tag:theconversation.com,2011:/global/topics/oxycontin-29080/articlesOxyContin – The Conversation2023-10-16T21:49:31Ztag:theconversation.com,2011:article/2137162023-10-16T21:49:31Z2023-10-16T21:49:31ZThe roots of the North American opioid crisis, and 3 key strategies for stopping it<figure><img src="https://images.theconversation.com/files/554088/original/file-20231016-21-1blzbh.jpg?ixlib=rb-1.1.0&rect=31%2C7%2C4866%2C3210&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approaching the opioid crisis from a public health perspective includes massively increasing access to care and treatment for patients experiencing substance use disorder.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-roots-of-the-north-american-opioid-crisis-and-3-key-strategies-for-stopping-it" width="100%" height="400"></iframe>
<p>The Netflix series <em><a href="https://www.netflix.com/ca/title/81095069">Painkiller</a></em> recently depicted how the over-prescribing of the medicine OxyContin wreaked havoc on American society. </p>
<p>Today the grim reality is that opioid-related deaths in North America reached a record level in 2022, with more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">109,000 fatalities in the United States</a>. The same year in Canada, <a href="https://www.statista.com/statistics/812260/number-of-deaths-from-opioid-overdose-canada-province/">deaths exceeded 7,400</a>, a number equivalent to 20 opioid-related deaths every day, and this is <a href="https://www.thelancet.com/infographics-do/opioid-crisis-north-america">likely to continue to increase over the coming years</a>.</p>
<p>The opioid overdose crisis has been ongoing for over two decades in Canada and the U.S. The current mortality rate is greater than the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm">worst years</a> of the <a href="https://www.jstor.org/stable/41994093">HIV/AIDs epidemic</a> in these <a href="https://doi.org/10.14745%2Fccdr.v43i12a01">countries</a>. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids.html">Opioids</a> are drugs primarily used to treat severe pain, such as after surgery. When prescribed responsibly they are an effective medication, but if over-prescribed or used recreationally they can lead to an addiction (known as <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">opioid use disorder</a>) that can result in overdose death and wider community problems.</p>
<h2>The roots of the crisis</h2>
<p>After introduction of the opioid painkiller OxyContin in 1996, <a href="https://doi.org/10.2105%2FAJPH.2007.131714">Purdue Pharma marketed the drug aggressively</a>, underplaying its potential for addiction. Prescriptions increased and many patients became addicted. Purdue Pharma eventually <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty to criminal charges in 2020</a>.</p>
<p>To address addiction, <a href="https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4997.pdf">prescription monitoring programs</a> aimed to limit supply but many patients then sought illicit opioids, leading to large heroin markets in the 2010s. </p>
<p>From 2015 onwards, illegally made <a href="https://www.canada.ca/en/health-canada/services/substance-use/controlled-illegal-drugs/fentanyl.html">fentanyl</a> — a very strong opioid that is easy to manufacture — became widely available, and rapidly replaced the heroin market. Fentanyl is extremely toxic — up to 100 times stronger than heroin — and is largely responsible for the increase in overdose deaths. </p>
<p>Now North Americans face an urgency on how to end the suffering. There is no single solution given the complexity of the problem, but we explain three potential strategies for treating patients and managing this epidemic.</p>
<h2>1. Treat substance use disorders as a public health problem</h2>
<p>The traditional “<a href="https://www.lse.ac.uk/ideas/publications/reports/ending-drugs">war on drugs</a>” approach that focuses only on criminalization has been unsuccessful. In reality the data shows that illegal drug prices have fallen whilst purity and deaths have increased. <a href="https://www.themarshallproject.org/2021/07/15/inside-the-nation-s-overdose-crisis-in-prisons-and-jails">Overdose deaths have also increased in prisons</a> showing that places with even the highest level of security are vulnerable to drug smuggling.</p>
<p>Focusing on the opioid crisis through a public-health approach includes massively increasing access to care and treatment for patients experiencing substance use disorder. It requires more evidence-based services such as addiction clinics, psychotherapy harm reduction strategies and education for both patients and families about treatments that are available to them. </p>
<p>Beyond initial treatment there should be continued professional social support and a wider national effort to address the <a href="https://doi.org/10.2105%2FAJPH.2017.304187">socioeconomic causes</a> in disadvantaged communities. </p>
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<figcaption><span class="caption">Scott McFadden, an addictions counsellor in recovery from opioid use, shares his own journey and the impact of stigma and shame.</span></figcaption>
</figure>
<p>Just as there is <a href="https://www.youtube.com/watch?v=HHiN7JftdcY">stigma associated with addiction</a> that stops people from seeking help, there also appears to be stigma at the political and community level, as there is reluctance to fully acknowledge community drug problems. This <a href="https://doi.org/10.1371/journal.pmed.1002969">stigma needs to be reduced</a> so patients can get help.</p>
<h2>2. Find better treatments through research</h2>
<p>There are currently three main medicines approved for <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">treating patients with opioid use disorder</a> in Canada and the U.S.: methadone, buprenorphine/naloxone and extended-release naltrexone.</p>
<p>Although these are effective when used, there are barriers to access and long-term engagement with these treatments. <a href="https://thetyee.ca/News/2023/10/06/Catastrophe-No-Sense-Crisis/">Less than 10 per cent of overdose survivors have access to meaningful care.</a> The limited number of medications available does not work for everyone. We need more innovation to rapidly increase access to care and to find better therapies that suit the needs of different patients.</p>
<p>For example, our <a href="https://www.bccsu.ca/about/">research centre in Vancouver</a>, is evaluating a slow-release formulation of morphine compared to methadone, which has been the dominant treatment for the past 40 years. This study will generate real-world evidence on the effectiveness of novel treatments in contexts of increasing fentanyl use.</p>
<p>Other research is exploring <a href="https://classic.clinicaltrials.gov/ct2/show/NCT05985850">cannabis-based therapy</a> and the <a href="https://www.bccsu.ca/road-to-recovery-study/">best pathways patients can access for recovery</a>. These research initiatives aim to increase the number of evidence-based treatments that can be used to enhance patient recovery and quality of life.</p>
<h2>3. Stop the international spread of the epidemic</h2>
<p>Currently the epidemic is contained within North America but there is the real <a href="https://doi.org/10.1007/s40429-018-0231-x">concern of the crisis spreading</a> to other countries. There is a steady <a href="https://theconversation.com/over-the-counter-opioids-does-britain-have-a-codeine-problem-205331">increase in prescription</a> and illicit opioid use in the United Kingdom and other European countries, which should be an early warning sign that they do not follow the same trajectory. Clinicians must remain actively vigilant on how they prescribe these drugs. </p>
<p>There should be <a href="https://doi.org/10.1016/S0140-6736(21)02252-2">greater international regulation</a> in the marketing and operational strategies of pharmaceuticals, and oversight of the “<a href="https://www.science.org/content/article/fda-s-revolving-door-companies-often-hire-agency-staffers-who-managed-their-successful">revolving door</a>” between industry and regulator employment. There is a potential conflict of interest when pharma companies hire the government employees who oversee their applications. As shown in <em>Painkiller</em>, the FDA regulator who initially had issues with the drug’s approval, and then later approved it, subsequently went on to work for Purdue.</p>
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Read more:
<a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids</a>
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</em>
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<p>Another concern is that the current increase in overdose deaths is coinciding with increased deaths where other illicit recreational drugs, such as cocaine and benzodiazepines, are <a href="https://www.bccsu.ca/blog/news/fentanyl-laced-cocaine-appears-in-b-c-amid-calls-for-safe-supply/">contaminated with fentanyl</a> unknown to the users. More effort should be made towards the public awareness of the dangers of an increasingly toxic drug market.</p>
<p>Speaking at a health-care summit in June, Rahul Gupta, the <a href="https://www.politico.com/news/2023/06/07/gupta-opioid-crisis-deaths-00100756">director of the U.S. Office of National Drug Control Policy</a>, said, “There is almost no other area today (that) affects our public health, national security and economic prosperity.”</p>
<p>Valuable knowledge has been gained in confronting this crisis. Governments and communities should support evidence-based recommendations to help patients. There are still many challenges, but they are not beyond solving.</p><img src="https://counter.theconversation.com/content/213716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Smith Foundation for Health Research/ St. Paul’s Foundation Scholar Award.
