exposure was associated with preterm birth. </p>
<p>Stimulants include cocaine, methamphetamines, ecstasy and prescription stimulants such as those used for the treatment of attention-deficit/hyperactivity disorder. Illicit or misuse of prescription stimulants have <a href="https://www.cdc.gov/pregnancy/meds/treatingfortwo/features/keyfinding-ADHD-med-increase.html">increased among pregnant women</a> over the past decade. </p>
<p>While many national and statewide efforts have focused their attention on addressing the opioid crisis, the prevalence of prenatal stimulant use remains a growing and <a href="https://doi.org/10.1097%2FGRF.0000000000000418">underrecognized epidemic in the U.S</a>.</p>
<p>After alcohol, cannabis is the <a href="https://doi.org/10.1186/s12978-020-0880-9">most common psychoactive substance</a> used during pregnancy and its rate is increasing. This trend in cannabis use may be due to the increasing legality for medicinal or recreational purposes and the social acceptability that comes with it. </p>
<p>In addition, <a href="https://theconversation.com/mounting-research-points-to-health-harms-from-cannabis-thc-and-cbd-use-during-pregnancy-adolescence-and-other-periods-of-rapid-development-198206">many people wrongly assume</a> that cannabis is relatively safe and helps manage pregnancy-related conditions such as morning sickness, nausea, vomiting, weight gain and sleep difficulty. </p>
<p>However, a <a href="https://doi.org/10.1001/jama.2023.21146">growing body of research</a>, including our own, has shown that <a href="https://www.marchofdimes.org/find-support/topics/pregnancy/marijuana-and-pregnancy">prenatal cannabis exposure</a> is associated with <a href="https://doi.org/10.1016/j.jpeds.2022.11.040">adverse pregnancy outcomes</a>, including low birth weight, preterm birth, stillbirth or hypertensive disorders of pregnancy. </p>
<p>In addition, using multiple substances during pregnancy poses a higher risk to infants than using a single substance. We found that compared to no substance exposure during pregnancy, the risk of low birth weight was twice with opioids alone, four times with concurrent exposure to opioids and stimulants, and <a href="https://doi.org/10.1016/j.jpeds.2022.11.040">almost six times with concurrent exposure</a> to opioids, stimulants and cannabis.</p>
<p>Another adverse outcome that is associated with prenatal substance exposure, primarily to opioids, is a <a href="https://www.marchofdimes.org/find-support/topics/planning-baby/neonatal-abstinence-syndrome-nas#">set of withdrawal symptoms</a> experienced by the newborn known as <a href="https://www.ncbi.nlm.nih.gov/books/NBK551498/">neonatal abstinence syndrome</a>. Symptoms include irritability, feeding difficulties, tremors and respiratory issues. The syndrome requires specialized care and attention in neonatal units and a prolonged stay in the hospital.</p>
<p>Alongside the rising prevalence of opioid use in pregnancy, a <a href="https://doi.org/10.3390%2Fchildren10061030">fivefold increase</a> in incidence of infants with this condition has been documented over the past two decades. The highest rate <a href="https://doi.org/10.1111/ppe.12728">has been observed in West Virginia</a>, at 53 per 1,000 births. Other states with high rates include Maine, Vermont, Delaware and Kentucky, which are between <a href="https://doi.org/10.1001%2Fjama.2020.24991">three and four times the national average</a> of 7.3 per 1,000 births. </p>
<h2>Substance exposure in the womb and long-term outcomes</h2>
<p>Research on long-term outcomes of infants exposed to substances in the womb is still evolving. Limited studies have shown an association between neonatal abstinence syndrome and long-term neurodevelopmental consequences that may develop as early as <a href="https://doi.org/10.1001/jamanetworkopen.2019.7025">6 months old and persist into adolescence</a>. These include delays in learning and language skills, physical growth and motor skills, as well as difficulty in regulating <a href="https://doi.org/10.1007%2Fs10802-020-00766-w">behavior and emotions</a>.</p>
<p>However, research on the long-term effects of prenatal alcohol exposure is well established. A broad range of deficits are referred to as <a href="https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-fetal-alcohol-spectrum-disorders">fetal alcohol spectrum disorders</a>. These include growth deficiency, developmental delay, craniofacial malformations, intellectual disabilities, behavior issues and emotional well-being. A recent study of first graders in the U.S. estimated that the prevalence of <a href="https://doi.org/10.1001/jama.2017.21896">fetal alcohol spectrum disorders range from 1% to 5%</a>, which means up to 1 in 20 school-age children may have this disorder. </p>
<p>With the <a href="https://doi.org/10.1016/S2215-0366(23)00235-3">changing landscape of substance use</a> in the U.S., more research is needed to understand and establish the association between the various emerging types and forms of substance exposures and their lasting effects. But the findings are difficult to discern because of the influence of other environmental factors, preexisting medical conditions and <a href="https://www.cdc.gov/publichealthgateway/sdoh/index.html#">social determinants of health</a>.</p>
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<figcaption><span class="caption">Natalie is 6 years old. She has fetal alcohol syndrome.</span></figcaption>
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<h2>Efforts to reduce harms</h2>
<p>As a maternal and child health epidemiologist, I am fortunate to be part of the <a href="https://www.wvdhhr.org/birthscore/index.html">Project WATCH</a> team that works closely with health care providers and policymakers. </p>
<p>As high-risk infants are identified through this program, its referral system notifies pediatricians of substance exposure and connects these families to early intervention services and home visitation programs. </p>
<p>These services include developmental testing, interventions appropriate to the child’s needs and case management during the first few years of life. The data also informs state-level strategies and initiatives to address the substance use crisis for this vulnerable population.</p><img src="https://counter.theconversation.com/content/217360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Project WATCH is a grant funded by the West Virginia Department of Health. </span></em></p>Many people wrongly assume that cannabis use during pregnancy is safe. Research is increasingly documenting a host of serious health harms from prenatal exposure to cannabis and other substances.Amna Umer, Associate Professor of Pediatric Epidemiology, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125272023-09-13T12:26:32Z2023-09-13T12:26:32ZOffering treatment to drug users instead of arresting them reduces crime and addiction – new research into police diversion program shows<figure><img src="https://images.theconversation.com/files/547289/original/file-20230908-28933-n5gp3f.jpg?ixlib=rb-1.1.0&rect=16%2C8%2C5447%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People mourn loved ones who have died from drug overdoses before replica tombstones in Binghamton, N.Y., on Aug. 19, 2023.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/friends-and-family-members-of-people-who-have-died-from-news-photo/1626209256?adppopup=true">Andrew Lichtenstein/Corbis via Getty Images</a></span></figcaption></figure><p>When police get suspected drug abusers treatment rather than arresting them, those people are less likely to abuse drugs or commit drug-related crimes in the future, <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">new, limited research finds</a>. This kind of police intervention can help reduce opioid abuse.</p>
<p>The U.S. has been in the throes of <a href="https://www.npr.org/2021/12/30/1069062738/more-than-a-million-americans-have-died-from-overdoses-during-the-opioid-epidemi">rampant opioid abuse since the late 1990s</a>. Communities around the country have experienced <a href="https://doi.org/10.1016/j.drugpo.2021.103555">increases in opioid-related deaths</a> and crimes as a result. </p>
<p>One study <a href="https://doi.org/10.1001/jamanetworkopen.2018.0217">shows opioid-related deaths more than quadrupled</a> from 9,489 in 2001 to 42,245 in 2016. Another study indicates that people addicted to opioids are more likely than people who don’t use opioids <a href="https://doi.org/10.1001/jamanetworkopen.2018.0558">to have run-ins with police</a>. The rate of opioid-related crimes in the U.S. has increased substantially, <a href="https://doi.org/10.1016/j.drugpo.2021.103555">from 32 per 100,000 people in 2005 to 78 per 100,000 people in 2018</a>. </p>
<p>Historically, for public safety, <a href="https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/432/817">police have arrested people suspected of using drugs</a>. Research <a href="https://doi.org/10.1186/s12954-022-00652-2">shows, though, that this approach has not been effective</a> at reducing drug abuse or related crimes. </p>
<p>But there is another way that appears to work better. In Arizona, the Tucson Police Department is trying an approach known as <a href="https://www.thenationalcouncil.org/program/deflection-and-pre-arrest-diversion-to-prevent-opioid-overdose/">pre-arrest diversion</a>. When officers respond to community calls about crime, they sometimes suspect the perpetrator may be abusing drugs. When they do, they don’t always arrest that person. Instead, officers connect that person with substance abuse treatment providers. I <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">recently led a study</a> that found this approach is as effective as arrest at reducing both drug abuse and crime.</p>
<p>As a professor of social and behavioral sciences, <a href="https://sirow.arizona.edu/person/josephine-korchmaros-0">I study treatment models and policy improvement</a> regarding substance use and the criminal justice system. Following a <a href="https://doi.org/10.1146/annurev.publhealth.19.1.173">community-based approach</a>, I share the findings with other researchers and policymakers, as well as with the groups I studied.</p>
<figure class="align-center ">
<img alt="A man with his back to the camera points a heroin needle in the direction of his neck." src="https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man shoots heroin in a South Bronx park in New York on June 7, 2017.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/man-shoots-heroin-in-a-park-in-the-south-bronx-on-june-7-news-photo/693529400?adppopup=true">Spencer Platt/Getty Images</a></span>
</figcaption>
</figure>
<h2>The shift in policing</h2>
<p>Before 2011, most police departments in the U.S. typically arrested people for drug abuse without giving them an option for substance abuse treatment.</p>
<p>Seattle’s Law Enforcement Assisted Diversion program, which was launched in 2011, <a href="https://www.fordfoundation.org/work/learning/research-reports/seattles-law-enforcement-assisted-diversion-program/">is the first known pre-arrest diversion program in the country</a>. Seattle police worked with <a href="https://kingcounty.gov/en/legacy/depts/community-human-services/mental-health-substance-abuse/diversion-reentry-services/lead">behavioral health providers, court officials and community groups</a> to set up the program, commonly referred to as LEAD.</p>
<p>LEAD focuses on <a href="https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/432/817">addressing crime and community safety issues related to drug abuse</a>. The program also focuses on reducing problems such as difficulty finding a job when a person has a criminal record. </p>
<p>In 2015, the <a href="https://paariusa.org/about-us/">Police Assisted Addiction and Recovery Initiative</a> grew out of Gloucester, Massachusetts’ policy to send people who use drugs to substance abuse treatment instead of arresting them. The initiative has helped <a href="https://paariusa.org/about-us/">nearly 600 police departments, including Tucson’s, across 34 states</a> to put in place similar drug- and opioid-abuse diversion programs.</p>
<p>In Tucson, instead of arresting people for illicit drug use or related crimes such as trespassing, <a href="https://ptaccollaborative.org/wp-content/uploads/2019/11/11-12_Hall.pdf">officers may encourage those people</a> to enroll in substance abuse treatment and give them rides to treatment providers. In addition to <a href="https://doi.org/10.1176/foc.1.2.115">evidence-based substance abuse treatment</a>, such as providing medication that treats withdrawal symptoms, the providers offer <a href="https://www.codac.org/services/">other health care services</a>, mental health treatment and other support.</p>
<p>The department <a href="https://tucson.com/news/local/tucson-police-pushing-treatment-rather-than-jail-for-hundreds-of-drug-users/article_0d3dd2fa-83af-5457-acce-8dfb0168b100.html">rolled out the program in July 2018</a>. That year, Pima County, where Tucson is located, <a href="https://www.azdhs.gov/opioid/#dashboards-overdose-deaths">had 175 fatal opioid overdoses</a> and <a href="https://ptaccollaborative.org/wp-content/uploads/2019/11/11-12_Hall.pdf">an increase in property crime due to substance and opioid abuse</a>, and there were 1,116 opioid overdose deaths statewide in Arizona. </p>
<p>My <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_FeasAccept_Report_2022_final.pdf">research shows</a> that 2,129 times in a three-year period, officers sent people to substance abuse treatment instead of arresting them. And officers gave <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_FeasAccept_Report_2022_final.pdf">people rides to treatment</a> 965 times. The data I analyzed also shows this approach takes 25 minutes less time, per incident, on average, than arresting people.</p>
<p>Programs like these represent a shift from arrest and criminalization of people who abuse drugs toward a police response that focuses on longer-term reduction of drug abuse.</p>
<figure class="align-center ">
<img alt="Two women drop flowers on the pavement as five people sit with their arms locked and their backs against a building entrance." src="https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Protesters calling for overdose prevention policies drop flowers at the New York governor’s New York City office on Aug. 28, 2019, to symbolize the lives lost to drug overdose.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protesters-dropped-flowers-by-the-people-risking-arrest-news-photo/1164771437?adppopup=true">Erik McGregor/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>The effectiveness of pre-arrest diversion programs</h2>
<p>Findings from research on the effectiveness of Seattle’s pre-arrest diversion program suggest that these criminal diversion programs result in <a href="https://doi.org/10.1016/j.evalprogplan.2017.05.008">fewer arrests for people with substance abuse disorders</a>. The findings also indicate that the program decreased homelessness, another program goal, with participants <a href="https://doi.org/10.1177/0011128716687550">twice as likely to have housing after participating</a>.</p>
<p>My team’s research shows that people who were offered substance abuse treatment, instead of being arrested, decreased their drug use more than people who were not offered substance abuse treatment and were arrested. On average, <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">six months after their interaction with Tucson police</a>, people who accepted diversion to a substance abuse treatment program used illegal drugs less frequently than people who had been arrested. </p>
<p>In addition, diversion to substance abuse treatment in Tucson was as effective as arrest in <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">decreasing criminal activity</a>. </p>
<p>That is why these programs may be an effective way to address the opioid epidemic.</p><img src="https://counter.theconversation.com/content/212527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Josephine Korchmaros received funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Grant Number H79TI081559 and Arnold Ventures to support a research study evaluating the Tucson Police Department's pre-arrest deflection program.</span></em></p>Police diversion programs for drug users shift officers’ focus from criminalization to treatment.Josephine Korchmaros, Professor of Social and Behavioral Sciences, University of ArizonaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2046222023-06-13T12:29:56Z2023-06-13T12:29:56ZAnnual numbers of excess deaths in the US relative to other developed countries are growing at an alarming rate<figure><img src="https://images.theconversation.com/files/527599/original/file-20230522-14385-h3se2w.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C5100%2C3802&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Homicides and the opioid epidemic both contribute to the rising U.S. death rates.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/people-at-a-funeral-royalty-free-image/104302939?phrase=U.S.+cemetery&adppopup=true">Rubber Ball Productions/Brand X Pictures via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>People in the U.S. are dying at higher rates than in other similar high-income countries, and that difference is only growing. That’s the key finding of a <a href="https://doi.org/10.1371/journal.pone.0283153">new study that I published</a> in the journal PLOS One.</p>
<p>In 2021, more than 892,000 of the 3,456,000 deaths the U.S. experienced, or about 1 in 4, were “<a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm#">excess deaths</a>.” In 2019, that number was 483,000 deaths, or nearly 1 in 6. That represents an 84.9% increase in excess deaths in the U.S. between 2019 and 2021. </p>
<p>Excess deaths refer to the actual number of deaths that occur in a given year compared with expected deaths over that same time period based on prior years or, as in this study, in other countries.</p>
<p>In my study, I compared the number of U.S. deaths with those in the five largest countries in Western Europe: England and Wales, France, Germany, Italy and Spain. Those five countries make for a good comparison because they are nearly, if not quite, as wealthy as the U.S. and their combined population is similar in size and diversity to the U.S. population.</p>
<p>I also chose those countries because they were used in an earlier study from another research team that documented a <a href="https://doi.org/10.1073/pnas.2024850118">34.5% increase in excess deaths</a> in the U.S. between 2000 and 2017. </p>
<p>The acceleration of this already alarming long-term trend in excess deaths in the U.S. was exacerbated by the fact that the U.S. experienced higher death rates from COVID-19 <a href="https://doi.org/10.1136/bmj.n1343">compared with similar countries</a>. However, <a href="https://theconversation.com/279-700-extra-deaths-in-the-us-so-far-in-this-pandemic-year-147887">COVID-19 alone does not account</a> for the recent increase in the number of excess deaths in the U.S. relative to comparison countries.</p>
<h2>Why it matters</h2>
<p>Rising living standards and medical advances through the 20th century have made it possible for people in wealthy countries to live longer and <a href="https://doi.org/10.1257/jep.20.3.97">with a better quality of life</a>. Given that the U.S. is the largest economic power in the world, with cutting-edge medical technology, Americans should have an advantage over other countries in terms of life span and death rates.</p>
<p>But in the last 50 years, many countries around the world have outpaced the U.S. in how fast death rates are declining, as revealed by <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220831.htm#">trends in life expectancy</a>.</p>
<p>Life expectancy is an average age at death, and it represents how long an average person is expected to live if current death rates remain unchanged throughout that person’s lifetime. Life expectancy is based on a complex combination of death rates at different ages, but in short, when death rates decline, life expectancy increases. </p>
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<p>Compared to about 20 other high-income countries, since around the mid-1970s <a href="https://www.npr.org/sections/health-shots/2023/03/25/1164819944/live-free-and-die-the-sad-state-of-u-s-life-expectancy#">the U.S. life expectancy</a> has been <a href="https://doi.org/10.17226/13497">slipping from about the middle, or median, to the lowest rungs</a> of life expectancy. So the relative stagnation in life expectancy in the U.S. compared with other countries is directly related to the fact that death rates have also declined more slowly in the U.S.</p>
<p>The U.S. has higher death rates than its peer countries due to a variety of causes.