Peer-review grants from the Canadian Institutes of Health Research and Vancouver Foundation.
Partial funding from Indivior for an investigator initiated study.
</span></em></p><p class="fine-print"><em><span>Rohan Anand 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>There were more than 100,000 opioid-related deaths in North America in 2022. How the crisis grew to such proportions, and three potential paths to ending it.Rohan Anand, Post Doctoral Fellow, British Columbia Centre on Substance Use, University of British ColumbiaM. Eugenia Socias, Assistant Professor, Dept of Medicine, University of British Columbia and Research Scientist with the BC Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1863612022-07-07T21:01:59Z2022-07-07T21:01:59Z$150M is not enough: Canada’s proposed Purdue Pharma settlement for opioid damages is paltry and won’t prevent future crises<figure><img src="https://images.theconversation.com/files/472872/original/file-20220706-95-jgs9g3.jpg?ixlib=rb-1.1.0&rect=273%2C62%2C2627%2C2070&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">OxyContin, an opioid drug heavily marketed by Purdue Pharma, is associated with billions of dollars of health-care costs in Canada related to the opioid crisis.</span> <span class="attribution"><span class="source">(AP Photo/Toby Talbot)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/150m-is-not-enough--canada-s-proposed-purdue-pharma-settlement-for-opioid-damages-is-paltry-and-won-t-prevent-future-crises" width="100%" height="400"></iframe>
<p>On June 29, Canadian federal and provincial governments reached a proposed <a href="https://www.theglobeandmail.com/canada/article-purdue-canada-agrees-to-pay-150-million-over-opioid-harms/">$150-million settlement with Purdue Pharma Canada</a>, makers of OxyContin, an opioid-based pain medication. The settlement is intended to recover the health-care costs related to the damaging effects from the sale and marketing of OxyContin.</p>
<p>While this is the largest settlement of a governmental health-care cost claim in Canadian history, it is also a paltry amount compared to the approximately <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/sacklers-will-pay-up-6-bln-resolve-purdue-opioid-lawsuits-mediator-2022-03-03/">US$6 billion</a> that Purdue will pay in the United States. A population-equivalent Canadian settlement would have been closer to CA$900 million. </p>
<p>Until this $150-million fine, there is no record of any drug company ever having been fined for its promotion of one of its prescription drug products in Canada. Despite illegal drug promotion documented in the United States, Health Canada did not investigate whether such practices were also present in Canada. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/pdf/221.pdf">One example</a> was the distribution of 15,000 copies of a video in the U.S. claiming, without any substantiation, that opioids caused addiction in fewer than one in 100 patients.</p>
<p>When asked why, <a href="https://www.thestar.com/news/canada/2014/06/26/dangers_of_offlabel_drug_use_kept_secret.html">agency officials responded</a> that Health Canada “has not been made aware of any specific similar issue in Canada and has not received complaints.” </p>
<p>Equally concerning, however, is the intense focus on financial settlements at the expense of regulatory changes.</p>
<h2>Regulatory loopholes</h2>
<p>Since the opioid crisis emerged, researchers and journalists have identified a range of strategies and policy loopholes that companies took advantage of to push their products. These included: </p>
<ul>
<li><p><a href="https://doi.org/10.2105%2FAJPH.2007.131714">industry influence over clinical practice guidelines</a>, which are <a href="https://www.ncbi.nlm.nih.gov/books/NBK390308/">recommendations for patient care</a>, </p></li>
<li><p><a href="http://dx.doi.org/10.1136/medethics-2013-101343">funding that can bias medical education</a>, </p></li>
<li><p>providing health-care professionals with <a href="https://doi.org/10.1016/j.amjmed.2017.12.045">free trips to exotic locations in order to listen to “expert opinions,”</a></p></li>
<li><p>insufficient transparency around <a href="https://www.motherjones.com/crime-justice/2019/08/unsealed-documents-show-how-purdue-pharma-created-a-pain-movement/">funding of non-profit organizations</a> and </p></li>
<li><p>a government-sanctioned culture of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999539/">self-regulation, enabling the pharmaceutical industry to regulate its own promotion practices</a>. </p></li>
</ul>
<p>Despite this knowledge, virtually all of these strategies remain entirely legal.</p>
<h2>Funding transparency</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protesters with signs and a skeleton made of pill bottles outside a building" src="https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protesters outside a Boston, Mass. courthouse in 2019, during a lawsuit against Purdue Pharma over its role in the national drug epidemic. The company’s U.S. settlements for OxyContin lawsuits total about US$6 billion.</span>
<span class="attribution"><span class="source">(AP Photo/Charles Krupa)</span></span>
</figcaption>
</figure>
<p>Transparency around pharmaceutical funding of health-care professionals and non-profit organizations remains virtually non-existent in Canada. The United States passed the <a href="https://www.healthaffairs.org/do/10.1377/hpb20141002.272302/full/">Physician Payments Sunshine Act</a> in 2010 requiring transparency of financial relationships between physicians and the health-care industry. Yet no such system of transparency exists in Canada. </p>
<p>In fact, the federal government has <a href="https://www.cbc.ca/news/health/pharmaceutical-drug-company-doctor-physician-payment-disclosure-transparency-1.4169888">explicitly rejected setting up a similar mechanism</a>. The one attempt to do so in Ontario was <a href="https://doi.org/10.1503/cmaj.109-5718">terminated in 2018</a> when Doug Ford’s Progressive Conservatives took office. Such a system would have significantly increased transparency around the types of physician payments that directly influenced opioid prescription patterns. </p>
<h2>Funding medical education</h2>
<p>Pharmaceutical companies are <a href="https://www.thestar.com/news/investigations/2019/02/11/family-doctors-can-no-longer-claim-ritzy-drug-dinners-as-professional-training.html"><em>still</em> permitted</a> to fund groups putting on accredited medical education events for Canadian doctors. This is despite <a href="https://doi.org/10.1371/journal.pmed.1000352">significant evidence</a> that industry funding leads to a bias in prescriptions and few improvements in prescribing. </p>
<p><a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">This type of funded “medical education”</a> was one of the main avenues through which Purdue Pharma and other companies managed to convince health-care professionals of the benefits of their products, while minimizing the products’ overall risk of addiction. </p>
<p>There is little evidence that removing industry funding would create an information gap, and it is <a href="https://doi.org/10.1371/journal.pmed.1000352">likely to drastically reduce overall industry influence over the profession</a>. Yet the federal government has often done little to use such practices to ensure appropriate drug prescribing and use, putting it at odds with governments in many other <a href="https://www.nps.org.au">wealthy industrialized countries</a>.</p>
<h2>Product monographs</h2>
<figure class="align-center ">
<img alt="White pills scattered on a black background" src="https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Since the opioid crisis emerged, researchers and journalists have identified a range of strategies and policy loopholes that companies took advantage of to push their products.</span>
<span class="attribution"><span class="source">(AP Photo/Keith Srakocic)</span></span>
</figcaption>
</figure>
<p>Canadian regulators have revealed little about how they plan to reduce industry influence over product monographs, which provide detailed information for doctors about specific drugs. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/applications-submissions/guidance-documents/product-monograph/frequently-asked-questions-product-monographs-posted-health-canada-website.html">Health Canada states</a> that a product monograph should be a “factual, scientific document on a drug product … devoid of promotional material.” </p>