Cardiovascular disease prevalence has been an <a href="https://doi.org/10.1161/CIRCRESAHA.116.309115">important driver of life expectancy changes across the globe</a> in recent decades. But while death rates from cardiovascular disease have continued to decline in other parts of the world, those <a href="https://doi.org/10.1073/pnas.1920391117">rates have stagnated in the U.S.</a>. </p>
<p>A key reason for this trend is the <a href="https://doi.org/10.1073/pnas.1716802115">rise in obesity</a>, as research shows that <a href="https://doi.org/10.1161/CIR.0000000000000973">obesity increases the risk of death from cardiovascular disease</a>. High prevalence of obesity in the U.S. also likely contributed to the <a href="https://doi.org/10.1136/bmj.n1343">relatively high death rates from COVID-19</a>. </p>
<p>Another cause is that the U.S. has disproportionately high death rates from intentional injuries in the form of homicides, <a href="https://doi.org/10.1097/TA.0b013e3181dbaddf">in particular those caused by firearms</a>. Moreover, it also has high death rates from unintentional injuries, <a href="https://doi.org/10.1111/padr.12228">in particular drug overdoses</a>. </p>
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<figcaption><span class="caption">People are being exposed to fentanyl without knowing it, and because the synthetic opioid is so highly potent, people are dying in unprecedented numbers.</span></figcaption>
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<h2>What other research is being done</h2>
<p>While these specific causes of deaths should clearly be health policy priorities today, there might be more fundamental causes to the elevated U.S. death rates. </p>
<p>In the early 1990s, young people in the U.S. between the ages of 15 and 34 were already dying at <a href="https://doi.org/10.1016/S1054-139X(01)00329-9">higher rates than their peers in other countries</a> from a combination of homicides, unintentional injuries – in large part from motor vehicle accidents – and <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/">deaths from HIV/AIDS</a>. </p>
<p>Research is underway to understand the more <a href="https://doi.org/10.1097/PHH.0000000000001626">fundamental societal causes</a> that may explain the vulnerability of the U.S. population to successive epidemics, from HIV/AIDS and COVID-19 to gun violence and opioid overdoses. </p>
<p>These <a href="https://doi.org/10.1073/pnas.2014750117">include racial</a> and <a href="https://doi.org/10.2105/AJPH.2008.139469">economic inequalities</a>, which combined with a weaker social security net and lack of health care access for all may help explain larger health and death disparities compared to European countries.</p><img src="https://counter.theconversation.com/content/204622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Heuveline does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research shows that preventable deaths are increasing in the US at the same time that life expectancy keeps dropping.Patrick Heuveline, Professor of Sociology, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1961062023-01-06T13:30:39Z2023-01-06T13:30:39ZAlcohol use is widely accepted in the US, but even moderate consumption is associated with many harmful effects<figure><img src="https://images.theconversation.com/files/501999/original/file-20221219-26-6hbnxe.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6720%2C4466&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research increasingly shows that the dangers of alcohol have been downplayed and its benefits exaggerated.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/an-elderly-man-abuses-alcohol-royalty-free-image/1175893790">Nes/E+ via Getty Images</a></span></figcaption></figure><p><a href="https://theconversation.com/el-consumo-de-alcohol-esta-ampliamente-aceptado-en-estados-unidos-pero-incluso-el-consumo-moderado-esta-asociado-a-numerosos-efectos-nocivos-201655">Leer en español.</a></p>
<p>This month, millions of Americans are taking part in “<a href="https://www.today.com/health/dry-january-what-it-what-are-benefits-women-t146331">Dry January</a>” in an effort to forgo alcohol for a month and cleanse themselves of the excesses of the holiday season.</p>
<p>Alcohol is the <a href="https://www.globaldrugsurvey.com/">most widely used drug</a> in the world, including in the U.S.</p>
<p>In 2020, nearly 70% of people ages 18 and older in the U.S. said they had consumed an alcoholic drink <a href="https://www.samhsa.gov/data/report/2020-nsduh-detailed-tables">in the previous year</a>, according to the National Survey on Drug Use and Health. Additionally, 24% of people reported binge drinking – defined for women as four or more drinks per occasion and five or more drinks per occasion for men – in the previous month. </p>
<p>The COVID-19 pandemic brought with it important changes in alcohol consumption. One nationally representative sample found that while the number of people who reported drinking in the past year remained consistent from 2019 to 2021, the number of people <a href="https://doi.org/10.1111/acer.14839">consuming alcohol every day increased from 6.3% to 9.6%</a>.</p>
<p>Partially because alcohol is such a commonly used substance, heavily marketed and glamorized in pop culture, Americans’ comfort with and acceptance of its use in everyday life is remarkably high. But should it be? </p>
<p><a href="https://www.sph.pitt.edu/directory/christina-mair">I research alcohol use</a> and the associations between drinking and a wide range of problems. While the <a href="https://www.cdc.gov/opioids/basics/epidemic.html">rising opioid epidemic</a> has received a lot of attention in recent years, the number of deaths attributable to alcohol each year is on par with the overall number of annual deaths from <a href="https://www.cdc.gov/nchs/products/databriefs/db457.htm">drug overdose</a>, with both increasing rapidly in the past few years. </p>
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<figcaption><span class="caption">Having even one drink a day can have a negative effect on your health.</span></figcaption>
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<h2>What about moderate drinking?</h2>
<p>In the past two decades, the idea that moderate drinking may actually confer health benefits <a href="https://doi.org/10.2337/diacare.28.3.719">has taken hold</a>, backed up by <a href="https://doi.org/10.1136/bmj.319.7224.1523">some preliminary and limited evidence</a>. This led to the broad notion <a href="http://www.health.com/health/article/0,,20410287,00.html">in the popular media</a> that a glass of red wine a day reduces the risk of cardiovascular disease and diabetes. </p>
<p>But there was one major flaw in many of the studies used to back up the claim that a glass of red wine is good for health. They compared those who drink at moderate levels to people who consume no alcohol whatsoever, rather than comparing those who drink heavily versus at lower levels. </p>
<p>There are many reasons why people who drink at moderate levels may be fundamentally different – and healthier – than those who do not drink at all. For example, many people who develop new illnesses unrelated to their alcohol use quit drinking, making the group of alcohol abstainers <a href="https://doi.org/10.1093/aje/kwn093">appear less healthy</a> than those who consume alcohol at low or moderate levels. </p>
<p>In 2018, the National Institutes of Health initiated a large randomized control trial – the gold standard for understanding causal relationships – to look into the <a href="https://www.nytimes.com/2017/07/03/well/eat/alcohol-national-institutes-of-health-clinical-trial.html">benefits of moderate drinking</a>.</p>
<p>That trial was designed to pick up the heart benefits of consuming one drink a day, but was not going to be able to detect the negative consequences of moderate alcohol use, such as <a href="https://www.nytimes.com/2018/06/18/health/nih-alcohol-study.html">increases in breast cancer</a>. Because of its inability to <a href="https://doi.org/10.1136/bmj.k3888">pick up on known alcohol-related harms</a> and concerns that the study was co-funded by the alcohol industry, the trial was <a href="https://clinicaltrials.gov/ct2/show/study/NCT03169530">halted after a few months</a>. </p>
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<figcaption><span class="caption">A landmark 2022 study found that even low levels of alcohol consumption can be dangerous.</span></figcaption>
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<h2>Alcohol’s link to cancer and other harms</h2>
<p>Thanks to lobbying by <a href="https://doi.org/10.1111%2Fadd.13048">the powerful</a> <a href="https://doi.org/10.1371/journal.pone.0170366">alcohol industry</a>, alcohol’s dangers may be underplayed and its benefits exaggerated. There are many <a href="https://doi.org/10.1016/j.ypmed.2003.11.027">well-established problems with drinking even at moderate levels</a> that likely outweigh any potential benefits. </p>
<p>Alcohol is the <a href="https://doi.org/10.1001/jama.291.10.1238">third-leading cause of premature death</a> in the U.S. and one of the leading <a href="https://doi.org/10.3389/fpubh.2020.00279">modifiable causes of death worldwide</a>, while receiving some of the least media and policy attention. Worryingly, the number of deaths attributed to alcohol increased by 25% between 2019 and 2020 – a faster rate of increase than for the percentage increase in all deaths – 17% – in the <a href="https://doi.org/10.1001/jama.2022.4308">first year of the COVID-19 pandemic</a>. These rates increased most rapidly among people ages 25 to 44.</p>
<p>The lifetime prevalence of alcohol use disorder – defined as an impaired ability to stop or control alcohol use despite <a href="https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder">adverse social, occupational or health consequences</a> – is nearly 30%. In other words, nearly a third of the population has been severely impacted by their drinking at some point in their lifetime.</p>
<p>Alcohol use, even at low levels, is linked to a number of cancers, including <a href="https://doi.org/10.1001/jama.2011.1590">breast</a>, <a href="https://doi.org/10.1093/annonc/mds337">colorectal, liver and esophagus</a>. Alcohol contributes to approximately <a href="https://doi.org/10.1016/j.canep.2021.101893">75,000 cancer cases and 19,000 cancer deaths per year</a>. Furthermore, a recent study found that more than 50% of adults in the U.S. are unaware of the <a href="https://doi.org/10.1158/1055-9965.EPI-22-0420">cancer-related risks of alcohol consumption</a>.</p>
<p>Alcohol also causes a number of serious harms to others, many of them violence-related. These include increased <a href="https://doi.org/10.1016/j.chiabu.2014.03.011">risk of child maltreatment</a>, physical abuse, intimate partner violence, <a href="https://doi.org/10.15288%2Fjsas.2002.s14.118">sexual assaults</a> and <a href="https://doi.org/10.1111%2Fj.1530-0277.2009.00912.x">gun violence</a>. Alcohol-involved traffic fatalities in the U.S. – after several decades of decreasing – <a href="https://www.nhtsa.gov/risky-driving/drunk-driving#">ticked up by 14% to 11,654 in 2020</a>.</p>
<h2>Disparities in alcohol-related consequences</h2>
<p>The effects of alcohol are not felt equally by all: The most vulnerable among us suffer the greatest consequences. In the U.S., Black and Latino people who drink experience a greater number of social consequences from drinking than white people who drink, <a href="https://doi.org/10.1111%2Fj.1530-0277.2008.00880.x">particularly among groups who consume alcohol at low levels</a>. These consequences include arguments or fights, accidents and workplace, legal and health problems.</p>
<p>In addition, studies show that adolescents who report minority sexual orientation tend to <a href="https://doi.org/10.1001/archpedi.162.11.1071">start drinking at younger ages</a> and continue to <a href="https://doi.org/10.1016/j.amepre.2013.11.010">binge drink more frequently as adults</a>. These differences in alcohol-related problems at the same level of alcohol consumption contribute to disparities in many other health outcomes for these populations.</p>
<h2>Raising taxes and drinking age could offset harms</h2>
<p>There are a number of things the U.S. could do to reduce the burden of alcohol consumption through public policy. One proven effective policy includes increasing <a href="https://www.irs.gov/businesses/small-businesses-self-employed/excise-tax">alcohol excise taxes</a>, which are selective sales taxes on the purchase of alcohol. Other policies that have been shown to be effective include restrictions on the number of stores that sell alcohol, restrictions on <a href="https://doi.org/10.1016/j.amepre.2013.03.008">hours of sale</a> and <a href="https://doi.org/10.1162/REST_a_00615">increases in the minimum legal drinking age</a> from 18 to 21. While the current minimum drinking age in the U.S. is 21, prior to 1984 the minimum drinking age <a href="https://www.cdc.gov/alcohol/fact-sheets/minimum-legal-drinking-age.htm#">varied from state to state</a>, with some states allowing drinking as early as age 18.</p>
<p>While the alcohol industry often stands against many of these policies and regulations, they are relatively easy to implement. Despite this, in the U.S., alcohol control policies have been in decline over the past several decades, with many states moving to <a href="https://doi.org/10.1111/add.16003">privatize alcohol sales</a> – in direct opposition to what experts know can reduce alcohol-related harms. Privitization, which <a href="https://doi.org/10.1016/j.amepre.2012.01.002">removes state monopolies on alcohol sales</a>, greatly increases per capita alcohol sales and consumption.</p>
<p>Although alcohol plays a pivotal role in American culture, in my view the undisputed consequences of drinking make it unwise to recommend alcohol as a path to better health and well-being. As I see it, the small reductions in cardiovascular disease that are questionably linked to low levels of consumption are hardly offset by the sizable harms of alcohol on individual and population health.</p>
<p><em>This is an updated version of an article <a href="https://theconversation.com/alcohols-health-benefits-hard-to-prove-but-harms-are-easy-to-document-98813">originally published on July 9, 2018</a>.</em></p><img src="https://counter.theconversation.com/content/196106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christina Mair receives funding from the National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism</span></em></p>The number of deaths related to alcohol use in the US grew by a staggering 25% between 2019 and 2020, the first year of the COVID-19 pandemic.Christina Mair, Associate Professor of Behavioral and Community Health Sciences, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1782622022-07-29T12:20:56Z2022-07-29T12:20:56ZTaking certain opioids while on commonly prescribed antidepressants may increase the risk of overdose<figure><img src="https://images.theconversation.com/files/476389/original/file-20220727-1345-spk5fx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2127%2C1407&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Certain SSRIs can inhibit the breakdown of opioids in the body.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hands-of-man-in-robe-surrounded-by-prescription-royalty-free-image/588316210">Glasshouse Images/The Image Bank via Getty Images</a></span></figcaption></figure><p>Taking oxycodone at the same time as certain selective serotonin reuptake inhibitors (SSRIs), a commonly prescribed class of antidepressant, can <a href="https://doi.org/10.1001/jamanetworkopen.2022.0194">increase the risk of opioid overdose</a>, according to a study my colleagues <a href="https://scholar.google.com/citations?user=nqtrb3oAAAAJ&hl=en">and I</a> published.</p>
<p>Doctors prescribe the opioid <a href="https://www.cdc.gov/opioids/basics/prescribed.html">oxycodone</a> to treat moderate to severe pain after surgeries and injuries or certain conditions like cancer. Opioids are also a <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">common drug of abuse</a>. In the U.S., over 70% of drug overdose deaths in 2019 involved an opioid. </p>
<p>Because many patients with depression <a href="https://doi.org/10.1001/archinte.163.20.2433">also experience chronic pain</a>, opioids are often <a href="https://doi.org/10.18773/austprescr.2021.004">coprescribed with antidepressants</a> like SSRIs. <a href="http://dx.doi.org/10.2174/1389200023338017">Prior research</a> has shown that certain SSRIs, namely fluoxetine (Prozac or Sarafem) and paroxetine (Paxil, Pexeva or Brisdelle), can strongly inhibit a liver enzyme crucial to the proper breakdown of drugs in the body, including oxycodone. The resulting increased concentration of oxycodone in the blood may lead to accidental overdose.</p>
<p>To see whether different types of SSRIs might affect a patient’s risk of overdosing on oxycodone, my colleagues and I examined data from three large U.S. health insurance claims databases. We included over 2 million adults who began taking oxycodone while using SSRIs between 2000 and 2020. The average age of the group was around 50, and a little over 72% were women. A little over 30% were taking the SSRIs paroxetine and fluoxetine.</p>
<p>We found that patients taking paroxetine or fluoxetine had a 23% higher risk of overdosing on oxycodone than those using other SSRIs.</p>
<p><a href="https://doi.org/10.7556/jaoa.2019.136">About 30% of patients</a> with chronic pain experience adverse drug interactions while taking opioids. Other types of drugs have been shown to increase the risk of overdose and other harmful interactions. These include some <a href="https://doi.org/10.1002/cpt.1807">muscle relaxants</a> commonly used to treat pain, <a href="https://doi.org/10.1001/jamanetworkopen.2018.0919">benzodiazepines</a> commonly used to treat anxiety or poor sleep and some <a href="https://doi.org/10.1093/schbul/sbab116">antipsychotics</a> commonly used to treat schizophrenia or bipolar disorder. Similarly, in 2019, the Food and Drug Administration required drugmakers to <a href="https://www.fda.gov/news-events/fda-brief/fda-brief-fda-requires-new-warnings-gabapentinoids-about-risk-respiratory-depression">include new warnings</a> on using gabapentinoids, a class of drugs commonly used to treat epilepsy and pain, concurrently with opioids and other drugs that suppress the central nervous system. This mandate was due to an increased risk of <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">dangerously reduced breathing rates</a> that can result in overdose and death when these drugs are taken together.</p>
<p>The findings from our study offer insight on which of the most commonly used antidepressants could most likely lead to opioid overdose. Further investigation of how other drugs interact with opioids could help doctors and patients better understand which drugs are safe to take at the same time.</p><img src="https://counter.theconversation.com/content/178262/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ismaeel Yunusa does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Drugs can interact with one another in ways that are harmful. A study finds that taking oxycodone with certain SSRIs can make an opioid overdose more likely.Ismaeel Yunusa, Assistant Professor of Clinical Pharmacy and Outcomes Sciences, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1818202022-06-10T15:10:50Z2022-06-10T15:10:50ZWhy opting out of opioids can be dangerous in the operating room<figure><img src="https://images.theconversation.com/files/467588/original/file-20220607-14-psmm5p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioids can help reduce the amount of medication needed to achieve anesthesia.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-anesthesiologist-during-hard-operation-royalty-free-image/1139854034">gpointstudio/iStock via Getty Images Plus</a></span></figcaption></figure><p>Currently, patients in <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2793282">seven states</a> can tell their physicians they don’t want to be treated with opioids in any health care setting, even during surgery. While unnecessary opioid exposure is a big reason behind the opioid epidemic in the U.S., we believe that <a href="https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2019/03/28/nonopioid-directive-form-helps-fight-opioid-epidemic-by-allowing-patients-to-notify-health-professi">non-opioid directives</a> that allow patients to opt out of opioids in the operating room may lead to unexpected harms.</p>
<p>Non-opioid directives share some common features with <a href="https://medlineplus.gov/advancedirectives.html">advance directives</a>, legally recognized documents that allow patients to list their preferences for what happens at the end of life. Both documents guide care based on the desires of the patient. Non-opioid directives are mandates that a patient must not receive opioids under any circumstances. Exceptions are rare.</p>
<p>Congress is currently considering legislation allowing access to these directives across the nation. While only one of the seven states with non-opioid directives excludes <a href="http://legislature.mi.gov/doc.aspx?2021-HB-5261">care during surgical procedures</a>, both proposed bills in the <a href="https://www.congress.gov/bill/117th-congress/house-bill/4098">House</a> and <a href="https://www.congress.gov/bill/117th-congress/senate-bill/1292/">Senate</a> contain an exclusion specific to care in the operating room.</p>
<p>We are a <a href="https://scholar.google.com/citations?user=mQswfH4AAAAJ&hl=en">team</a> <a href="https://www.uofmhealth.org/profile/1322/paul-edward-hilliard-md">of</a> <a href="https://scholar.google.com/citations?user=FyPUG8cAAAAJ&hl=en">physicians</a> who work with and study the use of opioids in surgical settings. Two of us co-direct the <a href="https://michigan-open.org">Opioid Prescribing Engagement Network</a>, which develops best practices for opioid prescriptions after surgery. We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2793282">difficult if not impossible</a> to avoid harming patients.</p>
<h2>The role of opioids in anesthesia</h2>
<p>Anesthesia is tailored for each patient depending on the surgical procedure, with the appropriate <a href="https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia">degree of sedation</a> varying for each case. At one end of the scale is minimal sedation, which usually allows patients to respond to verbal commands. At the other end is general anesthesia, which keeps patients unconscious even during pain. Different medications make this range of sedation possible. </p>
<p>A concept called <a href="https://doi.org/10.1016/j.jclinane.2003.07.005">balanced anesthesia</a> has guided clinicians in how they care for patients in the operating room for more than a century. The goal is to give a patient different types of medications to obtain loss of pain, memory, movement and consciousness while preserving other essential functions of the body.</p>
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<figcaption><span class="caption">Scientists are still learning about the biomechanisms behind how anesthesia works.</span></figcaption>
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<p>Relying on only one or two types of medication usually requires higher doses to achieve anesthesia, which can result in bothersome or concerning side effects. Using a <a href="https://doi.org/10.1213%2FANE.0000000000003668">combination of drugs</a>, on the other hand, lowers the amount of drug needed to achieve sedation. Because each drug works on a different set of receptors in the body, the desired effects can be attained with smaller doses of each drug than with one drug given alone. This reduces the risk of side effects and leads to more stable vital signs during surgery.</p>
<p>Opioids stand out among the typical sedatives and anesthetics used in the operating room by <a href="https://doi.org/10.1016/s0952-8180(97)00122-0">significantly reducing</a> the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness. Even small doses of opioids are sufficient to <a href="https://doi.org/10.1097/ALN.0b013e318238bba6">activate areas</a> in the brain that decrease the input of pain signals from other areas of the body.</p>
<h2>Why the operating room is different</h2>
<p>As broader calls to reduce unnecessary opioid use rise, anesthesiology and surgery researchers have asked whether avoiding all opioids in the operating room would lead to better patient outcomes. The first set of published studies on this question suggests that completely eliminating opioids from the operating room may do more harm than good.</p>
<p>In <a href="https://doi.org/10.1097/aln.0000000000003725">one study</a>, researchers randomly assigned patients who needed general anesthesia for surgery to either a group that received an ultrafast-acting opioid or a non-opioid sedative commonly used in intensive care units. After a surprising number of patients in the non-opioid group experienced serious adverse events during surgery, such as dangerously reduced heart rates and low oxygen blood concentration, the researchers stopped the study early because of safety concerns.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of IV drip in operating room." src="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Eliminating opioids in the OR may not have many benefits over reducing dosages.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-iv-drip-bag-royalty-free-image/1347166189">Porta/E+ via Getty Images</a></span>
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<p>Similarly, a <a href="https://doi.org/10.1097/ALN.0000000000003572">review of studies</a> found that eliminating opioids during surgery did not decrease either patient use of prescription opioids after discharge or provider overprescription of opioids beyond just reducing opioid dosage during the procedure.</p>
<h2>Non-opioid directives and the OR</h2>
<p>Drug overdoses in the United States continue to reach record numbers, with estimates of more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">107,000 deaths</a> in 2021. How best to use pharmaceutical company lawsuit settlement payouts given to <a href="https://www.wsj.com/articles/j-j-settles-with-west-virginia-in-opioid-suit-for-99-million-11650302927">West Virginia</a> and <a href="https://apnews.com/article/health-business-washington-lawsuits-opioids-9de7c4bdf0f3c4360d355bb8da8c740f">other states</a> has been hotly <a href="http://doi.org/10.1001/jamahealthforum.2021.1765">debated</a>. But we believe that approaches that allow patient to opt out of opioids in the operating room may lead to unsafe care. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="White pills spilling out of orange bottle" src="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Non-opioid directives can help reduce unintended opioid exposure but may not be safe when applied to the OR.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pills-pour-out-of-prescription-medication-bottle-royalty-free-image/828608164">DNY59/iStock via Getty Images Plus</a></span>
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<p>Opioids are useful beyond pain reduction and play a role in helping patients safely emerge from general anesthesia. Avoiding opioids may be a safe option when general anesthesia is not needed, such as procedures on the hand, leg or feet that use only <a href="http://doi.org/10.1097/EJA.0b013e3283349d68">nerve blocks</a> to reduce pain. Prescription opioids may also not be needed when patients recover at home <a href="https://michigan-open.org/prescribing-recommendations/">after many types of surgery</a>.</p>
<p>Opioids are a tool that can complement a thoughtful anesthetic and surgical plan. Whether or not patients receive opioids during surgery doesn’t affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.</p><img src="https://counter.theconversation.com/content/181820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark C. Bicket receives funding from the National Institutes of Health, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the US Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. He received past funding from the Arnold Foundation. He served as a consultant in the past for Axial Healthcare and Alosa Health.</span></em></p><p class="fine-print"><em><span>Jennifer Waljee receives funding from the National Institutes of Health, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the US Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. </span></em></p><p class="fine-print"><em><span>Paul Edward Hilliard does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Non-opioid directives allow patients to refuse opioids in all health care settings. For surgical procedures that require anesthesia, however, this may do more harm than good.Mark C. Bicket, Co-Director, Opioid Prescribing Engagement Network and Assistant Professor, University of MichiganJennifer Waljee, Associate Professor of Plastic and Reconstructive Surgery, University of MichiganPaul Edward Hilliard, Clinical Associate Professor of Anesthesiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657322021-08-20T15:16:24Z2021-08-20T15:16:24ZOpioid lawsuit payout plans overlook a vital need: Pain management care and research focused on smarter use of addictive drugs<figure><img src="https://images.theconversation.com/files/417080/original/file-20210819-25-qghrw5.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4927%2C3823&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The improper prescription of opioids for pain treatment is one of the central drivers of the opioid epidemic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/men-and-women-suffering-with-pain-trapped-royalty-free-illustration/901762524">ah_designs/iStock via Getty Images Plus</a></span></figcaption></figure><p>The opioid crisis has resulted in <a href="https://wonder.cdc.gov/controller/saved/D77/D205F251">more than 500,000 overdose deaths</a> over the past two decades. The federal government, states and other entities have <a href="https://doi.org/10.1056/NEJMp1710756">filed litigation</a> against drug manufacturers, suppliers and pharmacies as one approach to address the harm and suffering caused by inappropriate opioid prescribing practices. <a href="https://www.wsj.com/articles/states-announce-26-billion-settlement-to-resolve-opioid-lawsuits-11626890613">Billions</a> of <a href="https://www.cnn.com/2021/07/20/investing/opioid-settlement-new-york-1-1-billion/index.html">dollars</a> of <a href="https://www.wsj.com/articles/purdue-pharma-reaches-8-34-billion-settlement-over-opioid-probes-11603292613">funds</a> have since been awarded, and more is likely to come. </p>
<p>To ensure these funds are used in areas relevant to opioids, policy and public health groups led by experts at <a href="https://opioidprinciples.jhsph.edu/">Johns Hopkins University</a>, <a href="https://fxb.harvard.edu/warondrugstoharmreduction/">Harvard University</a> and other organizations have <a href="https://www.lac.org/resource/opioid-settlement-recommendations-from-the-addiction-solutions-campaign">proposed</a> <a href="https://www.lac.org/resource/evidence-based-strategies-for-abatement-of-harms-from-the-o">frameworks</a> detailing priorities on what to do with the money. But none of them address the needs of one critical group: patients who suffer from acute and chronic pain.</p>
<p>Gaps in pain care and treatment, one of the key factors that enabled inappropriate opioid prescribing in the first place, persist. I am a <a href="https://scholar.google.com/citations?user=mQswfH4AAAAJ&hl=en">physician scientist specializing in pain medicine</a>. My colleagues, law professor <a href="https://michigan.law.umich.edu/faculty-and-scholarship/our-faculty/barbara-l-mcquade">Barbara McQuade</a> and anesthesiologist <a href="https://scholar.google.com/citations?user=FQIBJYEAAAAJ&hl=en">Chad Brummett</a>, and I believe there are <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2783468">three key ways</a> these funds could be used to improve pain treatment and address resource gaps for patients with acute and chronic pain.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider holding a person's bent leg below the knee." src="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=453&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=453&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=453&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Expanding pain treatment beyond medication could help curb the opioid epidemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-man-having-medical-exam-royalty-free-image/846421676">gilaxia/E+ via Getty Images</a></span>
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<h2>1. Comprehensive pain management</h2>
<p>There are two common types of pain. <a href="https://doi.org/10.1016/S0140-6736(99)03313-9">Acute pain</a> is usually sharp and sudden. It’s the pain typically felt after a cut or an injury, and helps warn the body about tissue damage. Acute pain is very common, and generally goes away once the body heals. </p>
<p><a href="https://medlineplus.gov/chronicpain.html">Chronic pain</a>, on the other hand, persists even after tissue has healed and the injury has resolved. When this happens, pain can transform from a symptom into a chronic disease. Many conditions can cause chronic pain, ranging from <a href="https://medlineplus.gov/arthritis.html">arthritis</a> and <a href="https://medlineplus.gov/migraine.html">migraines</a> to <a href="https://medlineplus.gov/fibromyalgia.html">fibromyalgia</a> and nerve pains like <a href="https://medlineplus.gov/sciatica.html">sciatica</a> and <a href="https://www.cdc.gov/shingles/about/complications.html">postherpetic neuralgia from shingles</a>, among others. Why acute pain transforms into chronic pain is not always clear. </p>
<p>Due to a <a href="https://dx.doi.org/10.1016%2Fj.drugalcdep.2016.12.002">combination of factors</a>, recent approaches to pain treatment, such as the concept of the <a href="https://dx.doi.org/10.1016%2Fj.pmn.2017.10.010">fifth vital sign</a> which reduced pain to a number on a scale between 0 and 10, led to an over-reliance on medications and limited approaches to treatment, all of which persist to this day.</p>
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<figcaption><span class="caption">People have different responses to different levels of pain. What may be an effective treatment for one person might not be for someone else.</span></figcaption>
</figure>
<p>The most effective care for chronic pain, however, typically includes therapy beyond pills. <a href="https://www.ncbi.nlm.nih.gov/books/NBK82511/">Comprehensive pain management</a> involves care from a <a href="https://doi.org/10.1016/0304-3959(92)90145-2">diverse team of clinicians</a>, such as physical therapists and pain psychologists, to name a few. It also involves a suite of treatment approaches and care methodologies, including <a href="https://doi.org/10.1136/bmj.h444">behavioral therapy</a> which focuses on the psychological and social aspects of pain. <a href="https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name">Complementary and integrative approaches</a>, such as acupuncture, biofeedback and yoga, can also be combined with <a href="https://doi.org/10.1016/j.cger.2016.06.003">interventional approaches</a> like injections, dry needling and electrical stimulation.</p>
<p>While the right combination of therapies depends on the individual patient, the goal is to alleviate their pain, help them regain their ability to perform everyday activities and improve their quality of life.</p>
<p>This multidisciplinary and multimodal approach to pain management became less common due to <a href="https://dx.doi.org/10.1016%2Fj.drugalcdep.2016.12.002">financial pressures after the rise of managed care</a> in the late 1980s and early 1990s. Limited access to comprehensive pain management can lead to worse outcomes for patients. One study found that insurance policies that <a href="https://www.healthychildren.org/English/family-life/health-management/health-insurance/Pages/What-Is-an-Insurance-Carve-Out.aspx">carve out</a> physical therapy from pain management programs led to <a href="https://doi.org/10.1213/01.ane.0000058886.87431.32">worse physical and psychosocial function</a> up to one year after treatment in patients with chronic pain compared to patients whose insurance policies directly covered physical therapy.</p>
<p>Funding to bolster team-based and multidisciplinary approaches to treatment could not only improve care for patients in pain, but also increase their <a href="https://doi.org/10.1037/a0035514">accessibility outside of academic medical centers</a>.</p>
<h2>2. Evidence-based care models</h2>
<p><a href="https://doi.org/10.1136/bmj.a1714">Translating research into evidence-based care models</a> will help bring the best treatment approaches to patients in pain. These models of care <a href="https://www.ahrq.gov/opioids/evidence.html">review the evidence provided by clinical studies</a> and implement their findings to improve patient care. </p>
<p>For example, there is <a href="https://www.doi.org/10.23970/AHRQEPCCER240">evidence to support the use</a> of heat therapy and acupuncture for acute lower back pain, and non-opioid pills for kidney stone pain. Yet patients may not be offered these treatments due in part to <a href="https://doi.org/10.1001/jamanetworkopen.2018.0235">wide variation</a> <a href="https://doi.org/10.1001/jamanetworkopen.2018.3044">in coverage</a> of these treatments.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider performing acupuncture on a person's back." src="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=450&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=450&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=450&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Complementary therapies can be integrated with traditional interventional approaches to treat pain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/physio-performing-acupuncture-on-a-patient-royalty-free-image/1290749382">Catherine Falls Commercial/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Opioid prescribing represents another area where several gaps in evidence exist for their effectiveness in treating both <a href="https://doi.org/10.17226/25555">acute</a> and <a href="https://stacks.cdc.gov/view/cdc/38026">chronic</a> pain. Until a few years ago, there was no data-driven answer as to what dose of opioids should be prescribed <a href="https://michigan-open.org/prescribing-recommendations/">after common types of surgery</a>. This was partly based on an assumption that patients needed prescription opioids after certain surgeries, which is <a href="https://doi.org/10.1097/sla.0000000000004965">not always the case</a>. Building evidence-based pain management recommendations to prevent unnecessary exposure to prescription opioids remain a focus of organizations like the <a href="https://michigan-open.org/">Michigan Opioid Prescribing Engagement Network</a>. </p>
<h2>3. Research on acute and chronic pain</h2>
<p>Additional research is needed to advance therapies to treat acute and chronic pain. A recent summary of acute pain treatments noted a <a href="https://www.doi.org/10.23970/AHRQEPCCER240">lack of evidence to support current therapies</a> for patients with sickle cell, acute nerve and neck pain, among others.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Group of five health care providers sitting around a table in discussion." src="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Multidisciplinary care teams offer a more holistic way to manage pain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/multidisciplinary-meetings-make-for-a-more-thorough-royalty-free-image/1248714799">shapecharge/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>The National Institutes of Health has boosted funding for research on pain and opioids in recent years via the <a href="https://heal.nih.gov/">HEAL Initiative</a>, a program focusing on opioid addiction and pain management. In 2019, the NIH <a href="https://www.nih.gov/news-events/news-releases/nih-funds-945-million-research-tackle-national-opioid-crisis-through-nih-heal-initiative">awarded US$945 million to projects</a> on improving chronic pain treatment, reducing opioid misuse and overdose and facilitating recovery from opioid addiction. Despite this effort, however, significant gaps still exist in both <a href="https://www.nap.edu/read/24781/chapter/6#120">lab-based</a> and <a href="https://doi.org/10.23970/AHRQEPCTB33">clinical</a> pain research. </p>
<h2>Giving patients with pain a seat at the table</h2>
<p>The economic impact of pain has been estimated to have a <a href="https://www.ncbi.nlm.nih.gov/books/NBK92521/">more than $700 billion dollar price tag</a> in the U.S. when adjusted for inflation. A little more than half of that amount comes from care costs, while the other half comes from reduced productivity or the inability to work. </p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Addressing gaps in <a href="https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm#fig64">addiction treatment</a> and <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">overdose prevention</a> is vital to turning the tide on the opioid epidemic. But implementing even some of these three ways to improve pain care could also put a dent in how much the U.S. spends on pain. Giving patients with pain a say in how funds from the opioid lawsuits are distributed can help make sure they’re not forgotten.</p><img src="https://counter.theconversation.com/content/165732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Bicket receives grant funding from the National Institutes of Health (R01DA042859, R01DA044987, R01DA049789), the Arnold Foundation, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and the US Centers for Disease Control and Prevention. He served as a consultant in the past for Axial Healthcare and Alosa Health. </span></em></p>Ending the opioid epidemic requires addressing not only treatment gaps in addiction and overdose, but also inadequate pain management.Mark C. Bicket, Assistant Professor of Anesthesiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1642862021-08-11T19:29:30Z2021-08-11T19:29:30Z‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids<figure><img src="https://images.theconversation.com/files/415383/original/file-20210810-13-9vnesq.jpg?ixlib=rb-1.1.0&rect=92%2C29%2C3140%2C2004&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone can prevent deaths from opioid overdose, but there is no way to reverse the effects of benzodiazepine overdose without risk.</span> <span class="attribution"><span class="source">(THE CANADIAN PRESS/Jonathan Hayward)</span></span></figcaption></figure><p>Canada has seen a drastic shift in the unregulated drug supply with the emergence of benzodiazepine-adulterated opioids (also known as “benzo-dope”). Benzodiazepines have been detected in as many as <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">60 per cent of overdose deaths in British Columbia</a>.</p>
<p>Recent data from B.C. has observed a steady rise in opioids testing positive for benzodiazepines between August 2020 and April 2021, <a href="https://drugcheckingbc.ca/monthly-reports/">from a low of five per cent to a high of 25 per cent</a>.</p>
<p>British Columbia is not alone in seeing this trend: data from Toronto has shown that this issue is even more prominent. During the same time period, there was an increase from <a href="https://drugchecking.cdpe.org/">45 per cent to 57 per cent</a> in samples containing etizolam, a specific benzodiazepine-like compound.</p>
<p>Commonly prescribed benzodiazepines include drugs like Xanax and Valium. These medications treat a variety of conditions such as anxiety and insomnia and have been used since the 1960s. </p>
<p>However, what is being detected in opioids in Canada are not pharmaceutical drugs. They are drugs from the benzodiazepine class that are neither prescribed nor used in medicine in Canada, meaning they may possess unknown strengths or side-effects. Since benzodiazepines are sedatives, combining them with another type of depressant, like opioids, significantly increases the risk of overdose.</p>
<p>As researchers in substance use, we questioned whether the increasing supply of benzo-dope in the unregulated drug market would saturate the opioid supply in a similar way fentanyl did to heroin years ago. The data seem to suggest we should be prepared for the unregulated drug supply to adjust to a new normal.</p>
<p>In this context, there are significant public health issues that need to be considered. </p>
<h2>Emergence of ‘benzo-dope’</h2>
<p>The increasing availability of benzo-dope is cause for concern given that when taken together, the combined effects of benzodiazepines and opioids can result in overdose and death. According to the B.C. Coroner’s Service, there has been a substantial increase in benzodiazepines detected in illicit drug toxicity deaths, <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">from 15 per cent in July 2020 to 60 per cent in May 2021</a>. </p>
<p>Most people do not intend to consume benzodiazepines with their opioids. As a consequence, people wanting to use opioids may unknowingly increase their risk of overdose from benzodiazepine adulteration. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A test strip in a paper cup" src="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug checking services can provide people with timely information about the contents of their unregulated drugs using things like the fentanyl test strip shown here. However, benzodiazepine test strips may miss detecting the drug.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Benzodiazepines are also slower to take effect compared to opioids, meaning someone can experience delayed overdose symptoms. Thefts and sexual assaults have also been reported after people were given benzodiazepine-adulterated opioids without their knowledge and consequently knocked into an unresponsive state.</p>
<p>The reason behind the adulteration of benzodiazepines in opioids is unclear. Some suggest they may be added to opioids to produce similar effects at a lower total cost to drug suppliers, or intentionally used to prolong or enhance the desirable effects of opioids. Regardless, there is growing evidence that co-use and dependence on opioids and benzodiazepines is occurring in parallel to the rising supply of these drugs. </p>
<p>Deaths from opioid overdose can be prevented with <a href="https://towardtheheart.com/naloxone">naloxone, which counteracts the effects of opioids</a>. However, there is no evidence-based antidote to reverse the effects of benzodiazepines without potential consequences such as withdrawal or seizures.</p>
<p>Additionally, due to the complications of benzodiazepine withdrawal, many addiction treatment providers will not admit individuals who test positive for benzodiazepines. As a result, people may not be able to access substance use treatment because of an imposed adulterant to their drugs.</p>
<h2>Challenges detecting benzo-dope</h2>
<p><a href="https://drugcheckingbc.ca/">Drug checking services</a> have been implemented across Canada to monitor the unregulated drug supply and provide people with timely information about the contents of their drugs. In many settings in B.C., benzodiazepine test strips are used alongside a technology called <a href="https://drugcheckingbc.ca/what-is-drug-checking/overview-of-technologies/">Fourier-transform infrared</a> spectroscopy to detect the presence of benzodiazepines. However, limitations of these technologies sometimes cause benzodiazepines to be missed when present in small concentrations. </p>
<p>Etizolam, the most common benzodiazepine-like compound found in opioids, is particularly difficult to detect using point-of-care drug-checking technologies because of its chemical structure. Thus, there may be an under-reporting of how pervasive this issue really is in B.C. and elsewhere in Canada. </p>
<h2>A new wave of the overdose epidemic?</h2>
<p>There have been a number of crucial life-saving responses to address the fentanyl-driven overdose epidemic, such as <a href="http://www.bccdc.ca/our-services/programs/harm-reduction">supervised consumption sites and expanded distribution of naloxone</a>. However, less attention has been paid to the growing issue of benzo-dope and its associated health harms. As this public health emergency worsens, it is important that we incorporate a broader understanding of overdose risk that goes beyond opioids in our efforts to prevent, treat and respond.</p>
<p>It’s too soon to know whether benzo-dope will saturate the unregulated opioid market. As long as there remains a lack of any legal framework to promote a safer supply of drugs (safe supply and <a href="https://theconversation.com/decriminalizing-drug-use-as-we-contain-the-coronavirus-is-the-humane-thing-to-do-136165">decriminalization</a>), there will always be a level of unpredictability in the unregulated opioid supply that can harm people’s health.</p><img src="https://counter.theconversation.com/content/164286/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lianping Ti receives funding for her research from the Michael Smith Foundation for Health Research and Health Canada.</span></em></p><p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fentanyl adulteration led to the replacement of heroin in the unregulated drug supply of British Columbia. Now that benzodiazepines are present in many opioids, are we headed towards a ‘new normal?’Lianping Ti, Assistant Professor, Department of Medicine, University of British ColumbiaSamuel Tobias, Research Data Coordinator, British Columbia Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1635572021-07-16T12:28:11Z2021-07-16T12:28:11ZDesigning less addictive opioids, through chemistry<figure><img src="https://images.theconversation.com/files/411097/original/file-20210713-19-nm0d98.jpg?ixlib=rb-1.1.0&rect=0%2C21%2C4898%2C3666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One potential way to make opioids less addictive is to make them target injured tissue rather than the healthy brain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/falling-pills-royalty-free-image/1217370301">PM Images/Photodisk via Getty Images</a></span></figcaption></figure><p>What if there was a way for pain patients to get all the pain-relieving power of opioids with none of the addicting side effects? </p>
<p>Opioids are one of the <a href="https://medlineplus.gov/painrelievers.html">most powerful pain medications</a> available, but <a href="https://doi.org/10.7326/M17-0865">millions of Americans</a> have struggled with prescription opioid misuse after getting hooked on the <a href="https://medlineplus.gov/genetics/condition/opioid-addiction/">feelings of calm and euphoria they also induce</a>. But new research suggests there may be a way to chemically tailor opioids to reduce their addictive potential.</p>
<p>The first wave of the opioid epidemic in the United States began in the <a href="https://www.cdc.gov/opioids/basics/epidemic.html">1990s</a>. By 2015, approximately <a href="https://doi.org/10.7326/M17-0865">11.5 million Americans</a> were struggling with prescription opioid misuse. The Centers for Disease Control and Prevention estimates that <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">nearly 500,000 people died</a> from opioid overdose from 1999 to 2019. Recent reports have shown that this ongoing health crisis has only intensified during the <a href="https://doi.org/10.26099/3d62-cv07">COVID-19 pandemic</a>. The U.S. reached a record <a href="https://www.statnews.com/2021/07/14/us-overdose-deaths-record-2020-pandemic/">93,000 overdose deaths in 2020</a>, a 29% increase from the previous year.</p>
<p>Many people with opioid dependencies report using these drugs to relieve <a href="https://dx.doi.org/10.1111%2Fj.1521-0391.2012.00327.x">physical pain</a>: <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">Chronic pain treatment</a> is a leading cause of opioid abuse. But there currently are no equivalent medications capable of the providing the same level of pain relief without the potential risk of addiction.</p>
<p>A less addictive opioid, however, could be an important tool to deal with the opioid epidemic. I’m a <a href="https://scholar.google.com/citations?user=df8z7MQAAAAJ&hl=en">physical chemist</a> interested in this problem, and my research group used computational chemistry to investigate how opioids like morphine can be redesigned to <a href="https://doi.org/10.1016/j.cplett.2021.138723">target specific pain regions without affecting the brain</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/8xoOF2x0XzM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In the process of trying to develop a less addictive painkiller, researchers produced more forms of addictive opioids.</span></figcaption>
</figure>
<h2>The biochemistry of opioids</h2>
<p>There are many different classes of opioids that vary in chemical structure. However, all opioids contain the same type of chemical group that dictates their biochemical activity. Morphine, oxycodone and hydrocodone belong to the same major class of <a href="https://doi.org/10.1111/j.1365-2125.2012.04317.x">epoxymorphinan opioids</a> and share nearly identical <a href="https://doi.org/10.3389/fphar.2018.01210">chemical structures</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Structures of epoxymorphinan structures" src="https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=224&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=224&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=224&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=282&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=282&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=282&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Morphine, oxycodone, and hydrocodone belong to the same class of opioids and have similar structures.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Fentanyl, on the other hand, belongs to the <a href="https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2125.2012.04317.x">phenylpiperidine</a> class of opioids and looks quite different.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chemical structures of morphine and fentanyl" src="https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=351&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=351&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=351&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Morphine and fentanyl have different chemical structures but share a nitrogen group that undergo a similar chemical reaction in the bloodstream.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The chemical structures of these molecules will be a bit of mystery if you haven’t taken an organic chemistry class before. However, we can simplify the picture by focusing on what’s common between them. Both molecules contain a nitrogen that’s part of what’s called an <a href="https://2012books.lardbucket.org/books/introduction-to-chemistry-general-organic-and-biological/s18-13-amines-as-bases.html">amine group</a>. This group can become positively charged via a chemical reaction that happens in water-based environments such as the bloodstream.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Morphine reaction with water to generate active opioid." src="https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=194&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=194&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=194&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=244&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=244&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=244&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Neutrally-charged morphine undergoes a chemical reaction in water to become a positively-charged, biochemically active compound.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>This positively charged structure is the biochemically active form of the opioid – it won’t have any effect on your body until it gains this positive charge. The positive charge on the nitrogen helps these drugs bind to the target site where the pain is originating and provide relief.</p>
<p>The <a href="https://www.news-medical.net/health/pH-in-the-Human-Body.aspx">typical acidity level</a> of the average person’s body provides ideal conditions for morphine and fentanyl to become positively charged. This means that nearly all of the drug that’s consumed will be biochemically active throughout the body. Whether it’s in the brain or at the site of injury, cells all over the body will feel the effects of the drug.</p>
<h2>Making opioids less addictive</h2>
<p>Many of the addictive qualities of opioids are due to the <a href="https://doi.org/10.1177%2F0963689718811060">feelings of calm and euphoria</a> they induce in the brain. For conditions like arthritis and wound and postoperative pain, however, these drugs need to target only the diseased or injured areas of the body to provide pain relief. The question researchers face is whether it’s possible to limit the effect of opioids to specific areas of the body without affecting the brain.</p>
<p>One <a href="https://doi.org/10.1126/science.aai8636">recently proposed solution</a> focuses on the acidity difference between injured and healthy tissue. Injured tissue is more acidic than healthy tissue due to a process known as <a href="https://doi.org/10.1155/2018/1218297">acidosis</a>, where lactic acid and other acidic byproducts <a href="https://dx.doi.org/10.1074%2Fjbc.M112.426254">produced by damaged tissue collect</a>. This means that an opioid could potentially be altered to be positively charged and active only in injured tissue, while staying neutral and inactive in normal tissue. The drug would be biochemically active only at a higher acidity level than found in healthy tissue.</p>
<p>This theory was first explored using <a href="https://doi.org/10.1038/s41598-018-27313-4">fentanyl</a>. Researchers found that introducing a fluorine (F) atom near the nitrogen in the amine group can lower the acidity range in which fentanyl is active, making it less likely to be active at the normal acidity levels of the body.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chemical structure of fluorinated fentanyl" src="https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adding a fluorine atom to fentanyl can make it less likely to be biochemically active in healthy body tissues.</span>
<span class="attribution"><span class="source">Aaron Harrison</span></span>
</figcaption>
</figure>
<p>Adding fluorine to fentanyl showed increased opioid activity in the more acidic conditions of injured tissue compared to healthy tissue. This meant that the drug “turned on” only in parts of the body that needed pain relief. In addition, it showed a <a href="https://doi.org/10.1038/s41598-019-55886-1">decrease in the severe side effects</a> associated with opioids, like addictive potential and abnormally decreased breathing rates, while still providing pain relief.</p>
<p>My colleagues and I have recently extended this framework to <a href="https://doi.org/10.1016/j.cplett.2021.138723">morphine</a>. We showed that similar fluorine substitutions can also adjust morphine’s active acidity range to specifically target injured tissue. Given that molecules in the same class of opioids as morphine share similar structures, we believe this approach would also work in other opioids like hydrocodone and oxycodone.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chemical structure of fluorinated morphine" src="https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adding a fluorine atom to morphine can make it less likely to be biochemically active in healthy body tissues.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Effectively treating pain without putting patients at risk for addiction remains a significant problem in health care. This approach has been tested only in lab settings and might not be in pharmacies for some time, if ever. But chemically altering existing opioids is a promising avenue towards developing drugs that alleviate pain without causing addiction.</p>
<p>[<em>Understand new developments in science, health and technology, each week.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-understand">Subscribe to The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/163557/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aaron W. Harrison does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While the COVID-19 pandemic raged on, the opioid epidemic got worse as drug overdose deaths soared. New research proposes a way to chemically modify opioids to reduce the risk of addiction.Aaron W. Harrison, Assistant Professor of Chemistry, Austin CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1497982020-11-16T13:23:53Z2020-11-16T13:23:53Z7 things President-elect Biden can achieve on health care<figure><img src="https://images.theconversation.com/files/368796/original/file-20201111-21-wnhiau.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C2955%2C2020&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Biden administration can make significant changes in health care for Americans.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-elect-joe-biden-removes-his-mask-to-address-the-news-photo/1284977695?adppopup=true">Joe Raedle via Getty Images</a></span></figcaption></figure><p>President-elect Joe Biden has plenty of work ahead of him; reining in <a href="https://doi.org/10.1002/wmh3.371">the out-of-control pandemic</a> tops the list, and beyond that, there are significant challenges on health care in general. </p>
<p>Unquestionably, the incoming administration also faces limitations. Twelve years ago, Barack Obama had a <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">filibuster-proof majority</a> in the U.S. Senate. This time, that will not be the case, and many progressive dreams, like “Medicare for All,” are far out of reach. Even Biden’s modest goal to expand the Affordable Care Act <a href="https://www.milkenreview.org/articles/much-ado-about">via a public option</a> will likely fall on Mitch McConnell’s deaf ears.</p>
<p>As a <a href="https://publicpolicy.psu.edu/people/sfh5482">professor of public policy</a> analyzing the political landscape, I believe big, transformational reforms are unlikely in the next few years, particularly given the contentious aftermath to the presidential election. But Biden and Vice President-elect Kamala Harris can make changes in seven smaller but important policy issues that will improve the lives of millions of Americans. Some of these the Biden administration can achieve on its own via regulations and other administrative actions. Others require bipartisan cooperation, but Republicans might come on board if it suits them politically.</p>
<figure class="align-center ">
<img alt="The Affordable Care Act was passed on March 23, 2010." src="https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368801/original/file-20201111-13-ivsqjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Affordable Care Act, championed by then-President Barack Obama, was passed on March 23, 2010.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-barack-obama-leaves-after-speaking-in-a-rally-news-photo/152692518?adppopup=true">Jewel Samad via Getty Images</a></span>
</figcaption>
</figure>
<h2>1. Taking Executive Action</h2>
<p>To shore up the Affordable Care Act, Biden has a number of administrative policy tools that reverse course on many actions taken <a href="https://doi.org/10.1111/psj.12385">by the Trump administration</a>. In some instances, he can take executive action; he will not need Congress to cooperate. </p>
<p>To lower the uninsured rate, Biden can expand enrollment periods for the ACA marketplaces. He can also refocus on <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">advertising, outreach and enrollment</a> efforts. The Trump administration virtually eliminated this type of funding with <a href="https://doi.org/10.1377/hlthaff.2015.0215">significant implications for enrollment</a>. He can also move to strike regulations that <a href="https://doi.org/10.1215/03616878-8543250">weaken the marketplace</a>. Dozens more seemingly small technical changes to regulations can cumulatively have a considerable impact. </p>
<h2>2. Expanding Medicaid coverage</h2>
<p>The ACA was passed with the intent that states would broaden coverage for the uninsured by expanding Medicaid; <a href="https://doi.org/10.1215/03616878-2882219">most Republican states balked</a>. Biden may have a way around that; he can encourage states to expand their Medicaid programs via <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html">the Section 1115 waivers</a>. With those waivers, states may temporarily disregard certain Medicaid requirements to test innovations. </p>
<p><a href="https://doi.org/10.1111/psj.12385">Under President Obama</a>, some Republican states traded Medicaid expansion for smaller premiums or health-behavior incentives. Now work incentives and potentially work requirements may be <a href="https://doi.org/10.1215/03616878-8802198">on the table</a>.