<p>Despite this, Oxycontin’s original Canadian product monograph in 1996 recommended increased use of the product in cases of “<a href="https://www.gov.nl.ca/hcs/files/publications-oxycontin-final-report.pdf">breakthrough pain</a>,” a term that had previously appeared in Oxycontin advertisements. Moreover, the product monograph <a href="https://doi.org/10.1111/add.14929">provided no recommended maximum dose</a>, meaning there was no upper dose threshold for OxyContin when it was marketed. </p>
<p>Despite this, there has been no formal inquiry into how this scientific document could be so significantly affected by industry interests, or how to prevent similar influence from recurring.</p>
<h2>Gifts to health-care professionals</h2>
<p>The pharmaceutical industry continues to provide non-research-related transfers to health-care professionals. These transfers include gifts of food and drink, all-expenses paid travel to conferences and marketing-related consultancies. Again, <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">this form of funding was repeatedly used by opioid manufacturers</a> to influence health-care professionals, with companies even flying them out to exotic locations to listen to “key opinion leaders” speak on the benefits of Oxycontin and other opioids.</p>
<p>Despite virtually no rationale for the “educational” value of these events, such financial transfers continue today. In 2020, 10 of the 47 drug company members of Innovative Medicines Canada, the organization that represents the pharmaceutical industry, <a href="https://www.doi.org/10.12927/hcpol.2022.26729">spent over $28 million on fees and travel for health-care providers</a>.</p>
<p>The settlement with Purdue Pharma Canada is <a href="https://www.cbc.ca/news/canada/british-columbia/purdue-bankruptcy-filings-provinces-68b-us-opioid-crisis-oxycontin-1.5799580">frustratingly small in comparison to the billions in health-care costs of the opioid crisis</a>. But it also shouldn’t distract from the bigger issue: despite the many lessons learned from the crisis, there have been very few regulatory changes made in Canada since. </p>
<p>Unless something radically changes in how the pharmaceutical industry is regulated, there is little reason to assume a similar crisis won’t occur again.</p><img src="https://counter.theconversation.com/content/186361/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Eisenkraft Klein receives funding from a Social Sciences and Research Council Doctoral Fellowship and through internal grants from Johns Hopkins University's Opioid Industry Documents Archive. He is presently a part-time Policy Analyst in the Tobacco Control Directorate at Health Canada. </span></em></p><p class="fine-print"><em><span>In 2019-2021, Joel Lexchin received payments for writing a brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is a member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p>The Purdue Pharma settlement is paltry compared to costs of the opioid crisis. Without major changes to pharma industry regulation, there is little reason to think a similar crisis won’t occur again.Daniel Eisenkraft Klein, PhD Candidate, Dalla Lana School of Public Health, University of TorontoJoel Lexchin, Professor Emeritus of Health Policy and Management, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1737992022-01-25T13:25:57Z2022-01-25T13:25:57ZOpioid overdose: A bioethicist explains why restricting supply may not be the right solution<figure><img src="https://images.theconversation.com/files/441839/original/file-20220120-9541-1nz1c60.jpg?ixlib=rb-1.1.0&rect=31%2C12%2C2085%2C1399&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What's the best way to solve America's opioid overdose crisis?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/macro-of-oxycodone-opioid-tablets-with-prescription-royalty-free-image/1162845770?adppopup=true">BackyardProduction/ iStock via Getty images</a></span></figcaption></figure><p>Year after year, America’s drug overdose crisis is worsening.</p>
<p>In the 12-month period ending in June 2021, the most recent period for which there is reliable data, <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">more than 101,000 people died from drug overdose</a> in the U.S., – an increase of more than 20% from the previous year. </p>
<p>2021 was also an important year for analysis of the overdose crisis, with numerous books and articles shedding light on both the causes and potential solutions to the crisis.</p>
<p>Not all analysis is in agreement, however. As a <a href="https://www.travisrieder.com">bioethicist</a> who has spent much of the past several years researching the ethical and policy issues related to drug use, I’ve become particularly interested in an evolving tension between commentators on the drug crisis. </p>
<p>While many blame today’s crisis on <a href="https://doi.org/10.1093/qje/qjab043">an increase in drug supply</a> over the past 25 years, others suggest that increasing drug supply can <a href="https://doi.org/10.1503/cmaj.201618">actually be a solution</a>. So who is right? And what would ethical policy around drug supply look like? </p>
<h2>Access to drugs can be a problem</h2>
<p>The case against drugs is straightforward. As several experts have shown in recent years, the current drug overdose crisis was sparked by a steep increase in the supply of prescription opioids. </p>
<p>In his meticulously detailed book “<a href="https://www.penguinrandomhouse.com/books/612861/empire-of-pain-by-patrick-radden-keefe/">Empire of Pain</a>,” investigative journalist Patrick Radden Keefe reveals the extent to which Purdue Pharma, and the owning family, the Sacklers, utilized dishonest marketing strategies to drive aggressive prescribing of their extended-release opioid, OxyContin. Sales of the drug soared, and in the following years many <a href="https://www.nytimes.com/2019/08/27/health/johnson-and-johnson-opioids-oklahoma.html">other companies</a> followed similar playbooks.</p>
<p>Public health scientists have now shown that, starting in 1999, the volume of opioids prescribed and the overdose death rate from prescription opioids <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm">increased in parallel</a> for a decade, with prescription volume quadrupling by 2010 and overdose mortality quadrupling by 2008. </p>
<p>This is not the first time in American history that such a pattern occurred. As I argued in my 2019 book, “<a href="https://www.harpercollins.com/products/in-pain-travis-rieder?variant=32207679684642">In Pain</a>,” the prescription opioid problem of the early 2000s followed a pattern established by the development and marketing of morphine and heroin 100 years before.</p>
<p>When morphine was developed in the 19th century, its widespread use began to lead to addiction – especially among Civil War veterans. Historian <a href="https://vmi.academia.edu/JonathanJones">Jonathan Jones</a> has called this <a href="https://www.washingtonpost.com/history/2021/12/01/opioid-crisis-civil-war-addiction/">America’s first opioid crisis</a>. When heroin was developed by the Bayer AG company and marketed as a more potent, less addictive alternative to morphine that only <a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1953-01-01_2_page004.html">exacerbated the crisis</a>. </p>
<p>At least twice in recent history, then, increased access to opioids has resulted in significant public health harms. One could ask, if access to prescription opioids started the crisis, shouldn’t society work to restrict such access?</p>
<h2>Access to drugs isn’t America’s problem</h2>
<p>The problem with attempting to address overdose by restricting access to prescriptions is that the current drug overdose crisis is no longer a prescription opioid crisis. Although opioid prescribing has been dramatically curbed, overdose mortality has <a href="https://www.cdc.gov/opioids/basics/epidemic.html#three-waves">increased dramatically</a>.</p>