While these requirements certainly make individual enrollment harder for some, compromise may be necessary to bring Medicaid coverage to the remaining holdout states, all Republican.</p>
<h2>3. Tackling the opioid epidemic</h2>
<p>The opioid crisis has worsened because of <a href="https://www.npr.org/sections/health-shots/2018/03/06/590923149/jump-in-overdoses-shows-opioid-epidemic-has-worsened">the coronavirus outbreak</a>. While the Trump administration has made <a href="https://www.whitehouse.gov/opioids/">some efforts to address the issue</a>, those with addiction and substance use disorder need much more. Refocusing the attention of the government on opioids during the pandemic is crucial. Otherwise, things will get even worse. </p>
<p>Biden should secure additional bipartisan funding from Congress for states hit hardest by opioids, <a href="https://theconversation.com/how-killing-the-aca-could-lead-to-more-opioid-deaths-in-west-virginia-and-other-trump-states-79991">like West Virginia</a>. Once again, many of those states are red. Yet bipartisanship will be key to establishing a comprehensive national strategy is crucial here.</p>
<figure class="align-center ">
<img alt="Every year, Americans are haunted by surprise medical bills." src="https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368805/original/file-20201111-13-1asj2kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Surprise medical bills haunt millions of Americans every year.</span>
<span class="attribution"><span class="source">Damir Khabirov via Getty Images</span></span>
</figcaption>
</figure>
<h2>4. Improving access to organ transplants</h2>
<p>Organ transplants don’t get much attention, but the U.S. has suffered a <a href="https://www.milkenreview.org/articles/thinking-the-unthinkable">severe shortage</a> of available organs for decades. Every day, 13 Americans die waiting for a kidney, and <a href="https://www.organdonor.gov/statistics-stories/statistics.html">four more die</a> waiting for other organs. COVID-19 has further worsened the shortage. </p>
<p>The Trump administration <a href="https://www.hhs.gov/about/news/2019/12/17/trump-administration-proposes-new-rules-increase-accountability-availability-organ-supply.html">made advances</a> on this issue through regulations. These include increasing support for living organ donors. Biden should build on this progress. He could change the current approach to donations, which relies solely on altruism, by increasing financial support for donors. The <a href="https://www.congress.gov/bill/116th-congress/house-bill/7900/">Organ Donation Clarification Act</a>, from Democratic U.S. Rep. Matt Cartwright of Pennsylvania, is now languishing in Congress, but it could serve as a major step in this direction.</p>
<h2>5. Ending surprise medical bills</h2>
<p>The Trump administration talked about it, but never managed to eliminate <a href="https://theconversation.com/why-thousands-are-getting-hit-with-unexpected-medical-bills-117955">surprise billing</a>. Those are medical bills patients aren’t expecting, often because a provider is not part of their network. </p>
<p><a href="https://www.kff.org/health-costs/poll-finding/data-note-public-worries-about-and-experience-with-surprise-medical-bills/">Americans are overwhelmingly outraged</a> by surprise bills and want a solution. Both parties in Congress have worked on the issue for years, yet hospitals, physicians and insurers <a href="https://khn.org/news/when-your-doctor-is-also-a-lobbyist-inside-the-war-over-surprise-medical-bills/">have lobbied</a> to keep them untouched.</p>
<p>Some limited progress is likely through regulation. But it will take statutory change to establish meaningful protections for all Americans. Strong presidential and congressional leadership could make a difference here, but even then, it won’t be easy.</p>
<h2>6. Reining in prescription drug prices</h2>
<p>The U.S. pays substantially higher prices than the rest of the developed world for prescription drugs. This is primarily due to <a href="https://www.penguinrandomhouse.com/books/318776/an-american-sickness-by-elisabeth-rosenthal/9780143110859/">limited competition among drug companies and a patent system susceptible to gaming</a>. Moreover, our regulatory apparatus has focused <a href="https://www.penguinrandomhouse.com/books/318776/an-american-sickness-by-elisabeth-rosenthal/9780143110859/">largely on drug safety</a> while deemphasizing cost-effectiveness for new and existing drugs. </p>
<p>The Trump administration’s recent proposal to fix the problem <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">were limited</a>. Congress should follow the German example, which reins in prices <a href="https://theconversation.com/why-the-us-has-higher-drug-prices-than-other-countries-111256">by 30 percentage points</a> as compared with the U.S. and focuses on rewarding effective drugs. Pharmaceutical companies will vigorously fight to maintain their profits, but given the universal public disdain for high drug prices, a committed bipartisan coalition may bring some relief.</p>
<h2>7. Expanding children’s health coverage</h2>
<p>The years under Trump saw <a href="https://www.cnn.com/2020/10/09/politics/uninsured-children-increase-2019/index.html">increases</a> in the number of children without health insurance. Today, <a href="https://ccf.georgetown.edu/2019/10/29/the-number-of-uninsured-children-in-on-the-rise-acs/">more than 4 million American children</a> are without insurance. This occurred even before the job losses caused by the pandemic. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Bipartisanship has worked in the past to improve access for children both through <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">Medicaid</a> and the <a href="https://theconversation.com/time-to-stop-using-9-million-children-as-a-bargaining-chip-90293">Children’s Health Insurance Program (CHIP)</a>. Now Biden can strengthen both programs. Investments into <a href="https://doi.org/10.1016/j.jadohealth.2020.09.005">school-based health</a> also seems prudent. And while bipartisanship on the issue <a href="https://theconversation.com/clock-running-out-on-health-program-for-9-million-kids-84404">has grown less prominent</a>, there might be enough Republicans in Congress willing to join Democrats and expand coverage and benefits.</p><img src="https://counter.theconversation.com/content/149798/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems.</span></em></p>From expanding children’s coverage to reducing surprise bills, Biden and lawmakers may be able to broaden health care access.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1475212020-10-05T13:58:29Z2020-10-05T13:58:29ZA researcher reflects on progress fighting hepatitis C – and a path forward<figure><img src="https://images.theconversation.com/files/361658/original/file-20201005-20-uz1dfq.jpg?ixlib=rb-1.1.0&rect=180%2C167%2C4412%2C2923&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The hepatitis C virus was discovered in 1989 – research that's now earned a Nobel Prize.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/hepatitis-c-virus-hcv-causes-blood-borne-hepatitis-news-photo/1158016725">BSIP/Universal Images Group via Getty Images</a></span></figcaption></figure><p>When I began my medical career in Hong Kong in the early 1980s, I chose to focus on hepatitis B, in part because it was very common and because the hepatitis C virus had not yet been discovered. I witnessed the devastation that this virus caused – cirrhosis, liver failure and liver cancer – and the lack of treatments we could offer to patients.</p>
<p>Back then, scientists knew there was another type of hepatitis, but no one could identify it, so we called it non-A, non-B hepatitis. I would never have imagined that during the course of my career I would witness the <a href="http://doi.org/10.1126/science.2523562">discovery of what came to be known as hep C</a> and the <a href="http://doi.org/10.1056/NEJMoa1402454">development of a cure</a> for nearly all patients with <a href="http://doi.org/10.1056/NEJMoa1402355">chronic hepatitis C in 2014</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="three scientist projected on screen at announcement" src="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Announcement that the 2020 Nobel Prize in Physiology or Medicine will go to three researchers who identified the hepatitis C virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nobel-committee-members-patrik-ernfors-and-gunilla-karlsson-news-photo/1228905071">Jonathan Nackstrand/AFP via Getty Images</a></span>
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<p>Underscoring the importance of these discoveries for global human health, this year’s <a href="https://www.nobelprize.org/prizes/medicine/2020/summary/">Nobel Prize in Physiology or Medicine</a> was awarded jointly to Harvey J. Alter, Michael Houghton and Charles M. Rice for the discovery of the hepatitis C virus.</p>
<p>The development of treatments over the past 30 years reflects the amazing progress the field has made in tackling hepatitis C in a relatively short period of time. Initially, in the late 1980s, before a diagnostic test became available, some physicians started treating well-characterized cases of non-A, non-B hepatitis (hep C) with interferon, a natural protein that the body makes to fight viruses, and ribavirin, an antiviral drug. These medications were not specifically developed for hepatitis C, had to be given as injections for 6-12 months, had many side effects and resulted in a cure in only half of the patients who received treatment. It took more than two decades for the first direct-acting antiviral drugs to be approved by the FDA. </p>
<p>I remember the excitement when I and my colleagues tested one of the new drug combinations in patients and saw the virus count drop from more than 1 million to less than 20 within two weeks. <a href="http://doi.org/10.1056/NEJMoa1104430">We published the results</a> of our pilot study in the New England Journal of Medicine in 2012. Although the study involved only 21 patients, it was considered a watershed moment because it was the first study to prove that a combination of oral pills without interferon can cure hepatitis C.</p>
<p>Effective treatment for hepatitis C has become even more relevant today in light of the recent surge in new cases of hepatitis C due to rising opioid use.</p>
<h2>A pricey drug and new generics</h2>
<p>The first combo pill with two drugs that inhibits different steps in hepatitis C replication was <a href="http://www.gilead.com/news/press-releases/2014/10/us-food-and-drug-administration-approves-gileads-harvoni-ledipasvirsofosbuvir-the-first-oncedaily-single-tablet-regimen-for-the-treatment-of-genotype-1-chronic-hepatitis-c">approved by the FDA in 2014</a>. This pill is taken once a day for 8-12 weeks, has little to no side effects and improved the cure rate to 90-95%. It was hailed as a magical cure, but it came with a price tag of US$94,500 for a 12-week course of treatment. That led many insurers in the United States and national health departments in other countries to limit access to treatment. </p>
<p>Since then, <a href="http://doi.org/10.1056/NEJMoa1512610">several other</a> <a href="http://doi.org/10.7326/M15-0785">combo pills with</a> <a href="http://doi.org/10.1056/NEJMoa1702417">similar cure rates</a> that are equally well-tolerated have become available, and the cost has markedly decreased. In addition, low-cost generics and special pricing arrangements are available in many resource-limited countries. </p>
<p>While the current price of hepatitis C virus drugs is still very high, one needs to remember that for 95 percent of patients, this is a cure. It is unlike medicines for many illnesses that need to be taken for a long time, sometimes for the rest of the patients’ lives. Indeed, a cure for hepatitis C virus has allowed some patients who were on the liver transplant waiting list to <a href="https://doi.org/10.1016/j.jhep.2016.05.010">reverse their liver failure</a>, making transplantation unnecessary. This is good news not only for these patients but also for others on the waiting list. </p>
<p>The remarkable success of hepatitis C treatment has reenergized efforts to find a cure for hepatitis B. Current treatments can suppress hepatitis B virus replication but do not eliminate it. Most patients need to be on long-term treatment to prevent flare-ups of hepatitis when the virus reemerges after treatment is stopped. </p>
<h2>Deaths from hepatitis B and C infections rising worldwide</h2>
<p>Learning from the hepatitis C experience and with better understanding of the biology of hepatitis B virus and improved animal models, pharmaceutical companies are developing <a href="https://doi.org/10.1002/hep.29323">drugs that target different steps of the hepatitis B virus life cycle</a>. While a cure for hepatitis B will be more challenging because it can integrate into the patient’s DNA, enabling it to evade the patient’s immune response, I am optimistic that we will witness the availability of new combinations of drugs that will move us nearer the goal of a hepatitis B cure. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Members of Delhi Network of Positive People, a support group for HIV-positive people, in 2014 urged the Indian government to allow production of generic versions of direct-acting antivirals that could help thousands get affordable oral doses of medicine to control hepatitis C. Infection progresses more rapidly to damage the liver in HIV-positive patients.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-Health/14d6bce6d8fe430db7970e2bce717083/4/0">Saurabh Das/AP Photo</a></span>
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<p>But the news is not all positive. While we’ve seen mortality rates from HIV, tuberculosis and malaria decline in recent years, deaths from hepatitis B and C have risen. Globally, an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">257 million people have chronic hepatitis B virus infection</a>, and <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">71 million have chronic hepatitis C virus</a>. Together hepatitis B and C caused more than 1.34 million deaths in 2015. This led the World Health Organization to challenge countries around the world to develop national plans to <a href="http://apps.who.int/iris/bitstream/handle/10665/206453/WHO_HIV_2016.04_eng.pdf?sequence=1">eliminate these two viruses by 2030</a>. </p>
<p>Hepatitis B virus and hepatitis C virus are usually spread through contact with blood or body secretions such as semen from infected persons by sharing needles or sexual exposure. But they can also be spread through contaminated needles used for medical treatment, which continues to happen in many parts of the world. In addition, hepatitis B virus can be spread from infected mothers to newborn babies unless vaccination is given immediately after birth. </p>
<p>For people with hepatitis C virus, roughly two-third suffer chronic infection. For hepatitis B virus, the chance of chronic liver infection decreases the later the patient encounters the virus: the likelihood is 90% if infected during infancy; 20-30% if infected during childhood; and 2-5% if infected in adult life. Some people infected with hepatitis B virus or hepatitis C virus can recover on their own, but many develop chronic infections lasting more than six months and often years or lifelong. Those with chronic infection are at risk of cirrhosis (severe liver damage), liver failure and liver cancer. </p>
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<img alt="" src="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In 2017, a San Diego family was among several hundred people living in a campground for the homeless, set up to curb the worst hepatitis A outbreak in the United States in decades.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Homeless-Crisis-on-the-Coast-San-Diego/b0d09b99f82249138623efa6177d2e5f/33/0">Gregory Bull/AP Photo</a></span>
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<h2>Opioid epidemic, homeless lead to rise in hepatitis B and C infections</h2>
<p>In the United States, the number of new hepatitis B virus and hepatitis C virus infections has been decreasing for many years, but <a href="http://doi.org/10.2105/AJPH.2017.304132">this trend has been reversed</a> during recent years <a href="http://doi.org/10.1056/NEJMp1716871">due to the opioid epidemic</a> as more people use injection drugs, share needles or other paraphernalia and practice high-risk sexual behavior. This is particularly true for hepatitis C, where the number of new cases in the past 10 years has more than doubled, highlighting the need for a preventive vaccine, which is a vital tool to eliminate hepatitis C. The increase in number of new cases of hepatitis B is smaller and mainly seen in adults in their 30s because most younger persons have benefited from hepatitis B virus vaccination. </p>
<p>When we talk about viral hepatitis, the focus is on hepatitis B and C because they can cause chronic infection, while hepatitis A causes only acute infection and will not lead to cirrhosis or liver cancer. However, since 2016, many states in the U.S. have witnessed outbreaks of hepatitis A. The Centers for Disease Control and Prevention received more than 2,500 reports of hepatitis A between January 2017 and April 2018 associated with person-to-person transmission, with risk factors in <a href="https://emergency.cdc.gov/han/han00412.asp">two-thirds of these cases being drug use or homelessness</a> or both. In Michigan, where I live, 859 cases of hepatitis A, including 27 deaths, were reported between July 2016 and June 2018. We can prevent hepatitis A through vaccination and improved hygienic conditions. </p>
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<a href="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">World Hepatitis Day is celebrated on July 28, the birthday of Dr. Baruch S. Blumberg, a Philadelphia researcher who shared the 1976 Nobel Prize in physiology or medicine for his discovery of the hepatitis B virus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Obit-Blumberg/af5f0cf91a8a473582fb4fb5cf5106b8/1/0">Eddie Adams/AP Photo</a></span>
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<p>World Hepatitis Day occurs annually on July 28, a day chosen in honor of the late Baruch Blumberg, who received a Nobel Prize for discovering the hepatitis B virus. Today is another cause for celebration as a second Nobel is awarded for hepatitis research, this time for the discovery of hepatitis C virus. I marvel at how much progress we have made in the last three decades and am delighted to be not just an observer but also a contributor to the progress. Our work is not finished. Much more needs to be done to completely eliminate new cases of viral hepatitis and deaths from chronic hepatitis B and C. </p>
<p><em>This is an updated version of an <a href="https://theconversation.com/the-thrill-of-curing-hepatitis-c-and-the-pain-of-watching-the-disease-surge-with-opioid-abuse-99568">article originally published in July 2018</a>. It has been updated to include news of the 2020 Nobel Prize.</em></p><img src="https://counter.theconversation.com/content/147521/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Suk-Fong Lok has served on advisory panels of Roche, Viravaxx, and Spring Bank. She receives research funding from Bristol-Myers Squibb, Gilead, the National Institutes of Health, and the Patient Center for Outcome Research Institute provided to the University of Michigan. </span></em></p>The 2020 Nobel Prize for Physiology or Medicine goes to the discoverers of the hepatitis C virus. There’s an effective cure but homelessness and the opioid epidemic are driving a surge in infections.Anna Suk-Fong Lok, Professor of Internal Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1239622020-04-21T12:47:47Z2020-04-21T12:47:47ZPharmacists could be front-line fighters in battle against opioid epidemic<figure><img src="https://images.theconversation.com/files/315053/original/file-20200212-61929-1m6slzs.jpg?ixlib=rb-1.1.0&rect=48%2C24%2C5400%2C3564&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">On average, more than 130 Americans die from an opioid overdose every day.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/19331187675272/">AP Photo/Keith Srakocic</a></span></figcaption></figure><p>When you stop at your local pharmacy to pick up a toothbrush or an antacid, soon you may also be able to buy an over-the-counter drug to reverse an opioid overdose. The lifesaving drug, naloxone, currently requires a prescription, but it may become available as an over-the-counter purchase in 2020. </p>
<p>Despite the <a href="https://www.cdc.gov/vitalsigns/opioids/index.html">national decrease in opioid prescriptions</a> since 2012, the <a href="https://www.cdc.gov/drugoverdose/data/prescribing.html">opioid crisis</a> continues. Access to prescription opioids have decreased due to <a href="https://doi.org/10.1111/add.14394">stricter legislation</a>, insurance regulations and the Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain. At the same time, the use of heroin and illegally manufactured synthetic opioids, such as fentanyl and counterfeit prescription opioids, has <a href="https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf">escalated</a>. </p>
<p>In addition, <a href="https://doi.org/10.1001/jama.2018.2844">nearly 80% of opioid overdoses</a> involve multiple substances, compounding the risk of a fatal overdose. This reinforces the need for widespread, convenient naloxone access accompanied by <a href="https://doi.org/10.1097/ADM.0000000000000223">training on how to administer</a> this reversal drug. </p>
<p>As a <a href="https://cphs.wayne.edu/profile/ai6726">professor of pharmacy</a> and pharmacist, I believe that many more pharmacists can be engaged in providing naloxone for their patients.</p>
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<img alt="" src="https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Communities demand attention for the damage caused by the opioid crisis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-nyusa-0831-overdose-awareness-1168887157">Shutterstock.com/SCOOTERCASTER</a></span>
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<h2>Essential medication to save a life</h2>
<p>An opioid overdose can depress a person’s respiratory center to the point where breathing stops, resulting in death. Naloxone can reverse this effect within minutes. With minimal training, anyone can safely administer naloxone in various forms – nasal spray, auto-injector or intramuscular injection – to effectively buy more time and get medical help for someone who has overdosed. </p>
<p>Naloxone has been used in hospitals for more than 40 years to reverse excess sleepiness and respiratory depression from opioid anesthesia and pain medication or to treat overdoses in the emergency room. During the 1990s, naloxone use expanded <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">into communities</a> to first responders, laypersons and, most importantly, to people who use drugs to reverse opioid overdoses. </p>
<p>The U.S. surgeon general issued an <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">advisory</a> in April 2018 encouraging family, friends and individuals at risk for an opioid overdose to carry naloxone and be trained to administer it. <a href="http://doi.org/10.1001/jamainternmed.2019.0272">Research shows</a> that wider access to naloxone is associated with fewer deaths. Naloxone could <a href="https://doi.org/10.1186/s12954-019-0352-0">successfully reverse</a> every witnessed opioid overdose, but only if naloxone is in the hands of a trained bystander. The challenge has been how to get naloxone to the people who need it.</p>
<p>In 48 states and the District of Columbia, pharmacists are now able to dispense naloxone under a standing order that does not require a physician’s prescription, or they can <a href="https://ldi.upenn.edu/brief/expanding-access-naloxone-review-distribution-strategies">directly prescribe naloxone</a>. But people may still be hesitant to ask for naloxone.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacies may one day dispense naloxone as an over-the-counter drug.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/naloxone-medicine-used-block-effects-opioids-1591052014">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Why community pharmacists are key</h2>
<p><a href="https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder">Opioid use disorder</a> is a chronic, relapsing, lifelong condition. Managing opioid use disorder requires sustained treatment and support, similar to other chronic conditions, such as diabetes and heart disease. But opioid use disorder often carries a social stigma, which can make people hesitant about seeking help through traditional health care channels. </p>
<p>People may be afraid to request a prescription for naloxone because they may be accused of misusing drugs. Others may not know how or where to obtain naloxone, particularly if they don’t have a regular health care provider. People who use drugs report <a href="https://doi.org/10.1007/s11606-015-3394-3">feeling stigmatized</a>, while <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082708/">providers including pharmacists may be uncomfortable</a> starting a conversation with patients about the importance of carrying naloxone. </p>
<p>Yet the greater the access to naloxone, the more likely this lifesaving drug will be administered to reverse an overdose. I believe that pharmacists in the community are ideally positioned as a local resource to obtain naloxone. Community pharmacies have evolved into <a href="https://www.michiganpharmacists.org/Portals/0/patients/communitypharmacy.pdf">neighborhood health centers</a> where individuals can access a variety of services outside a traditional clinical setting including immunizations, health screenings and lab monitoring. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vial of naloxone.</span>
<span class="attribution"><a class="source" href="http://www.Shutterstock.com/418417357">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.1097/ADM.0000000000000223">Pharmacists</a> can recommend and provide naloxone, opioid education and overdose prevention information to high-risk individuals and their support network. Pharmacists can make their pharmacy a safe and nonjudgmental resource, where people obtain and learn to administer naloxone, seek self-care advice and reduce harm from drug use, including clean needles and syringes. And pharmacists are well positioned to provide connections to local programs for recovery and support. They can make referrals to supportive health care providers and provide “whole person” care for vulnerable individuals. </p>
<h2>Federal support to halt deadly overdoses</h2>
<p>The U.S. Department of Health and Human Services recognizes the importance of addressing opioid use disorder and the opioid crisis with a <a href="https://www.hhs.gov/opioids/about-the-epidemic/hhs-response/index.html">5-point strategy</a>. This includes better access to opioid use disorder treatment, research funding, improved pain management and expanded naloxone availability in health care and community settings. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Emergency overdose kit.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Abuse-Treatment/3c546feaea4d4b1a827a397a9aece342/115/0">AP Photo/Jim Cole</a></span>
</figcaption>
</figure>
<p>While naloxone is not yet available for purchase over the counter, the U.S. Food and Drug Administration supports this simple access and has developed a “drug facts naloxone label” with pictures making it easy for anyone to effectively administer the correct dose. Manufacturers can apply for over-the-counter status, and naloxone is expected to become available as an over-the-counter drug <a href="https://doi.org/10.1111/1475-6773.13125">this year</a>. The availability to purchase naloxone without a prescription and over the counter can remove the perceived stigma of having to request it from a health care provider or pharmacist. </p>
<p>Naloxone alone will not mitigate the opioid crisis. Yet the ability to reverse a fatal overdose – having someone nearby who carries and can administer naloxone – allows the survivor another chance to enter <a href="https://doi.org/10.2105/AJPH.2017.304187">treatment that addresses</a> the social, structural, genetic, behavioral and individual factors of opioid use disorder. Pharmacists have an important role in helping to remove the stigma associated with requesting and carrying naloxone by openly discussing its benefits and making naloxone available to all patients. </p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/123962/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Victoria Tutag Lehr has received funding from MDHHS, BCBSMF, Amerisource-Bergen.
</span></em></p>Pharmacists are well positioned to provide communities with a lifesaving drug.Victoria Tutag Lehr, Professor of Pharmacy, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225372019-11-03T18:55:46Z2019-11-03T18:55:46ZOpioid dependence treatment saves lives. So why don’t more people use it?<figure><img src="https://images.theconversation.com/files/299607/original/file-20191031-187898-1v815y4.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5597%2C3709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To reduce opioid-related harms, we must ensure treatments for opioid dependence are accessible to those who need them. </span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>In Australia last year, <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2018%7EMain%20Features%7EOpioid-induced%20deaths%20in%20Australia%7E10000">1,123 people</a> died from opioids – illicit drugs such as heroin, and pain relievers such as codeine, oxycodone and morphine. If used regularly, physical and psychological dependence can develop.</p>
<p>In recent years most deaths have been due to <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/table-of-contents">pharmaceutical opioids</a> – that is, overdoses of strong pain medicines. Though heroin-related deaths are <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/data">increasing rapidly</a>, so we need evidence-based responses for both.</p>
<p>One key approach to reducing these deaths is treatment for opioid dependence. Although the evidence shows treatments such as methadone and buprenorphine <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">are effective</a>, people who are dependent on opioids continue to face barriers to accessing them.</p>
<p>These include cost, stigma, restrictiveness of the treatment regime, and a lack of places to go to receive treatment. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">Weekly Dose: Naloxone, how to save a life from opioid overdose</a>
</strong>
</em>
</p>
<hr>
<h2>Opioid dependence treatment</h2>
<p>The dependence treatment backed by the strongest evidence is called “opioid agonist treatment”. An opioid “agonist” means a drug that produces opioid effects in the body.</p>
<p>Opioid agonist treatment is when a known and legal opioid medicine (the opioid “agonist”) is provided in a therapeutic setting, like a clinic or pharmacy, in a regular dose. This removes the need for using additional opioids by reducing craving and withdrawal.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=785&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=785&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=785&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=986&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=986&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=986&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Staying in treatment <a href="https://www.ncbi.nlm.nih.gov/pubmed/7259424">longer</a> is associated with better outcomes, with best results seen when treatment is continued <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/FAQ%20Pharmacetuical%20Opioid%20Dependence%20Treatment_0.pdf">for 12 months or more</a>. So this is a longer-term treatment providing an opportunity to make sustainable changes, as opposed to a short-term detox.</p>
<p>The two most common medicines used in Australia are methadone and buprenorphine. Both are available through general practitioners and community pharmacies, as well as specialist clinics. Newer forms such as <a href="https://www1.racgp.org.au/newsgp/clinical/advocates-hail-game-changing-pbs-listing-of-long-a">long-acting buprenorphine</a> have also recently entered the market. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<p>Methadone is what we call a “full opioid agonist”. It mimics the effects of other opioids, such as codeine or morphine, and it can remove the need to take other opioids by preventing opioid withdrawal and craving. Taken in daily oral doses methadone does not produce euphoria, or a “high”. At higher doses, methadone also blocks the effects of other opioids, helping to prevent return to other opioid use.</p>
<p>Buprenorphine (often provided in combination with naloxone, a medicine used to reverse the effects of an opioid overdose) is referred to as a “partial opioid agonist”. It’s less sedating and, unlike methadone and other opioids, is less likely to cause <a href="https://academic.oup.com/bja/article/100/6/747/303263">breathing difficulties</a> and overdose. </p>
<h2>Treatment is effective</h2>
<p>High-quality <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">evidence</a> shows these treatments work. They help reduce opioid use, improve health, prevent the spread of blood borne viruses by reducing the likelihood people continue to inject, are cost effective, and reduce crime. </p>
<p>The most profound effects of these treatments is their ability to save lives. Risk of death while in treatment is <a href="https://www.bmj.com/content/357/bmj.j1550">substantially reduced</a>, by around half compared to when a person is dependent on opioids and not receiving treatment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioids include pain relievers like codeine, oxycodone and morphine, and illicit drugs like heroin.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>These treatments have been shown to <a href="https://ndarc.med.unsw.edu.au/resource/frequently-asked-questions-opioid-agonist-treatment-pharmaceutical-opioid-dependence">work just as well</a> for people who develop dependence to prescribed opioids and people who use heroin. </p>
<p>In 2005 the World Health Organisation put methadone and buprenorphine on their list of <a href="https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/">essential medicines</a>, recognising their importance in treating opioid dependence.</p>
<p>So it might be surprising to learn many people in Australia who could benefit from these treatments choose not to use them, or are not able to access them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-methadone-the-most-effective-treatment-for-heroin-dependence-59814">Weekly Dose: methadone, the most effective treatment for heroin dependence</a>
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<h2>4 barriers to treatment</h2>
<p><strong>Cost</strong></p>
<p>Opioid agonist treatments attract some subsidies, but their dispensing fees are not covered by Australia’s <a href="http://www.pbs.gov.au/info/about-the-pbs">Pharmaceutical Benefits Scheme</a>, which subsidises prescription drugs. Where treatment usually adds up to A$35-A$70 a week, cost can be a <a href="https://creidu.edu.au/policy_briefs_and_submissions/10-opioid-pharmacotherapy-fees-a-long-standing-barrier-to-treatment-entry-and-retention">key barrier</a> to access.</p>
<p><strong>Stigma</strong></p>
<p>Some people choose not to access these treatments because they see them <a href="https://www.ncbi.nlm.nih.gov/pubmed/29762767">as being for people who use heroin</a>, or don’t want to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12859">attend services seen as being for people who use illicit drugs</a>. </p>
<p>Other people believe these treatments are just replacing one opioid with another, and are not aware of their strong scientific support. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
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<p><strong>Restrictiveness of the treatment regime</strong></p>
<p>The need to attend a pharmacy daily for dosing at the start of treatment can affect work, study or family commitments. </p>
<p><strong>Nowhere to go</strong></p>
<p>Finally, treatment access is limited in some regions because there are not enough GPs who prescribe these treatments. This is despite a change from many state governments in recent years to reduce barriers to prescribing. </p>
<p>In <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/pharmacotherapy/buprenorphine-and-naloxone-prescribing-guidelines">Victoria</a> and New South Wales, for example, all GPs can prescribe buprenorphine treatment without additional training. Nonetheless, prescriber numbers have been slow to increase, with some GPs remaining hesitant to offer these treatments.</p>
<h2>People turning to short-term treatments instead</h2>
<p>As a result of these barriers, many people who are dependent on opioids choose not to seek help, or are not able to access the treatment they need. </p>
<p>Some choose to access shorter-term treatments such as a “detox”, where over the course of seven to ten days they cease opioids while their withdrawal symptoms are treated with medications.</p>
<p>This is concerning because the rates of relapse from short-term treatment are high, and research shows the risk of non-fatal or fatal opioid overdose increases <a href="https://www.ncbi.nlm.nih.gov/pubmed/17280803">following short-term treatment</a>. This means these short-term treatments contribute to opioid-related deaths rather than preventing them. </p>
<p>To stem the loss of life from opioid use in Australia, it’s critical we break down the barriers to the opioid dependence treatments we know are most effective. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-happened-when-codeine-was-made-prescription-only-no-the-sky-didnt-fall-in-124169">Here's what happened when codeine was made prescription only. No, the sky didn't fall in</a>
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<img src="https://counter.theconversation.com/content/122537/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen has received funding from Indivior and Seqirus, and is the current recipient of an NHMRC Research Fellowship (#1163961) </span></em></p>Treatments for opioid dependence, such as methadone and buprenorphine, are effective. But some people who stand to benefit are missing out.Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1191482019-09-04T11:52:54Z2019-09-04T11:52:54ZAn opioid success story: Efforts to minimize painkillers after surgery appear to be working<figure><img src="https://images.theconversation.com/files/290207/original/file-20190829-106512-1ydlodk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many hospitals are implementing new procedures to replace prescribing opioids after surgery. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/urgent-surgery-professional-smart-intelligent-surgeons-1062215336?src=-1-28">Dmytro Zinkevych/Shutterstock.com</a></span></figcaption></figure><p>The opioid epidemic has been wreaking misery and death across the nation for years. In 2017 alone, opioid overdoses killed more than <a href="https://www.cdc.gov/drugoverdose/data/index.html">47,000 people</a> – <a href="https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812603">10,000 more deaths</a> than were caused by traffic accidents that year. </p>
<p>For many people who abuse opioids, the problem begins with opioid prescriptions from their doctors for pain relief. Government data show that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25785523">21%-29% of patients</a> who are prescribed opioids go on to misuse them, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25785523">8% to 12% develop an opioid</a> abuse disorder. From 2016-2017, <a href="https://www.hhs.gov/opioids/sites/default/files/2018-09/opioids-infographic.pdf">800,000 people used heroin</a> for the first time, according to the U.S. Department of Health and Human Services, with <a href="https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm">80% starting</a> with prescription drugs. </p>
<p>Many hospitals have begun to take steps to minimize the amount of opioids prescribed after surgery by managing pain through alternative methods. Research suggests that these programs can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943369/">reduce the need for opioids after surgery</a> and can reduce both post-surgical complications and the average length of hospital stay. </p>
<p>At Keck Medicine at the University of Southern California, I’m the director of our program to reduce opioid prescriptions and manage pain in other ways. I have spent the past year leading our enhanced recovery team to design and implement various pathways that have significantly reduced the opioid burden in our surgical patients. Here’s how these programs look in practice.</p>
<h2>New practices, less pain</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Making sure that patients are hydrated after surgery is an important part of pain management.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/selective-focus-orange-juice-bottle-blurry-1441467887?src=-1-3">Komsan Loonprom/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>We have modeled our program to manage pain after others that were developed originally to improve outcomes and shorten hospital stays after colorectal surgery. These programs, called Enhanced Recovery After Surgery, or ERAS, involve a range of measures, such as employing many different ways to reduce pain, and early mobility.</p>
<p>We have found that these protocols are easy to enact and can be as simple as giving the patients non-narcotic pain relievers in the days leading up to surgery to prep the body prior to surgery.</p>
<p>Some of the other methods include:</p>
<ul>
<li>Ensuring the patients and their families have clear understanding and expectations about post-surgical pain management</li>
<li>Making sure a patient has plenty of fluids and carbohydrates</li>
<li>Using a nerve block during surgery </li>
<li>Encouraging the patient to get up and walking within a day after surgery</li>
<li>Sending the patients home with no opioid prescriptions, or with a prescription for a very small number of pills. </li>
</ul>
<p>We have partnered with clinicians across the health care continuum. The process involves physicians, nurses, physical therapists, occupational therapists, case management, nutrition, pre-op management and social work. </p>
<p>While we have not yet published the results of our programs in an academic journal, I can say that these practices produced very tangible results; the post-operative opioid usage decreased by 50% in our division of thoracic surgery and by 60% in our department of urology.</p>
<p>The hospital’s division of cardiac surgery also reduced the use of post-operative opioid use by 45% for patients undergoing minimally invasive valve-replacement procedures. We anticipate publishing data on this finding as well. Some of our patients have gone through pre-op, surgery and post-operative care without the use of opioids at all and without any undue pain.</p>
<p>Other hospitals have reported success, too. </p>
<p>The <a href="https://www.modernhealthcare.com/care-delivery/hospitals-look-cut-opioids-surgery-and-beyond">University of Pittsburgh Medical Center</a> cut the number of post-surgical opioid prescriptions in half. </p>
<p>A <a href="https://www.wsj.com/articles/the-push-for-fewer-opioids-for-new-mothers-11559554201">Cleveland Clinic</a> pilot program to reduce opioid prescriptions in new mothers following Cesarean sections immediately reduced opioid use by two-thirds, and opioid-free hospital stays more than tripled. </p>
<p>A year after the <a href="https://www.ncbi.nlm.nih.gov/pubmed/29510097">University of Virginia</a> implemented its ERAS protocol for patients undergoing thoracic surgery, it reduced the use of post-surgical morphine equivalents by more than half, reduced length of stay by two days, and even cut hospital operating costs.</p>
<p>These practices go beyond minimizing opioid prescriptions and can contribute to better overall patient care. For example, at Keck Medicine, our preliminary results show that we have been able to decrease the length of patient stay by up to 21% and have reduced complications from <a href="https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af">atrial fibrillation</a>, or irregular heart beats that can lead to stroke, blood clots and heart failure, in thoracic surgery to less than 10%. We have also decreased intensive care stay for head and neck surgery by as much as one day. Also, we have cut by two days the length of time that catheters need to remain inserted into the bladders of post-operative urological patients. This is important because the <a href="https://www.emedicinehealth.com/foley_catheter/article_em.htm#foley_catheter_risks">risk of infection increases</a> the longer a catheter remains inserted.</p>
<h2>Advocating for patients</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Consulting with patients before surgery can help them understand how to deal with post-surgical pain in different ways.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-patient-having-consultation-doctor-office-317573702?src=-1-10">Monkey Business Images/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>An integral piece of the success is patient education. Most patients are so overwhelmed when they are about to undergo surgery and may be unaware that there are procedures to help limit opioid usage. And those who hear about opioid-minimizing practices may fear potential post-operative pain and may not consider that option. </p>
<p>It is important to educate patients well before their surgeries so they know their expected level of pain after their surgery and the different medication and procedures in place to minimize that post-operative pain. This kind of education is key in empowering patients to make informed decisions regarding opioids and their health.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/119148/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Kim works for Keck USC School of Medicine. </span></em></p>About 1 in 4 people prescribed an opioid for pain end up abusing it. New methods to reduce the need for opioids after surgery have been shown to work – and thus minimize the need for such drugs.Michael Kim, Clinical Assistant Professor of Anesthesiology, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1222852019-08-29T14:11:17Z2019-08-29T14:11:17ZTaking opioids for chronic pain: here’s what the experts recommend<figure><img src="https://images.theconversation.com/files/289203/original/file-20190823-170910-gzqojh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/drug-epidemic-illustration-about-mass-consumption-706093327">Shutterstock</a></span></figcaption></figure><p>Chronic pain – acute pain that lasts for longer than three months – affects around <a href="https://onlinelibrary.wiley.com/doi/full/10.1016/j.ejpain.2005.06.009">one in five people</a> in Europe. The increase in use of strong morphine-type drugs (opioids) for the treatment of chronic pain is an area of much concern, <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30479-0/fulltext">particularly in North America</a>.</p>
<p>Termed an “<a href="http://theconversation.com/opioid-epidemic-the-global-spread-explained-101649">opioid epidemic</a>”, most developed countries have seen a major increase in opioid prescribing over the last decade or so. Our latest <a href="https://www.sign.ac.uk/sign-136-management-of-chronic-pain.html">research</a> assesses how good the evidence is that opioids can help chronic pain effectively, balanced against any harms they can cause.</p>
<p>Chronic pain <a href="https://onlinelibrary.wiley.com/doi/full/10.1016/j.ejpain.2005.06.009">very often doesn’t get better</a>, so people can be prescribed opioids for a long time – years, or even decades. Is there evidence that opioids continue to work well to reduce chronic pain and improve quality of life? The majority of clinical trials only study opioid use for three months, so we don’t really know much about their effectiveness over the longer term.</p>
<hr>
<p><em><strong>Read more: <a href="https://theconversation.com/what-is-chronic-pain-and-why-is-it-hard-to-treat-57943">What is chronic pain and why is it so hard to treat?</a></strong></em> </p>
<hr>
<p>One of the few studies that has looked at how effective opioids are after 12 months, <a href="https://jamanetwork.com/journals/jama/fullarticle/2673971">found</a> that people who took opioid painkillers were not any more active than those on other types of painkillers.</p>
<p>There is also <a href="https://www.ncbi.nlm.nih.gov/pubmed/25581257">evidence</a> that long-term use of opioids may be harmful. This is likely to be dose-related as risks increase at higher doses. Known harms include increased risks of:</p>
<ol>
<li><p><a href="https://www.theguardian.com/science/audio/2018/sep/21/opioid-addiction-can-the-uk-curb-the-looming-crisis-science-weekly-podcast">Addiction and misuse</a>: this can affect anyone who is prescribed opioids for pain. Prescribers and patients need to be aware of, and minimise, the risk from the beginning. </p></li>
<li><p>Overdose and death: deaths from prescription opioids are <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">increasing dramatically in the US</a> for example.</p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590093/">Interfering with the endocrine system</a>: changes in hormone levels that can impact on sexual function and fertility.</p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pubmed/25581257">Heart problems</a>: heart attack risk is more than doubled in people taking long-term opioids. </p></li>
<li><p>Being in a <a href="https://www.ncbi.nlm.nih.gov/pubmed/25581257">road traffic accident</a>: the risk is higher among drivers taking even relatively low doses of opioids.</p></li>
<li><p>Worsening pain or “<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30430-1/fulltext?rss=yes">opioid-induced hyperalgesia</a>”: when long-term use makes pain worse. This is often difficult to recognise.</p></li>
<li><p><a href="https://insights.ovid.com/article/00006396-201208000-00011">Opioid tolerance</a>: when the body becomes used to opioids and requires a bigger dose to get the same painkilling effect.</p></li>
<li><p>Adverse effects on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28213891">immune system</a>: people taking opioids eventually become more prone to infections.</p></li>
</ol>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/289206/original/file-20190823-170935-385lpx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One in five Europeans suffers from chronic pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lower-back-pain-590676011">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Should we use opioids for chronic pain?</h2>
<p>Yes, when appropriate – but with caution. The <a href="https://www.sign.ac.uk/what-we-do.html">Scottish Intercollegiate Guideline Network</a> (SIGN) publishes high-quality evidence-based management guidelines. <a href="https://www.sign.ac.uk/assets/sign136.pdf">SIGN 136</a> was the first comprehensive guideline on the management of chronic pain, published in 2013.</p>
<p>As a result of <a href="https://www.sign.ac.uk/sign-136-management-of-chronic-pain.html">new evidence</a>, SIGN 136 has specifically reviewed the section on opioid use and <a href="https://www.sign.ac.uk/sign-136-management-of-chronic-pain.html">updated recommendations</a> have recently been published. New research since 2013 has been critically reviewed to ensure that the new recommendations are based on the best available evidence. Some of the key points in the new advice include the following:</p>
<ol>
<li><p>Opioids should be used for as short a time as possible, in carefully selected people with chronic pain. This should happen when other treatments haven’t worked to manage the pain and where the benefits outweigh the risks of the serious harms listed above.</p></li>
<li><p>Before starting treatment, the person with chronic pain and the prescriber should agree what the treatment aims are. These might include reduced pain, increased activity and/or better quality of life. If this doesn’t happen then there should be an agreed action plan to reduce and stop opioids. </p></li>
<li><p>There should be ongoing, regular review by a member of the primary healthcare team, especially if the daily dose is equivalent to more than 50mg of morphine. Review should be frequent in the early stages, and at least annually, after treatment is established. If problems arise – such as opioids no longer providing good pain relief, increasing the dose provides no sustained pain relief or then there is evidence of addiction – then more frequent review will be needed and consideration given to reducing/stopping treatment.</p></li>
<li><p>We should always use the lowest effective dose. Higher doses (equivalent to more than 90mg/day of morphine) should only be prescribed alongside review by a pain specialist.</p></li>
</ol>
<p>These recommendations are consistent with those of <a href="https://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=7194">The International Association for the Study of Pain</a> (IASP). The organisation emphasises that the use of other approaches, including behavioural therapies and increasing physical activity to improve quality of life, is preferred.</p>
<h2>Where do we go from here?</h2>
<p>Current evidence indicates that widespread, long-term opioid prescribing for chronic pain is likely to cause more harm than benefit in society. But some individuals with chronic pain do benefit. They should continue to be prescribed opioids, with the recommended caution, careful monitoring and review, and use of proven non-pharmacological therapies. Some people may also need support to reduce and stop long-term opioids, where the harms outweigh the benefits.</p>
<p>There is an urgent need for research to understand how to manage chronic pain better, including the safe use of and withdrawal from opioids. In tandem we need national policies, based on best available evidence and approaches to educate healthcare professionals and patients. This is likely to require investment in the short term, but it may be a small price to pay for the longer term benefits and probable cost savings of improving chronic pain management, which is the <a href="https://www.thelancet.com/gbd">leading cause of disability</a> globally.</p><img src="https://counter.theconversation.com/content/122285/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Colvin receives funding from Scottish Government for quality improvement work on chronic pain. She is a member of SIGN Council and chaired the original Guideline Development Group (2013). She is a member of the MHRA Opioid Expert Working Group, and an Editor for the British Journal of Anaesthesia</span></em></p><p class="fine-print"><em><span>Within the last five years, Blair H. Smith has received research funding from the European Union, Medical Research Council, and Scottish Government, and previously from Pfizer Ltd, for research into causes and management of chronic pain. He is a member of the Scottish National Party. Ailsa Stein and colleagues at the Scottish Intercollegiate Guideline Network contributed a major component of the work described in this article.</span></em></p>Advice from the people who’ve reviewed all the latest evidence about the effectiveness of these painkillers.Lesley Colvin, Deputy Head of Division - Population Health & Genomics & Chair in Pain Medicine, University of DundeeBlair H. Smith, Professor of Population Health Science, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1131012019-08-29T12:20:40Z2019-08-29T12:20:40ZWhy companies file for bankruptcy – and how it protects both debtors and creditors<figure><img src="https://images.theconversation.com/files/289919/original/file-20190828-184217-85d8hm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Critics have worried Purdue might use bankruptcy to avoid accountability. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Purdue-Bankruptcy/59244806d067425bba37138857b93bc9/62/0">AP Photo/Jessica Hill</a></span></figcaption></figure><p><a href="https://www.nytimes.com/2019/08/27/health/sacklers-purdue-pharma-opioid-settlement.html?action=click&module=Top%20Stories&pgtype=Homepage">Reports have emerged</a> that Purdue Pharma is in settlement talks to resolve thousands of federal and state lawsuits over its role in fueling the <a href="https://theconversation.com/us/topics/opioid-epidemic-26182">opioid epidemic</a>. As part of the reported settlement, the company would file for bankruptcy. </p>
<p>Earlier this year, Insys Therapeutics <a href="https://www.npr.org/2019/06/10/731363225/insys-files-for-chapter-11-days-after-landmark-opioid-settlement-of-225-million">became the first opioid drugmaker</a> to enter bankruptcy following its US$225 million settlement with the Department of Justice. In recent months, <a href="https://www.commondreams.org/news/2019/03/04/when-we-say-pharma-greed-kills-what-we-mean-critics-respond-possible-purdue">there’s been speculation</a> that drugmakers might use bankruptcy as a way to escape accountability and avoid billions of dollars in litigation costs. </p>
<p>Fortunately, that’s not how bankruptcy works. Rather, as <a href="http://www.law.uga.edu/profile/lindsey-simon">I’ve learned in my experience</a> studying and practicing bankruptcy law, the process is designed to not only protect debtors like Insys or Purdue but also creditors such as states and other opioid litigants. </p>
<p>Bankruptcy is not perfect, and sometimes outcomes seem unfair. But it’s definitely not the “get out of jail free” card that many fear. </p>
<h2>Making the best of a grim situation</h2>
<p>To most people, bankruptcy <a href="https://hbswk.hbs.edu/item/how-chapter-11-saved-the-us-economy">has a negative image</a>. And for good reason: A filing almost always means there’s not enough money to go around. </p>
<p>But the system makes the best of a grim situation by imposing an orderly and open process that preserves value and encourages negotiation. Bankruptcy reorganizations by well-known brands such as <a href="https://www.reuters.com/article/us-delta-bankruptcy/delta-exits-bankruptcy-after-19-month-restructuring-idUSWNAS850820070430">Delta</a> and <a href="https://ssrn.com/abstract=3252104">General Motors</a> show that it can bring parties together and resurrect struggling companies. </p>