<p>Many overdose deaths in recent years have been <a href="https://www.cdc.gov/drugoverdose/deaths/other-drugs.html#anchor_1636146406061">polysubstance</a> deaths, involving multiple drugs. Most commonly, this includes illicit fentanyl, which is approximately <a href="https://www.cdc.gov/drugoverdose/deaths/other-drugs.html#anchor_1636146932580">50 times</a> more potent than heroin. Fentanyl and its chemical analogs – synthetic opioids that are designed to mimic the properties of fentanyl and can be even stronger – make the illicit drug supply unpredictable. When suppliers cut their drugs with varying amounts of fentanyl products, <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">the potency differs dramatically</a>, making it difficult to dose. This unpredictability is <a href="https://www.cdc.gov/drugoverdose/featured-topics/overdose-prevention-campaigns.html">driving the striking increase</a> in accidental overdose being seen today.</p>
<p>In recognition of this fact, many scholars <a href="https://ycsg.yale.edu/sites/default/files/files/we_can%27t_go_cold_turkey.pdf">have argued</a> that policies focused on restricting drug access make the drug problem worse, not better. Making prescription opioids harder to get can <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575">push those with a use disorder</a> to the illicit market. And the illicit supply is unpredictable precisely because it is unregulated. Getting clean needles <a href="https://www.networkforphl.org/news-insights/ensuring-access-to-clean-needles-can-save-lives-but-legal-barriers-persist/">can be difficult</a> because of drug paraphernalia laws. And fear of arrest <a href="https://doi.org/10.1016/j.drugalcdep.2010.07.008">increases the risk of drug overdose</a> by leading people to use alone, or by making it risky to call for help if someone does witness an overdose. </p>
<p>In short: punitive drug policy makes using drugs more dangerous.</p>
<p>In her 2021 book “<a href="https://www.hachettego.com/titles/maia-szalavitz/undoing-drugs/9780738285757/">Undoing Drugs</a>,” journalist Maia Szalavitz shows that those advocating for harm reduction have long realized the negative effects of such policies, which is why they resist arguments that focus on restricting drug supply. Instead, they <a href="https://harmreduction.org/about-us/principles-of-harm-reduction/">argue for</a> policies that make using drugs safer.</p>
<p>These policies include <a href="https://www.cdc.gov/ssp/syringe-services-programs-summary.html">syringe exchange programs</a>, which reduce incidence of hepatitis and HIV among people who use drugs by reducing needle-sharing. Another example is distributing <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">naloxone, a medication that reverses opioid overdoses</a>. In addition, <a href="https://drugpolicy.org/issues/supervised-consumption-services">overdose prevention centers</a> – sometimes called safe injection sites or safe consumption sites – reduce the risk of drug-related harms by allowing people to use drugs in a sterile, supervised setting. </p>
<h2>Can drug supply be the solution?</h2>
<p>Some harm reduction advocates do not, however, stop at strategies to make using contaminated drugs safer. They argue for simply <a href="https://newrepublic.com/article/164531/overdose-deaths-safe-supply?utm_term=Autofeed&utm_campaign=EB_TNR&utm_medium=Social&utm_source=Twitter#Echobox=1638423476">giving people safer drugs</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman holding a bottle of pills in one hand and examining the contents in the palm of another hand." src="https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441843/original/file-20220120-9024-1xqfpp3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Should people have access to a regulated drug supply?</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sick-asian-young-lady-holding-pill-take-a-look-royalty-free-image/1320983152?adppopup=true">Tirachard/iStock via Getty Images.</a></span>
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<p>The “safe supply” movement, for example, <a href="https://time.com/6108812/drug-deaths-safe-supply-opioids/">claims that</a> an important way to reduce drug overdose is for people who use drugs to have access to pure, regulated forms that are easy to accurately dose. Although counterintuitive to those who think any drug use is bad, the logic is straightforward: Some people are going to use drugs regardless of how dangerous they are, so it’s better if the drugs they have access to are consistent in potency and so safer. </p>
<p>Taking this logic further yet, some scholars <a href="https://www.nbcnews.com/think/politics-policy/fentanyl-drug-overdose-deaths-are-rising-biden-administration-rcna6384">have argued</a> that because people should have access to a regulated drug supply, all drugs should be legalized. According to this view, since the unpredictability of the drug supply increases overdose risk, making the drug supply predictable should be part of the solution. </p>
<p>Advocates for both safe supply and legalization, then, hold that an increase in drug supply is not only not a problem – it could be a solution.</p>
<h2>Resolving the tension</h2>
<p>The key to resolving this tension is to recognize that drug supply can mean different things. An “increase in supply” can be both a problem and a solution.</p>
<p>The historical cases of morphine and heroin at the end of the 19th century, and then OxyContin a century later, suggest that increased access to badly regulated drugs can lead to harm. As <a href="https://doi.org/10.1080/15265161.2021.1891332">I have argued</a> in the American Journal of Bioethics, these cases pose a serious challenge to the argument for full legalization – especially if legalization implies that all drugs should be accessible to anyone over a certain age, as with alcohol or tobacco. The tension between those concerned about drug supply and those on the pro-legalization side may be unresolvable.</p>
<p>[<em>Over 140,000 readers rely on The Conversation’s newsletters to understand the world.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140ksignup">Sign up today</a>.]</p>
<p>Providing people who plan to use drugs with a safe supply, however, can be done without making drugs easily accessible to everyone; they just need to be easily accessible to that population. What the public health infrastructure needs is <a href="https://doi.org/10.1016/j.drugpo.2020.102769">a way to prescribe drugs to those committed to using</a> without thereby giving easy access to everyone. </p>
<p>While carefully regulated access to drugs can be harm reduction, unrestricted access can lead to harm expansion. The evidence on drug-related harms therefore supports a carefully regulated safe-supply policy in order to balance the risks and benefits of access to drugs.</p><img src="https://counter.theconversation.com/content/173799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Travis N. Rieder 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>Restricting drug access can make the overdose crisis worse, not better. A bioethicist explains what that means for an ethical drug policy.Travis N. Rieder, Director of the Master of Bioethics degree program at the Berman Institute of Bioethics, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671002021-09-16T12:11:03Z2021-09-16T12:11:03ZOxyContin created the opioid crisis, but stigma and prohibition have fueled it<figure><img src="https://images.theconversation.com/files/421389/original/file-20210915-17-1lvjamv.jpg?ixlib=rb-1.1.0&rect=6%2C12%2C997%2C597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People around the world mourned loved ones on International Overdose Awareness Day on Aug. 31, 2021.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/edmontonians-pose-wooden-crosses-with-roses-on-news-photo/1234986137?adppopup=true"> NurPhoto/Getty Images</a></span></figcaption></figure><p>The <a href="https://theconversation.com/how-the-purdue-opioid-settlement-could-help-the-public-understand-the-roots-of-the-drug-crisis-166701">highly contentious</a> <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">Purdue Pharma settlement</a> announced Sept. 1, 2021, comes at a pivotal time for the U.S. overdose crisis: 2020 was the worst year on record, with over <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">93,000 Americans</a> losing their lives to fatal drug overdose. The drug overdose epidemic, now more than two decades long, has claimed the lives of <a href="https://www.cdc.gov/opioids/data/index.html">more than 840,000</a> people since 1999. Current estimates suggest that some <a href="https://www.rand.org/content/dam/rand/pubs/research_reports/RR3100/RR3140/RAND_RR3140.pdf">2.3 million people</a> in the U.S. use heroin and <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">1.7 million people</a> use pharmaceutical opioids without a prescription. </p>