<p>At the most fundamental level, the Bankruptcy Code creates an estate to collect all of the debtor’s assets into one place, identify and categorize claims against the debtor in terms of priority and then distribute the assets accordingly. </p>
<p>Exactly how those three core tasks play out in a given case will vary depending on what type of bankruptcy case the debtor files and specific facts about the debtor.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Delta went public after emerging from bankruptcy in 2007.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Delta-Stock/18e8c3a4e01748f190d454f514311bf3/8/0">AP Photo/Mark Lennihan</a></span>
</figcaption>
</figure>
<h2>Chapter 7 vs. Chapter 11</h2>
<p>Large business debtors have two bankruptcy options: liquidation or reorganization. </p>
<p><a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-7-bankruptcy-basics">Chapter 7 cases are designed</a> to liquidate the company, meaning it will no longer exist, and any remaining value will be divided up and distributed to creditors. </p>
<p>In contrast, a <a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-11-bankruptcy-basics">Chapter 11 reorganization</a> allows a debtor to sell some or all of its assets or propose a reorganization plan that aims to resolve and satisfy enough creditors to re-emerge as a going concern. </p>
<p>For example, airlines United, Delta and American <a href="https://www.vox.com/the-goods/2019/3/11/18259894/bankruptcy-business-chapter-11-close-stores">all filed for Chapter 11</a> protection in the mid-2000s and managed to unload enough debt to stay aloft. More recent filings seeking reorganization include those by <a href="https://www.investopedia.com/news/downfall-of-sears/">Sears</a>, <a href="https://www.reuters.com/article/us-pg-e-us-bankruptcy/pge-bondholders-propose-competing-bankruptcy-plan-worth-up-to-30-billion-idUSKCN1TQ21D">Pacific Gas and Electric Company</a> and <a href="https://www.dailyrepublic.com/all-dr-news/wires/business/toys-r-us-is-back-from-the-dead-but-its-new-stores-are-unrecognizable/">Toys R Us</a>. </p>
<p>Companies sometimes initially file under Chapter 11 to reorganize but later decide to shut down after they fail to confirm a plan or find a suitor. Recent examples of this include <a href="https://money.cnn.com/2018/04/19/news/companies/bon-ton-liquidation/index.html">Bon-Ton Stores</a>, <a href="http://www.nbcnews.com/id/28691963/ns/business-us_business/t/circuit-city-liquidate-remaining-us-stores/#.XPWBgS2ZNTY">Circuit City</a> and <a href="https://dealbook.nytimes.com/2011/02/16/borders-files-for-bankruptcy/">Borders</a>.</p>
<p>For companies looking to survive, the <a href="https://uscode.house.gov/view.xhtml?path=/prelim@title11&edition=prelim">Bankruptcy Code</a> requires either creditor support or payment in full. If even one class of impaired creditors votes against a plan, the company must go through a demanding “cramdown” process for court approval to proceed.</p>
<p>Once a Chapter 11 plan of reorganization is finalized and approved, a debtor emerges from bankruptcy and continues operating, usually in a stronger position than before. </p>
<h2>Benefits of bankruptcy for debtors</h2>
<p>Bankruptcy provides at least two valuable benefits to all debtors: time and space. </p>
<p>The moment a debtor files its petition, an automatic stay is imposed on creditors, which operates like a pause button on any collection efforts, litigation or similar actions. Creditors can ask the court to lift the stay under certain circumstances, but the standard for doing so is often difficult to meet.</p>
<p>The bankruptcy court has broad authority to control all matters involving the debtor’s estate, including claims that are distantly related to the main bankruptcy case. The debtor may ask the court to pause other lawsuits outside of the bankruptcy case if they affect the estate. By bringing together all those with a stake in the company’s assets in one place, a debtor can more efficiently deal with all claims against it.</p>
<p>While the stay is in place, debtors use the bankruptcy process to evaluate their problems and make the necessary changes to succeed after reorganizing. This includes deciding which contracts they want to carry forward and which to abandon. </p>
<p>To avoid a contested process, savvy debtors seek a global settlement with as many stakeholders as possible – which is what <a href="https://www.cnbc.com/2019/08/27/purdue-pharma-offers-10-12-billion-to-settle-opioid-claims.html">Purdue is likely trying to do</a> – and include “sweeteners” to sway undecided creditors in favor of the plan.</p>
<h2>Benefits for creditors</h2>
<p>Clearly, bankruptcy provides debtors with significant power to rearrange their business affairs.</p>
<p>What many people misunderstand, however, is that this power is balanced by <a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-11-bankruptcy-basics">strong creditor protections</a>. The Bankruptcy Code requires debtors to disclose significant information about their operations and imposes strict checks on debtor actions. </p>
<p>For example, the debtor must publicly file information about all of its assets and liabilities, sit for a bankruptcy deposition with creditors and seek the court’s permission before taking many actions outside of the ordinary course of business. </p>
<p>Under Chapter 11, the debtor is allowed to remain in possession of its estate and continue operating. Creditors that are concerned about the debtor’s ability to preserve the estate’s value may ask the court to appoint an examiner or <a href="https://www.justice.gov/ust">trustee</a> to take control. Creditors may even move to dismiss the case if they believe the debtor is abusing the bankruptcy process. </p>
<p>The Bankruptcy Code creates a committee of unsecured creditors – those without assets backing their claims – to advocate on behalf of claimants who are likely not involved in the case. The court may also form a special committee representing tort claimants in cases where debtors face litigation or future claimants whose injuries are not yet known. The court overseeing the bankruptcy of Imerys, for example, <a href="https://www.law.com/delbizcourt/2019/03/07/11-lawyers-named-to-tort-claims-committee-in-talc-suppliers-bankruptcy/">appointed plaintiffs</a> to represent cancer victims with <a href="https://www.bloomberg.com/news/articles/2019-02-13/imerys-sa-unit-seeks-bankruptcy-protection-over-talc-lawsuits">claims against the talc supplier</a>. </p>
<p>These and other features add a degree of fairness to an inherently unjust situation. The debtor may be sitting in the driver’s seat, but numerous other stakeholders have the power to make sure that the company follows the rules of the road.</p>
<p>With such protections in place, creditors and the general public need not fear the worst if bankruptcy plays a bigger role in the unfolding opioid saga.</p><img src="https://counter.theconversation.com/content/113101/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lindsey Simon does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While critics accuse companies facing lots of lawsuits of using bankruptcy as a sort of ‘get of jail free card,’ the reality of the legal procedure is more complicated.Lindsey Simon, Assistant Professor of Law, University of GeorgiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1182452019-07-30T13:03:58Z2019-07-30T13:03:58ZOpioid epidemic may have cost states at least $130 billion in treatment and related expenses – and that’s just the tip of the iceberg<figure><img src="https://images.theconversation.com/files/286106/original/file-20190729-43149-a6zk92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every state bears the burden of the opioid crisis. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/map-usa-made-out-white-pills-295148714?src=sXhlsyNre1nsjZUbjgvTgA-1-63&studio=1">Digital Deliverance/Shutterstock.com</a></span></figcaption></figure><p>The devastating health effects of the opioid epidemic have been <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">well documented</a>, with <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">over 700,000 overdose deaths</a> and millions more affected.</p>
<p>And <a href="https://www.washingtonpost.com/investigations/76-billion-opioid-pills-newly-released-federal-data-unmasks-the-epidemic/2019/07/16/5f29fd62-a73e-11e9-86dd-d7f0e60391e9_story.html?utm_term=.e67762f4a8a4">Americans are learning more</a> every day about the role drug companies and distributors played in flooding towns and cities across the country with pain pills. </p>
<p>We know comparatively less, however, about the financial costs of the crisis. Several studies have emerged in recent years that estimate the national economic costs of the epidemic at anywhere from <a href="http://www.doi.org/10.1097/AJP.0b013e3181ff04ca">US$53 billion</a> to <a href="http://www.doi.org/10.1097/MLR.0000000000000625">$79 billion</a> in a single year. </p>
<p>But given that <a href="https://www.npr.org/2019/05/27/724093091/this-case-will-set-a-precedent-first-major-opioid-trial-to-begin-in-oklahoma">states have led the charge</a> in suing opioid makers with the aim of recovering some of their own costs, we wanted to know more specifically how the crisis has hurt their budgets. This is critical to understanding what they can recover from their lawsuits. </p>
<p>So we led a team of 20 researchers at Penn State in a <a href="https://www.ajmc.com/journals/supplement/2019/deaths-dollars-diverted-resources-opioid-epidemic">series of studies</a> that looked at the various ways state budgets have borne the burden of the opioid crisis. The result is the first comprehensive tally of state opioid costs. </p>
<h2>The high cost of overdoses and treatment</h2>
<p>The most prominent – and largest – costs are those related to medical care. </p>
<p>Although <a href="https://www.ncbi.nlm.nih.gov/pubmed/16988561">prior</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/21392250">studies</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/21178601">have</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/23841538">estimated</a> the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975355/">medical</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/25141243">costs</a> of opioid misuse, none has provided a comprehensive accounting of costs to states’ Medicaid programs. These costs include those related to overdoses, treatment for opioid-related conditions and other care they may receive due to resulting health consequences such as hepatitis C and HIV.</p>
<p><a href="https://www.ajmc.com/journals/supplement/2019/deaths-dollars-diverted-resources-opioid-epidemic/the-economic-burden-opioid-epidemic-on-states-case-of-medicaid">Our team crunched the data</a> from 17 states’ Medicaid claims databases and then extrapolated the data to make national-level estimates. We estimate that overall, state Medicaid programs spent at least $72 billion due to opioid misuse from 1999 to 2013, the most recent year with available data. </p>
<p>Based on an estimate of Medicaid costs of $8.4 billion in 2013, we estimate states likely spent an additional $40 billion since then, bringing the total bill to at least $112 billion.</p>
<p><iframe id="I23ng" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/I23ng/10/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Lower employment, less tax revenue</h2>
<p>In addition to effects on health care use, opioid misuse can also lead to <a href="https://www.brookings.edu/wp-content/uploads/2018/02/kruegertextfa17bpea.pdf">significant</a> <a href="https://www.clevelandfed.org/en/newsroom-and-events/publications/working-papers/2019-working-papers/wp-1807r-opioids-and-labor-market.aspx">declines</a> <a href="http://jhr.uwpress.org/content/early/2019/01/09/jhr.55.4.0517-8782R1.abstract">in</a> employment, which in turn can then rob states of expected tax revenue. </p>
<p>Using an <a href="https://users.nber.org/%7Etaxsim/taxsim27/">online tax simulator</a> and an <a href="https://www.brookings.edu/wp-content/uploads/2018/02/kruegertextfa17bpea.pdf">existing study</a> on the effect of individuals leaving the workforce due to opioid misuse, we were able to estimate how much tax revenue states may have lost.</p>
<p><a href="http://www.doi.org/10.1097/MLR.0000000000001107">We estimate</a> that states may have lost nearly $12 billion in tax revenue from 2000 to 2016 due to the effect of opioid misuse on individuals’ ability to work. Ongoing costs are about about $700 million a year, bringing an estimated total through 2018 to over $13 billion. </p>
<p>There are other costs to states associated with a share of the population being unable to work, such as rising eligibility for cash assistance, nutrition programs, state-funded health insurance and other safety net programs. </p>
<p>While we do not have good data available to provide estimates, moving forward these will be important costs for states to consider.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/286110/original/file-20190729-43104-oztkm2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The costs of prosecuting and incarcerating people who misuse opioids can add up.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Inmates-Addiction-Medication/3f088b18813b4b8fa2a4b9a48301e210/31/0">AP Photo/Elise Amendola</a></span>
</figcaption>
</figure>
<h2>Criminal justice costs</h2>
<p>Criminal justice is another important component of opioid-related costs to states. </p>
<p>To date, many cost studies have focused on how those in prison or jail <a href="https://www.ncbi.nlm.nih.gov/pubmed/16988561">may</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/21392250">be</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/21178601">unable</a> <a href="https://www.whitehouse.gov/briefings-statements/cea-report-underestimated-cost-opioid-crisis/">to</a> <a href="https://altarum.org/sites/default/files/uploaded-publication-files/Research-Brief_Opioid-Epidemic-Economic-Burden.pdf">work</a>. Yet states and local municipalities <a href="https://www.ncbi.nlm.nih.gov/pubmed/16988561">spend</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/21178601">considerable</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975355/">resources</a> on arrests, courts and corrections that result from opioid misuse. </p>
<p>While several studies have attempted to estimate these costs, none have comprehensively examined the full set of opioid-related criminal justice costs at the state level. Due to the difficulty of obtaining reliable data, our team focused on Pennsylvania. <a href="https://www.ajmc.com/journals/supplement/2019/deaths-dollars-diverted-resources-opioid-epidemic/estimated-costs-pennsylvania-criminal-justice-system-from-the-opioid-crisis">We estimate</a> that, from 2007 to 2016, the opioid crisis cost the criminal justice system in the state $526 million. </p>
<p>These figures are highly variable from year to year and among all the states, making it very difficult to come up with a comprehensive, nationwide estimate. Given that Pennsylvania has both a large population and <a href="https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm">has been hit unusually hard</a> by the opioid crisis, costs in Pennsylvania are likely higher than average. </p>
<p>However, the Pennsylvania estimates demonstrate the costs are high and are likely to veer well into the billions of dollars nationwide.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=516&fit=crop&dpr=1 754w, https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=516&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/286112/original/file-20190729-43118-ra0oxm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=516&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children are affected by their loved ones’ addictions – and states pay for it.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Overcoming-Opioids-Struggles-for-Recovery/4d99e67450d64414bbf3548bfd5d2439/94/0">AP Photo/David Goldman</a></span>
</figcaption>
</figure>
<h2>Caring for children</h2>
<p>While much of the attention has focused on those misusing opioids, one of the <a href="https://aspe.hhs.gov/pdf-report/substance-use-opioid-epidemic-and-child-welfare-system-key-findings-mixed-methods-study%20and%20https://www.ncbi.nlm.nih.gov/pubmed/26564910">populations hardest hit</a> by opioid misuse is children. </p>
<p>Opioid misuse has been shown to lead to increased interventions from state welfare and child <a href="https://www.sciencedirect.com/science/article/pii/S0190740917308265">protection</a> <a href="https://www.sciencedirect.com/science/article/pii/S0190740918300458">agencies</a>. While data remain limited, our team used a modeling approach to show that opioid misuse may be associated with $2.8 billion in costs to the child welfare system across all states from 2011 to 2016.</p>
<p>Additionally, babies born to mothers who were using opioids prenatally may be born with withdrawal symptoms – namely, neonatal abstinence syndrome – that require <a href="https://www.ncbi.nlm.nih.gov/pubmed/22546608">significant care</a>. The effects of neonatal abstinence syndrome, and the related costs, may continue for a long time as affected children may require significant special education resources.</p>
<p>Data in this area are inherently difficult to identify in each state. However, <a href="https://www.ajmc.com/journals/supplement/2019/deaths-dollars-diverted-resources-opioid-epidemic/considering-child-welfare-system-burden-opioid-misuse-research-priorities-estimating-public-costs">we found</a> that for a cohort of children born with neonatal abstinence syndrome in Pennsylvania in 2015, additional costs to provide special education services might have been about $8.3 million. A very rough estimate of the nationwide costs would be in the ballpark of at least $50 million per year. </p>
<h2>Tip of the iceberg</h2>
<p>Collectively our studies tallied about $85 billion in estimated financial costs to state budgets during the periods identified in each one. After extrapolating that to cover costs through 2018, we think the total comes to at least about $130 billion, with an ongoing bill of $6 billion to $10 billion every year. </p>
<p>While these figures might be lower than some other estimates that either <a href="http://www.ibrc.indiana.edu/ibr/2018/spring/article1.html">include broader economic costs</a> or <a href="https://altarum.org/sites/default/files/uploaded-publication-files/Research-Brief_Opioid-Epidemic-Economic-Burden.pdf">fail to account for variations</a> from year to year, the bottom line is that our data show states are bearing a very high financial burden in this crisis. </p>
<p>Our estimates also provide a benchmark states can use in litigation as they seek to recoup these costs to help cover the ongoing expenses associated with containing and ending the epidemic – and hint at why <a href="https://www.washingtonpost.com/national/purdue-pharma-ceo-says-bankruptcy-is-an-option-as-company-faces-opioid-lawsuits/2019/03/12/6f794e1a-450b-11e9-90f0-0ccfeec87a61_story.html">so many opioid manufacturers are mulling bankruptcy</a>. </p>
<p>Yet our analysis is just the tip of the iceberg, as it covers only costs to state governments and excludes the broader economic costs of the crisis. Individuals and their families have also suffered enormously and are likely bearing even greater costs – both financial and emotional.</p><img src="https://counter.theconversation.com/content/118245/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joel Segel receives funding from from the Commonwealth of Pennsylvania under a grant entitled "Estimation of Societal Costs to States Due to Opioid Epidemic".</span></em></p><p class="fine-print"><em><span>Doug Leslie received funding from from the Commonwealth of Pennsylvania under a grant entitled "Estimation of Societal Costs to States Due to Opioid Epidemic." He also receives funding from the National Institute on Drug Abuse (NIDA).</span></em></p><p class="fine-print"><em><span>Gary Zajac received funding from from the Commonwealth of Pennsylvania under a grant entitled "Estimation of Societal Costs to States Due to Opioid Epidemic."</span></em></p><p class="fine-print"><em><span>Max Crowley received funding from from the Commonwealth of Pennsylvania under a grant entitled "Estimation of Societal Costs to States Due to Opioid Epidemic."</span></em></p><p class="fine-print"><em><span>Paul L. Morgan received funding from from the Commonwealth of Pennsylvania under a grant entitled "Estimation of Societal Costs to States Due to Opioid Epidemic."</span></em></p>State governments are leading the charge against opioid makers over their role in the epidemic. A team of researchers at Penn State examined just how much the crisis has cost them.Joel Segel, Assistant Professor of Health Policy and Administration, Penn StateDouglas L. Leslie, Professor of Public Health Sciences and Psychiatry, Penn StateGary Zajac, Managing Director of the Criminal Justice Research Center, Penn StateMax Crowley, Assistant Professor of Human Development and Family Studies, Penn StatePaul L. Morgan, Eberly Fellow, Professor Education and Demography, and Director of the Center for Educational Disparities Research, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1136042019-03-20T10:32:25Z2019-03-20T10:32:25ZViolence against women is overlooked in its role in opioid epidemic<figure><img src="https://images.theconversation.com/files/263942/original/file-20190314-28471-12auavw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women who are sexually assaulted by their partners or other men sometimes turn to opioids to numb themselves.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/women-bondage-lift-hands-against-violence-1283343403">Tinnakomjorruang/Shutterstock.com</a></span></figcaption></figure><p>One night, a woman I’ll call Tonya got a compliment from a guy when she was out with her boyfriend. Tonya’s boyfriend cursed her because another man had complimented her. He said: “You give it to everybody, I want it too.” In anticipation of his physical abuse, she reasoned, “I could go off to Wonder World.” She then injected heroin, to be “in her own world,” she later told me. </p>
<p>Tonya is only one of the hundreds of women I’ve interviewed for my research with similar stories in the span of my nearly 30-year career studying the links between intimate partner violence, sexual coercion, substance use disorders and HIV. </p>
<p>In the early 90s, I was among a few social scientists who <a href="http://bit.ly/2gdvuzu">identified intimate partner violence</a> as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658230/">major risk factor</a> for HIV risk behaviors and transmission and a barrier to treatment access, and engagement among women.</p>
<p>Over the years, <a href="https://scholar.google.com/citations?user=028yjbIAAAAJ&hl=en">I have designed, tested and promoted</a> the use of <a href="https://scholar.google.com/scholar?hl=en&as_sdt=0,5&q=nabila+El-Bassel+google+scholars">gender-specific HIV</a> and prevention interventions to address these issues simultaneously for women, men and couples who use drugs. </p>
<p>More recently, I have expanded my substance abuse research to include greater involvement in opioid overdose prevention among women and men. I have begun a <a href="https://sig.columbia.edu/news/announcing-new-multi-disciplinary-collaboration-facilitating-unique-response-address">cross-university collaboration</a> to tackle the opioid crisis and issues such as partner violence, reproductive health and gender equity are included in the interventions that we will develop, in order improve access to services and treatment for individuals who use opiates. </p>
<p>While progress has been made to address intimate partner violence among women who use drugs, those with opioid use disorders who experience partner violence are still in dire need of help in navigating and engaging in substance use treatment programs and other services.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/21303249">Our research found</a> that many men with substance use disorders often undermined their female partners’ recovery. They can control their ability to engage in treatment, deny them potential sources of protection, and jeopardize the custody of their children to maintain control over them and, for some men, have women take care of them.</p>
<h2>Medicating to mitigate trauma</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263950/original/file-20190314-28468-2lnrm8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stigma often keeps people from caring about women who are victims of violence and have substance use disorders.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-hand-holding-syringe-drug-1220657107">Tinnakomjorruang/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Many women in controlling and violent relationships like Tonya’s “self-medicate” – or use drugs that are not prescribed to them to help with their medical condition – to mitigate the trauma of physical and sexual assault. As a result, their bodies crave an ever-increasing steady supply of substances to get high in order to feel “better.” Today, the drugs of choice are usually opioids. </p>
<p>Research has <a href="https://www.ncbi.nlm.nih.gov/pubmed/21303249%20%22%22:%20http://bit.ly/2gdvuzu">repeatedly indicated</a> that drug use is associated with partner violence, specifically against women, who may be particularly susceptible to such violence when under the influence of opioids. Living with substance use disorders puts these women into a number of contexts that expose them to HIV and other sexually transmitted diseases that jeopardize their survival in many ways. </p>
<p>In my research with men on partner violence and drug use and HIV, a man reported pushing his partner to the floor and forcing her to have sex. He did not consider this violent, since she <a href="https://www.ncbi.nlm.nih.gov/pubmed/17701458">reportedly gave him a “signal.”</a> </p>
<p>In another study with women who use drugs, a woman said that her husband hit her and forced her to have sex: “I didn’t know I was raped because he was my husband.” </p>
<p>Treatment must address the need for escape that these women seek. As <a href="https://www.ncbi.nlm.nih.gov/pubmed/14512062">another woman said</a>, “When I was sober I didn’t dare have sex with him. I had to be high to be able … to make love to him.”</p>
<h2>A power imbalance</h2>
<p>Many women who use drugs <a href="https://www.ncbi.nlm.nih.gov/pubmed/14512062">lack the power</a> to negotiate safer sex and reduce drug risk behaviors, such as not sharing syringes with a partner or others, due to imbalanced power dynamics with their partners, and male controlling behaviors. Yet, most available HIV and substance use prevention strategies and treatment put the onus on women to insist on safe sex and drug risk reduction, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140673610610264/fulltext?rss=yes">increasing their risk of physical and sexual abuse</a>.</p>
<p>This can be dangerous. Studies have shown that women are often <a href="https://www.ncbi.nlm.nih.gov/pubmed/14512062">physically or sexually abused</a> when negotiating safe sex or refusing to engage in drug risk. Thus, a key person is missing from the conversation: her male partner. </p>
<p>My research has shown that counseling the couple may help. In a systematic <a href="https://www.ncbi.nlm.nih.gov/pubmed/24980246">review</a>, colleagues and I found that couple-based interventions for women and male sex partners who use drugs help reduce sexual- and drug-risk behaviors and promote healthy relationship. Counseling couples allows partners to <a href="https://www.ncbi.nlm.nih.gov/pubmed/14512062">address gender differences</a> in a safe environment, power imbalances and gender inequalities when sharing needles.</p>
<h2>No easy fixes</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=559&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=559&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263953/original/file-20190314-28468-1l0v8nn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=559&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cincinnati firefighters administer a nasal dose of naloxone, the anti-overdose drug that has saved thousands of lives, to a woman at a gas station in Clermont County, Ohio.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Overdose-Antidote-Divided-Police/21840605d81a46b88e50693e71587ffa/16/0">John Michillo/AP Photo</a></span>
</figcaption>
</figure>
<p>The opioid epidemic is complex and requires many approaches. In April 2018, the U.S. Surgeon General issued a public health advisory emphasizing the necessity of safe prescribing of opioids, accessing evidence-based <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">medication-assisted treatment (MAT) and distributing naloxone to reverse overdose</a>. However, the advisory makes no mention of the need for gender-specific approaches and interventions.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/26383533">A recent study</a> found that women were nearly three times less likely to receive naloxone during emergency resuscitation efforts than men, which is likely due to their being devalued. Emergency responders and police officers as well as family members and peers must be trained to overcome this gendered barrier and recognize signs and symptoms of overdose. </p>