<p>Since 2016, I’ve <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">studied the overdose crisis</a> with an eye to understanding its roots as well as its ramifications. As a <a href="https://www.holycross.edu/academics/programs/sociology-and-anthropology/faculty/emily_b_campbell">sociologist</a>, I came to this area of research in my own quest for meaning, as each year brought more funerals of former classmates and friends. What I found was an increasingly dangerous drug environment for people who use drugs, often exacerbated by policies not founded in research and by attitudes that harm those affected.</p>
<h2>How prohibition fuels dangerous markets</h2>
<p>Research shows that <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">the illicit drug market adapts</a> to both demand and drug enforcement efforts. </p>
<p>The first consequence of increased demand is that drugs become <a href="https://doi.org/10.1016/j.drugpo.2007.11.016">cheaper over time</a>. For example, the price of heroin and cocaine have been falling for decades. Political economists explain that demand, coupled with globalization, increases efficiency and competition. The result is that there are more drugs on the illicit market, which in turn lowers prices. </p>
<p>Second, as a response to drug prohibition, <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">drugs become more potent</a>. A stronger product in a smaller package is easier to transport and harder to detect. The American overdose crisis has become <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">a case study</a> in the devastating interplay of demand and prohibition. </p>
<p>OxyContin was released in 1996 and <a href="https://doi.org/10.2105/AJPH.2007.131714">mass-marketed as a revolutionary intervention</a> in the medical treatment of pain. Purdue Pharma, its maker, <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html?smid=url-share">knowingly downplayed</a> its addictive potential. As an opioid and central nervous depressant, <a href="https://doi.org/10.1300/J069v23n04_01">OxyContin has effects</a> similar to those of morphine or heroin. Not surprisingly, studies show that prescription patterns of opioids from 1999 to 2008 were <a href="https://pubmed.ncbi.nlm.nih.gov/22048730/">directly linked to a surge in overdose deaths</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pill bottle and pills of OxyContin prescription-only pain medication" src="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Oxycontin prescription-only pills were aggressively promoted to primary care physicians as a safe and effective pain control method for patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/oxycontin-pills-oxycodone-hydrochloride-prescription-only-news-photo/563590877?adppopup=true">Lawrence K. Ho/Los Angeles Times via Getty Images</a></span>
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<p>As concern over opioid overdose grew, doctors’ prescribing practices <a href="https://doi.org/10.1007/s11013-016-9496-5">came under scrutiny</a>. In 2010, Purdue Pharma replaced the original OxyContin with an <a href="https://doi.org/10.1001/jamapsychiatry.2014.3043">“abuse deterrent” formulation</a> that was more difficult to crush and inhale. As a result, many people who were addicted to OxyContin turned to heroin, which was <a href="https://doi.org/10.1162/rest_a_00755">cheaper and easier to get</a>. This spurred a surge in heroin-related fatal overdoses, which is often termed the <a href="https://doi.org/10.1016/j.drugpo.2019.01.010">second wave of the overdose crisis</a>.</p>
<p>The growing market for heroin paved the way for the <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">introduction of fentanyl</a> into the illicit U.S. drug market. Fentanyl, a drug used in medical settings for severe pain, is <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">50 times more potent than heroin</a>. From the standpoint of efficiency for shipping and trafficking, fentanyl is easier to transport and sell than heroin. Fentanyl’s entry into the illicit drug market, in particular in combination with heroin, <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">led to a doubling and tripling </a>of overdose deaths around 2012 to 2013. </p>
<p><a href="https://journals.lww.com/co-psychiatry/fulltext/2021/07000/the_rise_of_illicit_fentanyls,_stimulants_and_the.4.aspx">Since then, fentanyl</a> <a href="https://doi.org/10.1016/j.drugpo.2021.103353">has contaminated</a> the U.S. illicit drug supply: It is often found in not just heroin but cocaine, MDMA – commonly known as Ecstasy – methamphetamine and counterfeit prescription pills. The result is that most people <a href="https://doi.org/10.1016/j.drugpo.2019.07.008">do not know the potency or contents</a> of what they are using. </p>
<p>As the overdose crisis evolves, <a href="https://doi.org/10.1007/s40615-021-01007-6">communities of color</a> in particular have experienced a surge in fatal overdoses – deaths that are often preventable. And most recently, COVID-19 supply chain disruptions led people to use whatever was available, causing <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2021.306256">a surge in overdoses</a> from drug mixing. </p>
<h2>Barriers to treatment</h2>
<p>Too often, people who use drugs are bombarded with messages that are not supported by research and that deepen the harm. </p>
<p>Public health officials and community leaders urge people to seek treatment and highlight that recovery is within reach. Yet, roughly 70% of people who seek treatment are <a href="https://www.rcorp-ta.org/sites/default/files/2020-06/Improving-Access-to-Evidence-Based-Medical-Treatment-for-OUD_FINAL.pdf">unable to access it</a>. <a href="https://doi.org/10.1080/10826084.2017.1363238">Barriers to treatment</a> include health care costs, lack of available treatment options and social stigma. Research also demonstrates that some people are not ready for treatment or <a href="https://doi.org/10.1080/10826084.2017.1310247">do not want to be sober</a>.</p>
<p>Sobriety is touted as the ultimate goal for people who use drugs. Yet research shows that addiction is a <a href="https://doi.org/10.1038/s41386-020-00950-y">recurring brain disease</a>, and relapse is highly likely. Most people who use drugs do so in a <a href="https://www.ucpress.edu/book/9780520293472/hurt">sporadic way</a> that features bouts of controlled and uncontrolled use as well as sobriety. It is also well documented that fear of arrest and shame encourages people to hide their drug use in ways that <a href="https://doi.org/10.1080/10826084.2020.1790008">increase their risk</a> of a fatal overdose. This is because when people use alone, there is no one there to call 911 or perform CPR should an overdose occur. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding up phone with image of brother and son who died after taking fentanyl-laced drugs" src="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Laurie Restivo’s brother, David Restivo, 47 (left on phone image), died from fentanyl-laced heroin, and her son, Jason Fisher Jr., 25 (right), died from fentanyl-laced cocaine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/fentanyl-overdose-restivo-johnson-laurie-restivo-displays-a-news-photo/1315873058?adppopup=true">Reading Eagle/MediaNews Group via Getty Images</a></span>