<p>Women who use drugs face multilayers of stigma and disbelief, preventing them from disclosing problems such as partner violence. Staying in treatment is difficult for women when services are designed and delivered by men who may not know how to create an environment of trust for women. These issues must be changed if we are serious on addressing the opioid epidemic among women.</p>
<p>Women who use drugs have told our research teams that they feel unsafe in the locations where they are forced to inject. In fact, they face greater risks than men in these locations where men – who may have abused them – share. A movement toward <a href="https://www.huffingtonpost.ca/2017/05/31/sisterspace-women-only-safe-injection-site_n_16886004.html">safe injection locations</a>, similar to the site in Vancouver specifically for women, would ensure women can avoid violence and gain access to harm reduction services.</p>
<p>Women with active opioid use disorders and those in recovery need to be at the forefront of discussions of how to move forward effective policies and programs to curb gender disparities and partner violence. Only then can we observe better outcomes for women like Tonya.</p><img src="https://counter.theconversation.com/content/113604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nabila El-Bassel receives funding from the National Institute of Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH).</span></em></p>A strong link exists among sexual violence, substance use disorder and HIV in women. Why are the women who are most at risk being overlooked?Nabila El-Bassel, Professor of Social Work, Director of Social Intervention Group, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1133092019-03-13T10:41:34Z2019-03-13T10:41:34ZPurdue Pharma: Bankruptcy filing would make lawsuits slower and costlier for plaintiff cities and states<figure><img src="https://images.theconversation.com/files/263428/original/file-20190312-86696-ysb943.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Purdue faces about 2,000 lawsuits related to the opioid crisis.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Lawsuits-States/a54fadc047154c0fb8bdaea9516cad71/3/0">AP Photo/Toby Talbot</a></span></figcaption></figure><p>A <a href="https://www.reuters.com/article/uk-purduepharma-bankruptcy-exclusive/exclusive-oxycontin-maker-purdue-pharma-exploring-bankruptcy-sources-idUSKCN1QL1KP">report that Purdue Pharma may file for bankruptcy</a> has <a href="https://www.nhpr.org/post/possible-bankruptcy-purdue-pharma-could-affect-local-lawsuits-against-drugmaker">many</a> <a href="https://www.statnews.com/2019/03/04/if-purdue-pharma-declares-bankruptcy-what-would-it-mean-for-lawsuits-against-the-opioid-manufacturer/">wondering</a> how bankruptcy <a href="https://www.beckershospitalreview.com/pharmacy/what-happens-if-purdue-pharma-declares-bankruptcy.html">would affect</a> the ongoing opioid litigation. </p>
<p>Nationwide the OxyContin maker as well as other drug manufacturers and distributors face about 2,000 lawsuits related to <a href="http://www.jpml.uscourts.gov/sites/jpml/files/MDL-2804-Initial-Transfer-11-17.pdf">allegations that they contributed</a> to the <a href="https://theconversation.com/opioid-epidemic-the-global-spread-explained-101649">opioid crisis</a> through negligent marketing, fraud and unjust enrichment.</p>
<p>A bankruptcy filing by a defendant in such situations is always a possibility since the potential financial impact on companies in this type of <a href="https://definitions.uslegal.com/c/complex-tort-litigation/">tort litigation</a> is substantial and future exposure is hard to calculate. The same thing happened in 1982 over <a href="http://www.fundinguniverse.com/company-histories/johns-manville-corporation-history/">asbestos litigation</a>, in 1985 over <a href="http://articles.latimes.com/1985-08-22/news/mn-2221_1_dalkon-shield">flawed intrauterine devices</a> and in 2017 over <a href="https://www.usatoday.com/story/money/cars/2018/02/12/takata-settles-injured-drivers-exit-bankruptcy/328396002/">defective Takata airbags</a>. </p>
<p>In a recent paper <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3308838">I argued</a> that successful outcomes for the opioid litigation have always been fraught with uncertainty. </p>
<p>While a bankruptcy filing would definitely affect any litigation or settlement, it doesn’t mean plaintiffs wouldn’t get any compensation. It would mean, however, that there may be less money to go around and that plaintiffs would have to wait longer for a resolution of their cases. </p>
<h2>Litigating the opioid crisis</h2>
<p>A <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">record 48,000 people died</a> of overdoses related to opioids in 2017, including prescription painkillers, heroin and fentanyl. That brings the total number of U.S. deaths since the epidemic began around 20 years ago to <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">almost 400,000</a>, at an estimated cost of <a href="https://altarum.org/about/news-and-events/economic-toll-of-opioid-crisis-in-u-s-exceeded-1-trillion-since-2001">US$1 trillion</a>.</p>
<p>As a result, thousands of cities, states, counties and tribal nations that have suffered as a result of the <a href="https://theconversation.com/the-opioid-epidemic-in-6-charts-81601">opioid crisis</a> are trying to hold drugmakers responsible and recover some of their health care and law enforcement costs. </p>
<p>The largest lawsuit is taking place in Cleveland and involves more than 1,500 plaintiffs. Originally, these were separate lawsuits, but they were combined using a procedure called <a href="https://www.law.cornell.edu/uscode/text/28/1407">multi-district consolidation</a>. Consolidation is designed to promote a global settlement between all the parties, with so-called <a href="https://judicialstudies.duke.edu/sites/default/files/centers/judicialstudies/panel_5-bellwether_trials.pdf">bellwether trials</a> held to narrow down the issues in dispute. </p>
<p>In addition to the Cleveland case, another 300 have been filed in 45 state courts against most of the same defendants.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=414&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=414&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=414&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=521&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=521&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263431/original/file-20190312-86696-u5g8ad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=521&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Those who have lost loved ones to opioid overdoses protest outside Purdue headquarters.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Lawsuit-Massachusetts/47388fa1497e4bc284cd41bad99f24d8/2/0">AP Photo/Jessica Hill</a></span>
</figcaption>
</figure>
<h2>Purdue’s road to possible bankruptcy</h2>
<p>The possibility that Purdue <a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-11-bankruptcy-basics">might enter into Chapter 11</a> bankruptcy proceedings is not a surprise. </p>
<p>Back in August, the Oklahoma attorney general <a href="http://www.oag.ok.gov/Websites/oag/images/Emergency%20Motions.pdf">argued in a filing in his state’s case</a> against opioid manufacturers that Purdue was “trying to buy time so it can move assets and employees overseas … and either file bankruptcy or leave an empty shell here in the United States for all of the victims of its corporate greed.”</p>
<p>In addition, Purdue left visible breadcrumbs by <a href="https://www.insurancejournal.com/news/national/2019/03/04/519476.htm">hiring a law firm</a> as well as a <a href="https://www.bloomberg.com/news/articles/2018-07-23/-turnaround-kid-miller-tapped-to-lead-oxycontin-maker-s-board">new board chairman</a> with expertise in corporate restructuring. </p>
<p>While the the Cleveland litigation <a href="http://www.oag.ok.gov/Websites/oag/images/Emergency%20Motions.pdf">has stalled</a>, attention has shifted to actions brought by some states, notably those in Massachusetts and Oklahoma. </p>
<p>The Massachusetts complaint made public some <a href="https://www.npr.org/sections/health-shots/2019/02/01/690556552/lawsuit-details-how-the-sackler-family-allegedly-built-an-oxycontin-fortune">incendiary allegations</a> about some members of the Sackler family, which owns Purdue. For example, the <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">Massachusetts attorney general claimed</a> that family members “directed deceptive sales and marketing practices deep within Purdue, sending hundreds of orders to executives and line employees. From the money that Purdue collected selling opioids, they paid themselves and their family billions of dollars.” </p>
<p>Considerable attention has also been paid to the <a href="https://www.documentcloud.org/documents/5745056-Depo-022019.html">leaked deposition</a> of one of members of the Sackler family in the Oklahoma case. The Oklahoma lawsuit became even more important when it became clear that it would be the <a href="https://www.bloomberg.com/news/articles/2019-03-08/purdue-pharma-says-trial-timing-won-t-sway-bankruptcy-decision">first to go to trial</a>. On March 8, a judge ruled against Purdue and other drugmakers that had asked to delay it.</p>
<p>Cases brought by states in their own courts <a href="https://www.washingtonpost.com/national/oklahoma-could-provide-first-test-of-who-will-pay-for-the-opioid-crisis--and-how-much/2019/02/19/c35ad366-3082-11e9-8ad3-9a5b113ecd3c_story.html?utm_term=.286a65d377ed">pose great risk</a> to the defendants, a consideration that likely has amplified the bankruptcy chatter. For its part, <a href="https://www.bloomberg.com/news/articles/2019-03-08/purdue-pharma-says-trial-timing-won-t-sway-bankruptcy-decision">Purdue “categorically denied”</a> that it would affect its decision on whether to declare bankruptcy. </p>
<h2>Assessing the impact</h2>
<p>A bankruptcy filing by Purdue would be like hitting a <a href="https://www.law.cornell.edu/uscode/text/11/362">nationwide pause button</a> on all the claims against the company, whether in federal or state courts. </p>
<p>The claims against Purdue <a href="https://www.law.cornell.edu/uscode/text/28/157">would be put</a> under the exclusive jurisdiction of a <a href="https://www.law.cornell.edu/uscode/text/28/1334">federal bankruptcy court</a>. </p>
<p>It would then be the responsibility of that court to <a href="https://www.law.cornell.edu/uscode/text/28/157">determine any damages</a> to be allocated to plaintiffs as part of the company’s restructuring and possibly establish a trust fund that would apply to future opioid claims – for example, those individuals suffering from opioid use disorder not just their cities or states – after the company emerged from bankruptcy.</p>
<p>In advance, the court might also have to appoint a new attorney to <a href="https://www.law.cornell.edu/uscode/text/11/1123">represent the plaintiffs</a> during the restructuring, just one of the many procedural issues that could delay the resolution of the case. </p>
<p>The multi-district and state litigation could still proceed, except that Purdue would no longer be a defendant. However, the exit of a major defendant – and the only one to have <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html">pleaded guilty</a> to related conduct – is bound to have an impact on the representation and tactics of the other parties. </p>
<p>Further, complex <a href="https://www.justia.com/injury/negligence-theory/joint-and-several-liability/">legal rules</a> could come into play in deciding the extent to which the remaining defendants could be responsible for damages partially caused by Purdue.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263432/original/file-20190312-86707-oyu2tk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Overdoses kill nearly 200 people a day on average.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioids-Left-Behind-Sisterhood-of-Grief/10e312c16c20429f80b2d09f12a8e8ba/19/0">AP Photo/Jessica Hill</a></span>
</figcaption>
</figure>
<h2>Possible upside for co-defendents</h2>
<p>Purdue, of course, isn’t the only drugmaker on trial. </p>
<p>Johnson & Johnson, Teva Pharmaceuticals and Actavis are also defendants in most of the lawsuits, including the multi-district litigation in Cleveland. While the impact of a Purdue bankruptcy on individual co-defendants is complex, there is at least one scenario where it might actually end up benefiting them. </p>
<p>The opioid cases have always been viewed as an <a href="https://www.healthaffairs.org/do/10.1377/hblog20180517.992650/full/">uphill battle</a>, in contrast to the litigation in the 1990s that led to the <a href="https://www.npr.org/2013/10/13/233449505/15-years-later-where-did-all-the-cigarette-money-go">$246 billion settlement</a> between <a href="https://www.publichealthlawcenter.org/sites/default/files/resources/master-settlement-agreement.pdf">Big Tobacco and 46 states</a> in 1998. </p>
<p>After all, the opioid defendants can argue their products, unlike cigarettes, were <a href="https://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm338566.htm">approved by the Food and Drug Administration</a>. Furthermore, in the case of Big Tobacco,
<a href="https://www.nytimes.com/1994/05/07/us/tobacco-company-was-silent-on-hazards.html">whistleblowers revealed documents</a> demonstrating that the tobacco companies were fully aware of the dangers of smoking, prompting the settlement. </p>
<p>It is only recently that the hint of a potentially damaging smoking gun has emerged in the opioid cases, first in the allegations made in the Massachusetts case and in <a href="https://www.statnews.com/2019/02/21/purdue-pharma-richard-sackler-oxycontin-sealed-deposition/">deposition testimony</a> of the Sackler family member in Oklahoma. If Purdue is removed from the litigation, this possibly damaging evidence likely exits along with the company.</p>
<h2>Asbestos not tobacco</h2>
<p>Eventually, the litigation will reach a resolution. But most likely, compensation will be too little or too late for the victims who are suffering from the overdose epidemic. </p>
<p>And even if the lawsuits result in a substantial settlement resembling that in the tobacco litigation, there is little likelihood that those settlement dollars will find their way to the individuals or families most affected by the epidemic. </p>
<p>If the bankruptcy courts become involved, even those prospects may decrease. And instead of parallels to the tobacco litigation, we’ll see more comparisons to the <a href="https://www.rand.org/pubs/monographs/MG162.html">asbestos litigation</a>, which, in over 40 years, has failed to produce a global settlement.</p><img src="https://counter.theconversation.com/content/113309/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicolas Paul Terry receives funding from the Indiana University Addictions Grand Challenge, <a href="https://grandchallenges.iu.edu/addiction/index.html">https://grandchallenges.iu.edu/addiction/index.html</a> </span></em></p>OxyContin maker Purdue has reportedly been mulling a bankruptcy filling, just as the first of around 2,000 lawsuits against it prepares to go to trial.Nicolas Paul Terry, Professor of Law, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1123632019-03-04T11:39:13Z2019-03-04T11:39:13ZPurdue Pharma taps a Gilded Age history of pharmaceutical fraud<figure><img src="https://images.theconversation.com/files/260820/original/file-20190225-26181-1vgkr3o.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Classified advertisement for Leslie Keeley's Gold Cure.</span> <span class="attribution"><span class="source">ProQuest Historical Newspapers: Chicago Tribune, July 21, 1884</span></span></figcaption></figure><p>Newly unsealed <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">documents</a> from a <a href="https://www.propublica.org/article/oxycontin-purdue-pharma-massachusetts-lawsuit-anti-addiction-market">lawsuit</a> by the state of Massachusetts allege that Purdue Pharma, maker of OxyContin and other addictive opioids, actively sniffed out new, sinister ways to cash in on the opioid crisis. </p>
<p>Despite years of <a href="https://www.cnn.com/2019/01/31/health/purdue-pharma-unredacted-lawsuit/index.html">negative press coverage</a>, unwanted attention from regulators, multi-million dollar <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html">fines</a> and several major <a href="https://www.theguardian.com/us-news/2018/nov/19/sackler-family-members-face-mass-litigation-criminal-investigations-over-opioids-crisis">lawsuits</a>, Purdue staff and owners sought to expand the company’s sights beyond its usual array of opioid painkillers. Purdue planned to become an “end-to-end pain provider,” by branching into the market for opioid addiction and overdose medicines, looking to peddle these medicines even while the company continued to aggressively market its addictive opioids. Internal research materials coldly explained the rationale behind this plan: “Pain treatment and addiction <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">are naturally linked</a>.” </p>
<p>As thousands of Americans continue to <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state">overdose on opioids</a> annually, Purdue’s secret <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">marketing research</a> predicted that sales of <a href="https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/understanding-naloxone/">naloxone</a>, the overdose reversal drug, and <a href="https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine">buprenorphine</a>, a medicine used to treat opioid addiction, would increase exponentially. Addiction to Purdue’s opioids would thus drive the sale of the company’s opioid addiction and overdose medicines. Purdue even planned to target as customers patients already taking the company’s opioids and doctors who prescribed opioids excessively, according to the Massachusetts lawsuit filing. To keep the plan quiet, Purdue staff dubbed the scheme “Project Tango.” </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=756&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=756&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=756&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=950&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=950&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=950&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">According to the Massachusetts lawsuit, Purdue used this graphic in its internal strategy materials to illustrate Project Tango.</span>
<span class="attribution"><a class="source" href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">State of Massachusetts</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The audacity of Project Tango enraged many observers. But considered in historical context, the news that Purdue sought to peddle opioid addiction medicines while continuing to sell opioids seems less surprising. In fact, there is clear historical precedent for Purdue’s business plan. Over a century ago, “patent medicine” sellers pioneered this strategy during the U.S.’s Gilded Age opiate addiction epidemic.</p>
<h2>Opiate addiction in the Gilded Age</h2>
<p><a href="https://theconversation.com/opiate-addiction-and-the-history-of-pain-and-race-in-the-us-97430">Opiates</a> were some of the most commonly prescribed medicines in American history until the 20th century. Pills containing opium, hypodermic morphine injections and laudanum, a drinkable liquid concoction of opium and alcohol, constituted half or more of all medicines prescribed in American hospitals during most of the 19th century, <a href="https://books.google.com/books?id=qlIABAAAQBAJ&printsec=frontcover#v=onepage&q&f=false">according to research</a> by the historian <a href="https://hshm.yale.edu/people/john-harley-warner">John Harley Warner</a>. Opiates were also present in countless “<a href="https://dp.la/exhibitions/patent-medicine/1860-1920/opiates-alcohol-herbs">patent medicines</a>,” over-the-counter panaceas made of secret ingredients, often sold under catchy brand names like <a href="https://www.nytimes.com/1860/12/01/archives/mrs-winslows-soothing-syrup-for-children-teething-letter-from-a.html">Mrs. Winslow’s Soothing Syrup</a>. Americans could choose from <a href="https://books.google.com/books?id=27_cBAAAQBAJ&printsec=frontcover&dq=medical+monopoly&hl=en&sa=X&ved=0ahUKEwiTtb_m9t_gAhWCm4MKHXWVBnsQ6AEIKDAA#v=onepage&q=by%20the%20middle%20of%20the%201880s%20there%20were%20at%20least&f=false">5,000</a> brands of patent medicines marketed for all manner of ailments by the 1880s. In 1904, just before federal oversight began, patent medicines had matured into an astonishingly profitable industry, with <a href="http://sk.sagepub.com/reference/the-sage-encyclopedia-of-alcohol-social-cultural-and-historical-perspectives/n361.xml?fromsearch=true">estimated</a> sales at US$74 million dollars annually – equivalent to about $2.1 billion dollars <a href="http://www.in2013dollars.com/us/inflation/1904?amount=74000000">today</a>.</p>
<p>Opiate-laced prescriptions and patent medicines often caused addiction. The historian <a href="https://davidcourtwright.domains.unf.edu">David T. Courtwright</a> estimates that opiate addiction rates in the U.S. skyrocketed to 4.59 per thousand Americans by the 1890s – a high rate, although lower than the rate of fatal opioid overdoses in recent <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state">years</a>. Most individuals developed addictions through medicines, rather than the infamous smoking variety of opium. Victims of “the habit” cut across <a href="https://books.google.com/books/about/Dark_Paradise.html?id=VxUuPa3cnLMC&printsec=frontcover&source=kp_read_button#v=onepage&q&f=false">demographic</a> lines, encompassing middle-class housewives suffering from menstrual pain, Civil War veterans reeling from amputations and many others in between.</p>
<p>Yet even for those who became addicted to prescription opiates, the condition was socially <a href="https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-66640200R-bk#page/18/mode/2up">stigmatized</a> and physically dangerous. Like today, addiction to opiates often led to fatal overdose, condemnation and sometimes even involuntary commitment to mental asylums. As one doctor <a href="https://babel.hathitrust.org/cgi/pt?id=hvd.li2wt1;view=1up;seq=557">reported</a> to the Iowa Board of Health in 1885, addicted people lived “truly in a veritable hell.”</p>
<p>To avoid these frightful outcomes, desperate, opiate-addicted Americans frequently sought out medical treatment for their condition.</p>
<p>Gilded Age Americans could choose from a range of <a href="https://books.google.com/books?id=_MGJmdV-J4oC&pg=PA64&source=gbs_toc_r&cad=2#v=onepage&q&f=false">therapies</a> for opiate addiction. Wealthy patients frequented plush private clinics, where they could receive inpatient treatment for opiate addiction. The most popular were the <a href="https://daily.jstor.org/inside-a-nineteenth-century-quest-to-end-addiction/">Keeley Institutes</a>, which offered patients injections of the “Bichloride of Gold” remedy, invented by the doctor Leslie Keeley.</p>
<p>Scores of Keeley Institutes sprang up around the <a href="https://archive.org/details/bannerofgold2119reed/page/n35">country</a> in the late 19th century, a testament to the popularity of Keeley’s “Gold Cure,” which he marketed for alcoholism and drug addiction. No up-and-coming Gilded Age city was complete without a Keeley Institute. At the <a href="http://sk.sagepub.com/reference/the-sage-encyclopedia-of-alcohol-social-cultural-and-historical-perspectives/n286.xml?fromsearch=true">height</a> of the Gold Cure craze, there were 118 institutes serving 500,000 Americans between 1880 and 1920. Even the federal government had a <a href="https://books.google.com/books/about/Sing_Not_War.html?id=AgmVvmoeQ_gC&printsec=frontcover&source=kp_read_button#v=onepage&q=keeley&f=false">contract</a> with Keeley to provide the Gold Cure to addicted veterans. Although injections of the Gold Cure had little intrinsic medical value, historians believe that socializing with other like-minded patients in the Keeley Institutes may have helped some patients recover from addiction.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=894&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=894&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=894&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1123&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1123&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1123&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for the main Keeley Center, in Dwight, Illinois, 1908.</span>
</figcaption>
</figure>
<p>Keeley faced stiff competition, however. Other popular therapies for opiate addiction included patent medicine “cures” and “antidotes,” which were cheaper than inpatient care. These could be ordered by mail without a prescription, and consumed in the privacy of one’s home, away from prying eyes. </p>
<p>Fueled by high demand, during its heyday at the turn of the 20th century, addiction cures bloomed into a multimillion-dollar sector of the patent medicine industry. Dozens of pharmaceutical companies peddled their “cures” to willing, opiate-addicted customers, which they marketed through pamphlets, postcards, and newspaper and magazine classifieds.</p>
<p>Ironically, these “cures” for opiate addiction almost universally contained opiates, unbeknownst to hopeful customers, who received little therapeutic benefit by today’s standards. But in an era before federal regulation of medicines and narcotics, there were no effective safeguards to protect addiction patients from medical fraud. </p>
<h2>Pharmaceutical fraud</h2>
<p>Much like Purdue Pharma, which <a href="https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade/">famously</a> marketed Oxycontin as non-addictive precipitating the opioid crisis, Gilded Age patent medicine companies also fraudulently marketed their addiction treatments as non-addictive, targeting and intentionally deceiving addicted customers. For their part, Gilded Age doctors were deeply skeptical of such products, and they often accused proprietors of fraud in medical journals and newspapers.</p>
<p>Samuel B. Collins of La Porte, Indiana, inventor of the “Painless Opium Antidote,” one of the era’s most popular brands, insisted that his <a href="http://lcweb2.loc.gov/service/gdc/scd0001/2006/20060714002th/20060714002th.pdf">product</a> was not addictive. Collins was proven a fraud, however, by a skeptical Maine doctor, who in 1876 sent off a sample of Collins’ product to several chemists for analysis. Their tests <a href="https://www.nejm.org/doi/full/10.1056/NEJM187610260951705">indicated</a> that the Painless Opium Antidote contained enough morphine to perpetuate opiate addiction, actually fueling demand for Collins’s product, rather than curing the underlying addiction.</p>
<p>Despite the overwhelming evidence, however, without any effective medical regulation or oversight, Collins maintained his fraud for decades. His business strategy presaged Purdue’s Project Tango by targeting vulnerable opiate-addicted individuals.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1061&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1061&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1061&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1334&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1334&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1334&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for Theriaki, a painless cure for the opium habit. Exterior view of Dr. Collins’ Opium Antidote Laboratory, LaPorte, Indiana.</span>
<span class="attribution"><span class="source">National Library of Medicine</span></span>
</figcaption>
</figure>
<p>After decades of exposés by doctors and journalists, however, the opiate addiction cure trade collapsed during the Progressive Era under mounting public pressure and new federal legislation. One famous “muckraking” exposé, <a href="https://archive.org/details/greatamericanfr02adamgoog/page/n122">The Great American Fraud</a> by the journalist <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901284/">Samuel Hopkins Adams</a>, pulled back the curtain on the industry of opiate addiction cures for millions of appalled readers. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Collier’s ad, Dec., 1905, after the publication of articles on patent medicine fraud.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Hopkins painted such a scathing portrait of opiate addiction cures, whose proprietors the writer dismissed as “scavengers,” that the American Medical Association <a href="https://www.jstor.org/stable/2710829?seq=1#page_scan_tab_contents">paid</a> to disseminate Adams’s reporting as part of a lobbying campaign for the regulation of patent medicines. This strategy paid off. Although far from perfect solutions, the <a href="https://history.house.gov/Historical-Highlights/1901-1950/Pure-Food-and-Drug-Act/">Pure Food and Drug Act</a> of 1906 and the <a href="http://www.drugpolicy.org/blog/today-100th-anniversary-harrison-narcotics-tax-act">Harrison Narcotics Tax Act</a> of 1914 regulated the ingredients and sale of patent medicines and narcotics, including opiate addiction medicines. These measures ultimately ensured that Collins, Keeley and other patent medicine sellers could no longer prey upon opiate-addicted customers.</p>