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<p>In terms of effective treatment, <a href="https://doi.org/10.1176/appi.ps.201300256">medically assisted treatments</a> are considered the gold standard for opioid use disorder, yet they are still <a href="https://doi.org/10.1111/jrh.12328">underutilized</a>. <a href="https://doi.org/10.1001/jama.2021.1741">Buprenorphine</a> is an opioid with a “ceiling effect,” meaning it does not intoxicate like morphine or heroin but instead satiates an opioid craving. Buprenorphine assists people in transitioning away from uncontrolled use and mitigates physical cravings. People who are prescribed it are often able to work, attend therapy and regain enjoyment of day-to-day life. </p>
<p>Nonetheless, buprenorphine’s availability <a href="https://doi.org/10.1002/pds.4984">varies widely by state</a>, and people of color are <a href="https://doi.org/10.1377/hlthaff.2020.02261">persistently underprescribed</a> this lifesaving medication. Methadone has been used as a treatment for opioid use disorder since the 1950s, yet it is persistently <a href="https://doi.org/10.1007/s11606-018-4801-3">hard to access</a> long term. Researchers point to the <a href="https://doi.org/10.1080/08897077.2019.1640833">ongoing role of stigma</a> in the underuse of both of these medications. </p>
<h2>Better paths forward</h2>
<p>Public health officials, harm reduction activists and concerned citizens across the U.S. are working to secure <a href="https://doi.org/10.1097/01.NPR.0000534948.52123.fb">safer injection sites</a> where people can use drugs in the presence of medical staff. Such sites facilitate the prevention of fatal overdose by assuring an adequate and timely medical response and open a pathway for further health care and addiction-related treatment. In response to the pandemic’s strains on inpatient care facilities, <a href="https://doi.org/10.1016/j.jsat.2021.108552">take-home methadone</a> availability was expanded in new ways – a change that some treatment experts <a href="https://doi.org/10.1016/j.jsat.2020.108246">hope will be permanent</a>. </p>
<p>For people who use drugs, the <a href="https://doi.org/10.1016/j.jhealeco.2019.01.001">potency and contents of their drugs are often unknown</a>. <a href="https://doi.org/10.1016/j.drugpo.2018.10.001">Drug-checking programs</a> allow people to inspect the <a href="https://doi.org/10.1016/j.drugpo.2018.09.009">contents of their drugs for fentanyl</a> at home with a simple test strip. Such programs have recently gained traction with <a href="https://www.cdc.gov/media/releases/2021/p0407-Fentanyl-Test-Strips.html">federal support</a>. States also continue to expand <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049966/">access to naloxone</a>, an overdose reversal nasal spray that is simple to administer. People who use drugs or have loved ones who use drugs are encouraged to receive training on how to administer naloxone and to carry the nasal spray on them. </p>
<p>Those who argue for a <a href="https://doi.org/10.1503/cmaj.201618">safer supply</a> and <a href="https://doi.org/10.1016/j.socscimed.2021.113986">decriminalization of drugs</a> point to success abroad. <a href="https://www.rand.org/content/dam/rand/pubs/working_papers/WR1200/WR1263/RAND_WR1263.pdf">Heroin-assisted treatment</a> is shown to be effective in keeping people away from an unpredictable drug market, thus lowering the risk of overdose. Germany’s use of <a href="https://doi.org/10.1111/j.1360-0443.2008.02185.x">heroin-assisted treatment</a> improved patients’ physical and mental health while dramatically reducing illicit drug use. In the early 2000s, <a href="https://doi.org/10.1177/2050324516683640">Portugal decriminalized</a> all drugs in response to consistently having the highest fatal overdose rates in Western Europe. With diversion of funds away from prohibition to education and treatment, Portugal saw a drop in overall drug use and now boasts among the lowest fatal overdose rates in Western Europe.</p>
<p>Americans are the world’s <a href="https://doi.org/10.1111/add.14234">largest consumers</a> of drugs and consistently have among the highest rates of opioid and cocaine dependence globally. In <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">my own research</a>, I’ve found that people often describe drug use as a battle between sobriety and death. But the heartbreaking surge in accidental, fatal overdose deaths tells a much more complex story. Ignoring the evidence will surely cost many more lives.</p>
<p><em>If you or someone you care about has a substance use disorder and wants help, you can call SAMHSA’s National Helpline: 1-800-662-HELP (4357). Immediate emotional support is available from the National Suicide Prevention Hotline 800-273-8255.</em> </p>
<p>[<em>Get our best science, health and technology stories.</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-best">Sign up for The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/167100/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>False narratives about drug addiction and policies that are not supported by research are deepening the overdose epidemic in the US.Emily B. Campbell, Visiting Assistant Professor of Sociology, College of the Holy CrossLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1486042020-10-21T23:24:02Z2020-10-21T23:24:02ZOxyContin maker Purdue Pharma may settle legal claims with a new ‘public trust’ that would still be dedicated to profit<figure><img src="https://images.theconversation.com/files/364832/original/file-20201021-23-1j1jhkj.jpg?ixlib=rb-1.1.0&rect=496%2C229%2C5636%2C3723&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Deputy Attorney General Jeffrey A. Rosen announced a settlement between the Justice Department and opioid maker Purdue on Oct. 21.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/USOpioidCrisisPurduePharma/d69562dc33ef441d83f32833f91c4d57/photo?boardId=37be9465fcce45d283d5431cccb20a6a&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=36&currentItemNo=2">Yuri Gripas/Pool via AP</a></span></figcaption></figure><p>Purdue Pharma, the company that makes OxyContin and other potentially addictive prescription opioids, has agreed to plead guilty to three felony counts and reached a settlement potentially worth at least <a href="https://apnews.com/article/virus-outbreak-business-criminal-investigations-opioids-epidemics-5f0679ffee14577b1696a94b64abc9c2">US$8.3 billion</a> with the Justice Department.</p>
<p>The deal could clear the way for Purdue to transform from a profit-seeking privately held company into a <a href="https://www.npr.org/2020/10/21/926126877/purdue-pharma-reaches-8b-opioid-deal-with-justice-department-over-oxycontin-sale">public trust</a> that serves the public good, as the company <a href="https://www.npr.org/2019/08/28/755177086/purdue-pharma-considers-converting-to-a-public-trust-amid-lawsuits-over-opioid-c">has proposed</a>.</p>
<p>But the settlement is <a href="https://www.npr.org/2020/10/21/926126877/purdue-pharma-reaches-8b-opioid-deal-with-justice-department-over-oxycontin-sale">subject to the approval of the federal judge</a> overseeing <a href="https://www.vox.com/policy-and-politics/2019/9/16/20868487/purdue-pharma-oxycontin-bankruptcy-opioid-epidemic">Purdue’s bankruptcy case</a>. And it may not resolve the <a href="https://theconversation.com/why-companies-file-for-bankruptcy-and-how-it-protects-both-debtors-and-creditors-113101">thousands of lawsuits</a> Purdue faces for its role in creating the <a href="https://theconversation.com/us/topics/opioid-crisis-41093">opioid crisis</a>. Notably, the <a href="https://www.reuters.com/article/uk-purdue-pharma-opioids-investigations/u-s-states-oppose-settlement-being-negotiated-by-oxycontin-maker-purdue-and-justice-department-letter-idUSKBN26Z2WL">attorneys general from 25 states</a> called on the government a week before the Justice Department announced the deal to simply force the sale of the drugmaker to a new owner instead. </p>
<p>I study the <a href="https://www.davidherzberg.com/">history of prescription drugs</a> (and I have served as a paid consultant and expert witness in opioid litigation). Although there are some recent efforts to <a href="https://theconversation.com/nonprofit-drugmaker-civica-rx-aims-to-cure-a-health-care-system-ailment-104744">establish nonprofit drugmakers</a> to help make <a href="https://theconversation.com/theres-a-way-for-modern-medicine-to-cure-diseases-even-when-the-treatments-arent-profitable-122294">certain pharmaceuticals</a> more readily available, I know of no historical precedent for a big drugmaker like Purdue becoming a nonprofit public health provider.</p>
<p>But two similarly ambitious efforts to build alternatives to the profit-driven pharmaceutical model during and immediately after World War II suggest the potential limits of how well this arrangement might work.</p>
<h2>Antibiotics</h2>
<p>Penicillin was <a href="https://www.sciencehistory.org/historical-profile/alexander-fleming">discovered in 1928</a> but <a href="https://www.pbs.org/newshour/health/the-real-story-behind-the-worlds-first-antibiotic">did not come into use until World War II</a>. It was the first antibiotic: a genuinely revolutionary class of drugs that vanquished previously incurable infectious illnesses.</p>
<p>Because of penicillin’s importance for the war effort, the federal government played an active role in its development. <a href="https://www-jstor-org.gate.lib.buffalo.edu/stable/24623264?seq=24#metadata_info_tab_contents">Federal scientists</a> developed ways to mass-produce it, federal agencies persuaded reluctant pharmaceutical companies to manufacture it and the government’s “<a href="https://doi.org/10.1080/08998280.1988.11929660">penicillin czar</a>” decided which patients would receive the precious drug. </p>
<p>Despite the high stakes and the faith in centralized planning, no one at that time appears to have even considered the possibility of noncommercial or nonprofit development of antibiotics.</p>
<p>As was the case with wartime goods such as rubber and tanks, <a href="http://www.pbs.org/thewar/at_home_war_production.htm">private companies with federal contracts</a> made penicillin. As was also the case with other wartime goods, the arrangement was an unqualified success. It dramatically increased production, and allocated the antibiotic so as to best serve the war effort.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A capsule of original penicillin mold from which Alexander Fleming made the drug in 1928.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Britain-Penicillin-Mold/ed84ae41f06145cba41990abd847e6ec/9/0">AP Photo/Alastair Grant</a></span>
</figcaption>
</figure>
<p>For penicillin, as with other goods, federal economic controls quickly faded after the war. As the medical historian <a href="https://ghsm.hms.harvard.edu/faculty-staff/scott-harris-podolsky">Scott Podolsky</a> has observed, drugmakers, freed from government restraints, unleashed an avalanche of brand-name antibiotics whose high-powered marketing campaigns encouraged the <a href="https://jhupbooks.press.jhu.edu/title/antibiotic-era">overuse and misuse of the new medicines</a>.</p>
<p>Interestingly, the Sackler brothers got their start by <a href="https://www.politico.com/magazine/story/2017/12/28/raymond-sackler-obituary-216185">selling antibiotics</a>. The Sacklers, future owners of Purdue Pharma, were pioneers of medical advertising who abandoned earlier restraints and advised their sales representatives to see physicians as “<a href="http://www.doi.org/10.1056/NEJMp1902811">prey</a>.”</p>
<p>The Veterans Administration and the Public Health Service sought to keep their hands on the steering wheel by undertaking massive studies of the new, even mightier <a href="https://www.cambridge.org/us/academic/subjects/history/history-medicine/progress-experiment-science-and-therapeutic-reform-united-states-19001990">antibiotic streptomycin</a> to determine how best to use the drug against one of humanity’s deadliest microbial foes, tuberculosis. But their calls for precision and restraint stood little chance against drug marketers who skillfully exploited Americans’ desire for miracles. </p>
<h2>Metopon</h2>
<p>The second precedent involved the <a href="https://history.nih.gov/exhibits/opiates/docs/3_newDrugs.htm">semi-synthetic opioid Metopon</a>, discovered during World War II by <a href="https://www.jstor.org/stable/236321?seq=1#metadata_info_tab_contents">pharmacologists working for the U.S. National Research Council</a>.</p>
<p>Since the 1920s, opioids had been much more strongly regulated than other pharmaceuticals to <a href="https://theconversation.com/purdue-pharma-taps-a-gilded-age-history-of-pharmaceutical-fraud-112363">protect consumers</a>. As I explain in my new book “<a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo58927880.html">White Market Drugs</a>,” they could be sold only by a licensed pharmacist on a physician’s prescription. For decades, the Federal Bureau of Narcotics, working with <a href="https://tethys.pnnl.gov/institution/national-research-council-national-academies-nrc">National Research Council</a> pharmacologists, imposed tight restrictions on the development and marketing of new opioids.</p>
<p>It was a daily battle for these government agencies to identify and then counteract what they considered to be dangerous marketing hype by drug companies pushing the latest miracle opioid.</p>
<p>So, daringly, in 1946, the two agencies hatched a radical idea: They would take out a patent on Metopon and market it themselves. Instead of trying to achieve maximum profit, they would only serve public health. They would not advertise Metopon at all. Instead physicians would learn about it through sober, informative pronouncements from experts in medical journals. Moreover, sales would initially be restricted to patients suffering from end-stage cancer. </p>
<p>The government believed Metopon would win out over competitors not because of marketing hype but because it was actually superior. But it didn’t work out that way.</p>
<p>Sales were sluggish after Metopon’s launch in 1947, and remained low even after the authorities allowed sales for more types of pain. Even <a href="https://theconversation.com/re-criminalizing-cannabis-is-worse-than-1930s-reefer-madness-89821">Harry Anslinger</a>, head of the Federal Bureau of Narcotics and an otherwise ferocious critic of pharmaceutical opioid advertising, complained about lackluster marketing. While it remained technically available, Metopon never earned more than a minute fraction of the U.S. opioid market.</p>
<h2>New ownership</h2>
<p>The proposed transformation of Purdue differs from these earlier attempts to find alternatives to the profit-driven model of drug distribution.</p>
<p>Rather than attempting to get profit-making companies to do the right thing, or hoping that a single ethically marketed drug could win out, the Purdue settlement would legally require a major pharmaceutical manufacturer to make public health a higher priority than shareholder profits.</p>
<p>This would, at least in theory, serve two important goals.</p>
<p>First, by legally defining the company’s obligations to public health rather than to shareholders, it would eliminate the kinds of abuses that can result from the pursuit of profit such as marketing that encourages unnecessary or improper use.</p>
<p>Second, by providing addiction treatment at no cost, it would increase access to health care to the sorts of patients – addicted, poor and lacking adequate health insurance – typically ill served or even ignored in today’s system.</p>
<p>In other ways, however, the Purdue settlement seems less of a departure from standard operating procedures than 1940s-era attempts to reduce or eliminate the influence of profit in pharmaceuticals.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.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">Emergency responders use this drug to treat narcotic overdoses.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Purdue/2fd3d7f1b2ef4266b26dfd57af939e3e/5/0">AP Photo/Keith Srakocic</a></span>
</figcaption>
</figure>
<p>By all accounts, the new trust would be a for-profit entity. Indeed, profits from continued sales of pain medicines like OxyContin and addiction treatment medications like <a href="https://www.drugs.com/mtm/buprenorphine-and-naloxone-oral-sublingual.html">buprenorphine and naloxone</a> – <a href="https://www.washingtonpost.com/business/economy/sackler-legacy-is-at-stake-in-familys-bid-to-reinvent-purdue-pharma-as-a-public-trust/2019/11/05/479ea040-ee91-11e9-b648-76bcf86eb67e_story.html">estimated by Purdue to be up to $8 billion</a> per year – are crucial as the “payment” Purdue is offering to compensate the public for the company’s share of the costs of the opioid crisis.</p>