<p>Like its Gilded Age predecessors, today’s Big Pharma actively schemes to profit off of vulnerable, addicted customers, even while taking steps to ensure that opioid addiction persists. I believe that only sustained, vigilant oversight can prevent the reemergence of a medical Gilded Age, one in which companies like Purdue Pharma can manufacture an addiction crisis and charge customers for “curing” it.</p><img src="https://counter.theconversation.com/content/112363/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan S. Jones does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Considered in historical context, Purdue’s plan to peddle opioid addiction medicines to vulnerable people is not so surprising. Gilded-Age pharmaceutical companies used similar strategies.Jonathan S. Jones, PhD Candidate in History, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1083892019-01-13T14:13:45Z2019-01-13T14:13:45ZWhy Big Pharma must disclose payments to patient groups<figure><img src="https://images.theconversation.com/files/253277/original/file-20190110-43520-v171l8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Chronic Pain Association of Canada has received money from Eli Lilly Canada Inc., Purdue Canada Inc. and Merck Frosst Canada. A blog post on the association’s website contains messages favourable to increased opioid use.</span> <span class="attribution"><span class="source">(Flickr/Ajay Suresh)</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>A United States <a href="https://www.hsdl.org/?view&did=808171">congressional report</a> revealed last year that five opioid manufacturers made more than $10 million in payments to patient advocacy groups and professional societies between 2012 and 2017.</p>
<p>Initiatives from these advocacy groups and professional societies often echoed and amplified recommendations to increase opioid use. For example, they promoted opioid for chronic pain, minimized the risk of addiction and criticized the <a href="https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm">Center of Disease Control and Prevention (CDC) guidelines</a> to limit opioid prescriptions. </p>
<p>In addition, opioid manufacturers used these groups to lobby Congress to change laws directed at curbing opioid use. This, according to the report, “may have played a significant role in creating the necessary conditions for the U.S. opioid epidemic.”</p>
<p>Patient advocacy groups play an important role in democratic societies, giving voice to vulnerable populations, shaping health policy debates and acting to influence public policies to promote their members’ interests and needs. </p>
<p>When funded by the industry, however, they often serve merely as a marketing tool — promoting corporate interest.</p>
<p>To date, there has been no attempt to systematically investigate the relationships between opioid manufacturers and pain advocacy groups and societies in Canada. However, evidence shows that, similar to the U.S., opioid manufacturers fund such organizations in Canada.</p>
<h2>Advocacy groups echo corporate interest</h2>
<p>In <a href="https://www.ubcpress.ca/health-advocacy-inc"><em>Health Advocacy Group Inc: How Pharmaceutical Funding Changed the Breast Cancer Movement</em></a>, bioethicist Sharon Batt explores the alliance between patient-group advocacy and pharmaceutical companies in Canada. She suggests that this relationship can distort policies that have been put in place to protect public health. </p>
<p>Batt questions the ability of such groups to speak on behalf of people who need help, and shows how advocacy groups today echo the demands of pharmaceutical companies that are often counter to its members interests.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=547&fit=crop&dpr=1 754w, https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=547&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/252960/original/file-20190108-32133-1xyjsc9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=547&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Christine Gagnon of Southington, Conn. protests with other family and friends who have lost loved ones to OxyContin and Opioid overdoses at Purdue Pharma LLP headquarters in Stamford, Conn., Aug. 17, 2018.</span>
<span class="attribution"><span class="source">(AP Photo/Jessica Hill)</span></span>
</figcaption>
</figure>
<p>For example, in 2005 the <a href="https://cdn.ymaws.com/www.canadianpainsociety.ca/resource/resmgr/docs/accreditation_manual.pdf">Canadian Pain Society arranged a pain management event</a>, supported by an unrestricted educational grant from Purdue Pharma Canada, the manufacturer of OxyContin. A conference held by the same society in 2007 included a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2670718/">Purdue Pharma symposium</a>.</p>
<p>In another case, the <a href="http://chronicpaincanada.com/about_cpac/sponsors">Chronic Pain Association of Canada received money from several pharmaceutical companies, including Purdue Canada</a>. A <a href="http://chronicpaincanada.com/blog/opioid-medication-effective-for-chronic-pain--study">blog post</a> on the association’s website contains messages favourable to increased opioid use and criticizes arguments questioning opioid effectiveness, calling it “anti-opioid hysteria and propaganda” caused by prominent “anti-opioid activists.” </p>
<p>Two years ago, <a href="http://purdue.ca/wp-content/uploads/2017/06/Purdue-Disclosure-2016-FINAL.pdf">Purdue donated just shy of $1 million</a> to Canadian health-care organizations, some of which could have been patient groups. (The way the information is reported doesn’t allow us to identify which health-care organizations received money.)</p>
<h2>All payments should be disclosed</h2>
<p>We believe this marketing tactic is undesirable and might have contributed to the opioid epidemic in Canada as it did in the U.S. </p>
<p>Furthermore, using the vulnerability and the suffering of patients as a tool for maximizing profit is morally wrong. </p>
<p>Lack of transparency surrounding the advocacy groups is a real problem. Neither the industry nor advocacy organizations are required to fully and routinely disclose their financial ties. </p>
<p>Indeed, some patient organizations question why they should disclose sources of donations in the first place. <a href="https://www.cadth.ca/sites/default/files/cdr/relatedinfo/SR0522_Galafold_Patient_Input.pdf">Two such groups commented</a>: “We do not see the purpose of asking how much money has been contributed by any entity that may have an interest” in a recommendation about whether a drug should be funded by a provincial drug plan.</p>
<p>We call for the Canadian government to examine and disclose all payments from pharmaceutical companies to non-profit patients’ advocacy groups and societies.</p>
<p><em>This is an updated version of a story originally published Jan. 13, 2019. The earlier story included a reference to payments to the Chronic Pain Association of Canada by Eli Lilly Canada and Merck Frosst Canada. Both provided funding to the association, but neither company manufactures or sells opioids now, nor did they at the time they made these grants.</em></p><img src="https://counter.theconversation.com/content/108389/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2015-2018, Joel Lexchin was a paid consultant on three projects: one looking at indication-based prescribing (United States Agency for Healthcare Research and Quality), a second to develop principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a third deciding what drugs should be provided free of charge by general practitioners (Government of Canada, Ontario Supporting Patient Oriented Research Support Unit and the St Michael’s Hospital Foundation). He also received payment for being on a panel that discussed a pharmacare plan for Canada (Canadian Institute, a for-profit organization), a panel at the American Diabetes Association, for a talk at the Toronto Reference Library and for writing a brief for a law firm. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. </span></em></p><p class="fine-print"><em><span>Itai Bavli does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Evidence shows that opioid manufacturers fund patient advocacy groups in Canada, distorting policies to protect public health.Itai Bavli, PhD candidate in Interdisciplinary Graduate Studies (public health and political science), University of British ColumbiaJoel Lexchin, Professor Emeritus of Health Policy and Management, York University, Emergency Physician at University Health Network, Associate Professor of Family and Community Medicine, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1085922018-12-20T11:35:00Z2018-12-20T11:35:00ZAs the opioid epidemic continues, the holidays bring need to support those in grief<figure><img src="https://images.theconversation.com/files/251351/original/file-20181218-27776-1gui2w7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Listening to friends who are grieving can be more important than saying something. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-sad-diverse-women-talking-home-790056163?src=17w8FyNPWfG29kjhFJAL4w-1-32">prostock_studio.Shutterstock.com</a></span></figcaption></figure><p>For all the warm memories and goodwill shared during the holiday season, for many it is a time of acute grief. The American opioid crisis is rightfully understood as the worst public health crisis in American history, killing <a href="https://www.cdc.gov/nchs/products/databriefs/db329.htm">over 70,000 people</a> last year alone. Behind the statistics are the private, aching pains for loved ones lost. </p>
<p>As part of <a href="https://gc-cuny.academia.edu/EBCampbell">my research</a> on grief in the American opioid epidemic, I attended over 30 community events, vigils and support group meetings, and interviewed 23 mothers whose children died of an opioid overdose. These experiences give me insights into how to care for those dealing with the loss of a loved one to addiction or overdose. </p>
<h2>Be quiet and listen</h2>
<p>For many who know someone who has lost a loved one, it can be hard to know what to say or how to respond. Conversely, for those who have lost a love one, the silence can be deafening. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251637/original/file-20181219-45385-1asvncu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If you have a special memory of a lost loved one, share the memory with others.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-friends-having-fun-london-looking-1049767157?src=v7bay70BnwCWGlAx48Wthg-1-18">William Perugini/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>If you want to be supportive, consider your relationship to the person and the deceased and find an opportunity to approach the person one-on-one. Here are some things to keep in mind: </p>
<ol>
<li><p>Listen and affirm.
Let the person know you are willing to lend an ear. If someone takes you up on your offer, stop what you are doing and listen. Put away your cellphone or other distractions and focus on your interaction with that person. Allow them to speak and listen, without jumping to offer advice or talk about yourself. Losing someone you love is painful. Letting people express their feelings without feeling judged or corrected can be very powerful. Simple phrases like “I hear you” offer validation. </p></li>
<li><p>Give the gift of time.
Grief can be a very isolating experience, so spending time with others is important. One mother described being taken out to lunch by her late son’s friends on the one-year anniversary of his death. Their time together affirmed that her son was loved and missed by others and helped change an unbearable day into something else. </p></li>
<li><p>Names matter.
One of the things that came up time and again from mothers who had lost their children to overdose was missing the sound of their child’s name. One mother explained the change from hearing and saying her son’s name many times a day to not hearing it spoken at all. For her, the difference between, “I’m sorry for the loss of your son” and “I’m sorry for the loss of Jim” is profound.</p></li>
<li><p>If you have a fond memory of the person, share it.
Many describe the joy of hearing about their loved one from others that knew them. One mother shared a card that a former teacher had written to her after her son’s death. They had not interacted for many years, and knowing her son was remembered by this person was deeply comforting.</p></li>
<li><p>A person is more than their cause of death.
The often tragic and dramatic nature of a fatal overdose can sometimes overshadow the person’s life. This is also true for alcohol-related deaths and suicide. It’s important to remember that each person had a life history, a sense of humor and hope for the future. An entire life is not defined merely by how it ends. </p></li>
<li><p>If you can’t say it, try writing.
If you don’t know how to approach the person or know what to say, consider writing an email or sending a card. This form of support can open up future conversations and does not put anyone directly on the spot. It can simply say, “Thinking of you this time of year. If you ever want to talk about Jim or just get a coffee, please let me know.” </p></li>
<li><p>Grief is universal but takes many forms.
The experience of grief varies widely. There is no time limit on grief, and for many, the grieving process is lifelong. For some, staying busy is curative, while for others, it can be hard to keep going. This is especially true during the holidays. </p></li>
<li><p>If you are grieving, you are not alone.
There are support groups in person and online. <a href="https://www.teamsharinginc.org/">Team Sharing</a> is a national online and in-person platform and advocacy group for parents who have lost their children to overdose. <a href="http://grasphelp.org/community/meetings/united-states-chapters/">Grief Recovery After Substance Passing</a> (G.R.A.S.P.) provides a directory of in-person support meetings as well.</p></li>
</ol><img src="https://counter.theconversation.com/content/108592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Campbell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For many who know someone who has lost a loved one, it can be hard to know what to say or how to respond. For those who have lost a loved one, the silence can be deafening. Some things to keep in mind.Emily B. Campbell, Visiting Lecturer of Sociology, College of the Holy CrossLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1054802018-10-29T10:38:50Z2018-10-29T10:38:50ZBeating breast cancer only to die of opioid use – a sad Appalachian story<figure><img src="https://images.theconversation.com/files/242134/original/file-20181024-71017-kj7ta1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pain medication such as oxycodone often helps cancer patients deal with intense pain after treatment, but it also can lead to abuse.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/oxycodone-generic-name-range-opoid-pain-562612936?src=mtOGcdRwDhMqxSZh88sLYw-1-5">Steve Heal/Shutterstock.com</a></span></figcaption></figure><p><em><a href="https://theconversation.com/superar-el-cancer-para-morir-por-sobredosis-la-vida-dificil-de-las-mujeres-en-los-montes-apalaches-106744">Leer en español</a>.</em></p>
<p>The availability of life-prolonging treatments such as <a href="https://www.cancer.gov/types/breast/breast-hormone-therapy-fact-sheet">hormonal therapies</a> and other targeted chemotherapy has led to a sharp decline in breast cancer deaths in the United States. </p>
<p>But despite these advances, there’s a troubling discrepancy in America. Breast cancer death rates continue to remain <a href="http://www.cavalierdaily.com/article/2016/10/cancer-rates-increase-in-appalachia-while-decreasing-nationally">abnormally high in the Appalachian region</a> of the United States, and it’s partially <a href="https://www.hhs.gov/opioids/about-the-epidemic/index.html">due to a different epidemic</a> in the U.S: <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/28639031/?i=1&from=balkrishnan,%20tan">opioid use</a>.</p>
<p>I am an epidemiologist who specializes in cancer, and I began investigating this issue five years ago to try to come up with a picture of what was happening. One thing that struck me when I looked at health insurance and cancer registry data was the extremely high and prolonged rate of use of dangerous medications like opioids in this population, sometimes as high as 50 percent in some areas.</p>
<p>Life-saving hormone treatments are often associated with side effects such as pain and muscle weakness. Although opioids are not considered first-line treatment for cancer-related pain, they are <a href="https://www.curetoday.com/publications/cure/2017/breast-2017/a-delicate-balance-treating-cancer-in-the-midst-of-the-opioid-epidemic">increasingly used to manage unbearable pain</a> in breast cancer survivors. And that, my research shows, could be influencing breast cancer death rates to the tune of <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/28639031/?i=1&from=balkrishnan,%20ta">60 percent in rural Appalachia</a>. </p>
<h2>A deadly mix</h2>
<p>The Appalachian region of the U.S. is at the epicenter of a well-documented opioid epidemic, which <a href="https://www.usnews.com/news/best-states/articles/2018-06-11/opioid-overdoses-elevated-in-appalachia">preceded the current national epidemic</a> by more than a decade.</p>
<p>Cancer disparities have existed in Appalachia for a while, but now we need to add the opioid epidemic to the mix as well for this region. My team’s analysis found that counties with the highest opioid prescribing rates in the U.S. are disproportionately found in Appalachia, with rates 50 to 65 percent higher in <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/kentucky-opioid-summary">Kentucky</a> and <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/west-virginia-opioid-summary">West Virginia</a> than over national averages. And, West Virginia has led the nation in both the total number of <a href="https://www.statnews.com/2018/07/12/despair-deaths-opioid-crisis-west-virginia/">opioid-related deaths</a> and opioid-related deaths among elderly cancer patients for decades. </p>
<p>The picture that emerges is indeed a grim one. We find many patients in Appalachia who undergo successful breast cancer treatment and then start life-prolonging hormone treatments along with opioids to manage side effects such as pain. But many (over half in some counties) continue to remain on opioids, which are usually supposed to be prescribed only for the short term, and then <a href="http://www.chicagotribune.com/lifestyles/health/sc-hlth-managing-pain-after-breast-cancer-0927-story.html">discontinue long-term survivorship</a> treatments such as hormones. The reasons these women discontinue traditional treatments is not completely clear, but my colleagues and I suspect it is related to people’s dependence on opioids.</p>
<p>The addictive nature of the opioids, the overall feelings of hopelessness and other regional issues such as poverty and drug diversion make this a complex and <a href="https://blackbearrehab.com/blog/appalachia-cradle-opioid-epidemic/">complicated treatment issue</a> and one that needs more awareness and education of both survivors and their medical providers. </p>
<h2>What are the answers?</h2>
<p>Now that we know this problem, what can we do for Appalachia?</p>
<p>Overall, greater attention is desperately needed for Appalachian women with breast cancer, who have the <a href="https://www.hhs.gov/opioids/about-the-epidemic/index.html">worst breast cancer survivorship</a> outcomes in the U.S. </p>
<p>However, given the current political context in which the elimination of the Appalachia Regional Commission (ARC) is being considered, it is unclear how to best proceed with this endeavor. The ARC is charged with the economic development of Appalachia and releases periodic reports on the economic status of the region. As a result, I believe that universities and other research centers need to take a more active role in monitoring and surveillance related to both the health and economic development of the region, to aid better health policy related to this <a href="https://www.americanprogress.org/series/appalachian-regional-commission-cuts-by-state-in-the-trump-budget/view/">vulnerable and underserved population</a>. </p>
<p>It is heartbreaking to see a woman able to beat cancer, only to die because of sub-optimal use of a life-prolonging treatment or misuse of a short-term relief treatment such as opioids. We need to work harder to educate and empower Appalachian breast cancer survivors about their treatment choices and decision-making that can be most beneficial to improving their life quality and quantity. Patient and health care professional education in Appalachia related to safe and effective use of medicines could be effective in improving patient outcomes for the most vulnerable and under-served of us all in the United States.</p><img src="https://counter.theconversation.com/content/105480/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rajesh Balkrishnan receives funding from
the National
Institutes of Health and Merck and Company. </span></em></p>The opioid epidemic has hit parts of Appalachia very hard’ places where cancer rates are high. Many patients are surviving cancer treatment only to become addicted.Rajesh Balkrishnan, Professor, Public Health Sciences, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1043832018-10-15T10:28:59Z2018-10-15T10:28:59ZDispatches from the morgue: Toxicology tests don’t tell the whole story of the opioid epidemic<figure><img src="https://images.theconversation.com/files/240281/original/file-20181011-154542-16imlcg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mortality data show only the final result of opioid overdose, not why it happens.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scene-hospital-morgue-where-corpses-taken-761983000?src=UWs3b11-wDD_bFApQ5lCKg-1-0">Skyward Kick Productions/Shutterstock.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>“Drug overdoses killed more Tennesseans than ever last year, fentanyl deaths up 70 percent,” a recent headline from my hometown newspaper, <a href="https://www.tennessean.com/story/news/2018/08/20/tennessee-overdose-deaths-2017-opioid-fentanyl/1044057002/">The Tennessean</a>, proclaimed. </p>
<p>Variations of this headline have become routine across the U.S. In June 2017, a reporter at <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">The New York Times</a> revealed that opioid overdose deaths in 2016 in the U.S. surpassed the peak number of car deaths, a record that had stood since 1972. <a href="https://www.vox.com/policy-and-politics/2017/7/7/15925488/opioid-epidemic-deaths-2016">Vox</a>, an internet media outlet, announced that “in one year, drug overdoses killed more Americans than the entire Vietnam War did,” while <a href="https://www.cbsnews.com/news/drug-overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/">CBS News</a> claimed that “drug overdoses now kill more Americans than guns.”</p>
<p>These and similar dispatches from America’s morgues sound like an alarm bell. But, what do all these dead opiate users actually tell us about the opioid crisis? Having studied the history of drug screens, I’d say not much as much as we’d hoped, it turns out. </p>
<h2>The world the screens make</h2>
<p>Drug screens serve a number of clinical purposes. For clinicians in methadone programs, drug screens are an <a href="https://www.ncbi.nlm.nih.gov/pubmed/10473015">incomparable, albeit contentious, resource</a> to monitor patient compliance. For pathologists and medical examiners, screens identify chemicals present in a corpse. However, clinical care is only one fraction of why these screens matter. </p>
<p>Epidemiologists, scientists who study populations of people to learn about disease and injury patterns, aggregate machine-assisted, post-mortem diagnoses into the data of public health. Policymakers weigh these stats in forming governmental interventions. Screens, then, form a foundation on which decisions about medical care and governmental responsibility rest.</p>
<p>But, where did drug screens come from, how do they work and how reliable are they in helping us address the opioid crisis?</p>
<h2>Measuring drug addiction</h2>
<p>The first narcotics screens emerged in the <a href="http://jpet.aspetjournals.org/content/109/1/8">mid-1950s</a>. My own unpublished research has turned up two tests that composed most drug screening: the Nalorphine Test and chromatography. </p>
<p>The Nalorphine Test, also called the Nalline Test, comprised two steps. First, subjects received an injection of an opiate antagonist, N-<a href="https://ascpt.onlinelibrary.wiley.com/doi/pdf/10.1002/cpt196126713">allylnormorphine</a>. </p>
<p><a href="https://reference.medscape.com/drugs/opioid-antagonists">Opiate antagonists</a> are chemicals that sit on opioid receptors without activating them, essentially working the opposite of opiates. In the human body, antagonists induce withdrawal symptoms, including pupil dilation. After administering the antagonist, a clinician measured the pupil size against standardized circles – a ruler called the pupillometer.</p>
<p>Jailers and physicians were especially keen on this method. One <a href="https://www-heinonline-org.proxy.library.vanderbilt.edu/HOL/Page?handle=hein.journals/fedpro27&div=28&start_page=32&collection=journals&set_as_cursor=0&men_tab=srchresults">physician</a> remarked that “the test was designed to be and has been used as a club over the head of the addict whom no one should believe.” </p>
<p><a href="https://www.tandfonline.com/doi/abs/10.3109/10826087309048772">Critics</a> reaffirmed that the test was a club, describing the procedure’s painful induced withdrawals and its supposedly inexact methods. Accuracy was not paramount to the Nalorphine test. Its utility was forcing patients and prisoners alike to fear discovery. </p>
<h2>A gold standard emerges</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chromotography has been considered the best way to test for drugs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/illustration-chemistry-chromatography-technique-separating-components-1173724111?src=Fh-PjdNvU9UarRHL9735qQ-1-7">Nasky/Shutterstock.com</a></span>
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<p><a href="https://www.britannica.com/science/chromatography">Chromatography</a> involves separating a specimen – urine, blood, hair, even organs! – into its constituent chemicals. </p>
<p>Two types of chromatography exist and serve distinct goals. Thin-layer chromatography identifies the component chemicals in a specimen, while gas-liquid chromatography combined with a mass spectrometer (GLC-MS) identifies and weighs the mass of each substance. </p>
<p>Chromatography, unlike the Nalorphine test, found an early audience among toxicologists and chemists. The benefit of chromatography is its ability to quantify, and, supposedly, to render objective diagnoses.</p>
<p>Eventually, chromatography won out. GLC-MS remains the gold standard in drug testing. Insofar as GLC-MS measures the quantities of a given chemical, these screens work great. However, I remain skeptical of marshaling its results to understand the opioid crisis.</p>
<h2>The pitfalls of a toxicological imagination</h2>
<p>Drug screens aren’t just a means of diagnosing overdoses. They constitute a distinct mode of making and interpreting biological data using specialized laboratory measuring devices, a perspective I call the “toxicological imagination.” That perspective imports pitfalls into individual, and, by extension, aggregate cases alike.</p>
<p>First, GLC can never prove conclusively that this or that drug is responsible for an individual death. GLC belches out results in milligrams/milliliter, but the significance of these numbers is relative. And there is no universal lethal dosage. GLC-MS can’t account for individual tolerance levels, which affect the dose at which a drug becomes lethal. </p>
<p>Screens have to be juxtaposed against other data: patient history, anatomical and histological observation, and social setting of the death. Synthesis of all this data reinjects the human, and all of its subjectivity, into diagnosis.</p>
<p>Second, screens overemphasize misleading concerns, especially drug potency levels. Remember when we thought crack was going to kill us all because it was supposedly so much stronger than cocaine? Fentanyl currently sits on crack’s vacated throne in this regard.</p>
<p>When we evaluate the opioid crisis by confirmed overdose deaths, we advance the kinds of interpretations that colored reactions to, for example, crack.</p>
<h2>An alternative to the toxicological imagination?</h2>
<p>Instead, I think we need to discern the medical landscapes that turn an overdose into a mortality. What is the availability of <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">Narcan</a>, an opiate antagonist that reverses an overdose? Where is the nearest ER? How easily can drug users access in-patient rehab? </p>
<p>I choose these questions specifically to raise the point that when we see individual and aggregate deaths, or observe the potency of x, y or z drug, we miss out on distal causes that produce an overdosing death. Using overdose deaths or drug potency as a basis to address the opioid crisis is akin to responding to Hurricane Katrina knowing only its wind speed or inches of rain.</p>
<p>Let me be plain: I’m trying to say that drug screens, regardless of their sensitivity, can never reconstruct the social relations that underwrite individual mortalities.</p><img src="https://counter.theconversation.com/content/104383/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justin Wade Hubbard does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The toll of the opioid epidemic is often derived from toxicology reports. These rely on drug tests. A medical historian explains these tests and how they fall short of capturing why people are dying.Justin Wade Hubbard, Doctoral Candidate, Medical History, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.