<p>In other words, to achieve its mission, the new Purdue would have to pursue profits just like the old Purdue. And since all pharmaceutical companies officially declare themselves to be dedicated to serving the public good, how different would it really be?</p>
<p>Then, too, the new trust would still be Purdue Pharma, a company with a well-entrenched culture of <a href="https://khn.org/news/purdue-and-the-oxycontin-files/">maximizing sales and profits</a> even as the opioid crisis has grown. One could make a <a href="https://jhupbooks.press.jhu.edu/title/drug-dealer-md">credible case</a> that Purdue’s innovation – the “value” it brought to the table – was not related to any special therapeutic breakthrough in the drugs it developed but instead lay in its genius with marketing these products.</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>I can see why it is tempting to be excited about the prospect of a new public trust devoted to addressing addiction.</p>
<p>But for this proposed arrangement to make sense, Purdue would need the tools and expertise required to pursue a radically different mission than it was designed to serve. And history does not offer much assurance that isolated public-sector and nonprofit drugmakers can make a big difference in a pharmaceutical system designed for and powered by profit.</p>
<p><em>This is an updated version of an article originally published on <a href="https://theconversation.com/the-company-that-makes-oxycontin-could-become-a-public-trust-what-would-that-mean-126981">December 4, 2019</a>.</em></p><img src="https://counter.theconversation.com/content/148604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Herzberg was retained as a paid expert witness for the plaintiffs in opioid litigation.</span></em></p>The government has tried to harness profit-driven drugmaking to serve public health before. The results were underwhelming.David Herzberg, Associate Professor of History, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1327322020-03-09T19:01:05Z2020-03-09T19:01:05ZOpioid marketing to Canadian doctors hyped benefits, downplayed harms<figure><img src="https://images.theconversation.com/files/317913/original/file-20200301-166503-ukpk31.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5447%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The way opioid drugs were marketed to doctors may have contributed to the opioid crisis. </span> <span class="attribution"><span class="source">AP Photo/Mark Lennihan</span></span></figcaption></figure><p>Between January 2016 and June 2019 there were over <a href="https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html">13,900 deaths from opioid overdoses</a> in Canada, 4,500 of which occurred in 2018. Based on information to date, 2019 is likely to have a similar mortality rate. Most deaths these days are from street drugs laced with fentanyl, carfentanil and other similar products. </p>
<p>But most <a href="https://www.nature.com/articles/d41586-019-02686-2">experts agree that aggressive marketing of prescription opioids has been one of the major triggers for what we are seeing today</a>. In 2000, OxyContin (long-acting oxycodone), made by Purdue Pharma, was added to Ontario’s drug formulary, a list of all medications covered under the Ontario Drug Benefit program. By 2004, all opioid-related <a href="https://doi.org/10.1503/cmaj.090784">deaths had gone up by 50 per cent and deaths specifically from long-acting oxycodone had increased more than five-fold</a>.</p>
<p>At one point, Purdue was paying <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">100 doctors per year up to $2,000 per talk</a> to go across Canada and talk about pain management to other physicians. One of those doctors was CBC radio’s Brian Goldman, host of <em>White Coat, Black Art</em>. In his 2010 book, <em>Night Shift</em>, <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">Goldman recounts how he was treated by the companies who paid him</a>: </p>
<blockquote>
<p>“… I was put up in five-star hotels and taken to nice restaurants. When I travelled across the continent, I was invariably given a ticket in business class.”</p>
</blockquote>
<p>The most effective method companies have to promote their products, the one that they put the most money into, is visits to doctors by sales representatives. These men and women are paid to go from office to office touting the products made by their companies. In the United States, <a href="https://doi.org/10.1001/jama.2018.19320">over $5.5 billion </a>is spent on drug marketing by sales representatives.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.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">OxyContin, a long-acting oxycodone, was added to the Ontario drug formulary in January 2000.</span>
<span class="attribution"><span class="source">AP Photo/Toby Talbot, File</span></span>
</figcaption>
</figure>
<p>Here in Canada, sales representatives are regulated through the <a href="http://innovativemedicines.ca/wp-content/uploads/2018/06/Code-Formatted_Regular_EN-2.pdf">Code of Ethical Practices</a> of Innovative Medicines Canada (IMC), the lobby group representing the major pharmaceutical companies operating in Canada. The code states: </p>
<blockquote>
<p>“Members must provide full and factual information on products, without misrepresentation or exaggeration. Statements must be accurate and complete. They should not be misleading, either directly or by implication.”</p>
</blockquote>
<h2>Claims about benefits</h2>
<p>As researchers of pharmaceutical policy, we were interested in the extent to which these standards are upheld in practice. In 2009-10, we carried out a <a href="https://doi.org/10.1007/s11606-019-05584-5">research project with an international team</a>. In the Canadian side of this study, we asked general practitioners in Vancouver and Montréal who saw sales representatives, to fill out questionnaires after each visit to record what they had been told. In total this study included nearly 1,700 reports by doctors, around half in Canada and the rest in the U.S. and France. Claims about benefits of drugs were made twice as often as statements about harms. Contraindications — information on who should not use a medicine — were mentioned about 15 per cent of the time, and serious harmful effects only five to six per cent of the time.</p>
<p>This study was carried out at the height of opioid prescribing. We therefore went back to see what doctors reported about what sales representatives had said when they were promoting the opioids. There were 69 sales visits with opioid promotions, reported on by 54 doctors. We called this the “nuts and bolts” of opioid promotion as doctors reported on the specific messages sales representatives used to promote prescription opioids.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.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">In more than half of opioid promotions, pharmaceutical representatives did not mention any harmful effects.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graeme Roy</span></span>
</figcaption>
</figure>
<p>In over half of these opioid promotions, no harmful effects were mentioned, although health benefits were discussed nearly 80 per cent of the time. These benefits were often vague, broad claims, such as a promise of “better quality of life” with oxycodone use. Serious harms, such as respiratory depression or arrest, were mentioned in just 12 per cent of promotions.</p>
<p>Even when information on harm was provided, often the aim was to reassure. For example, when one doctor raised the risk of a potentially fatal interaction between an opioid and an antidepressant, the representative answered that “the drug label does not refer to this situation as dangerous and therefore the drug is not contraindicated.”</p>
<p>In nine per cent of promotions, doctors said that the sales representatives had mentioned addiction or abuse. However, the only information doctors reported hearing was claims of a low addiction or abuse potential. For example, statements included: “good drug if [you are] concerned about abuse, cannot get abused” and “safer than codeine and other opiates and non-addictive,” or for “elderly patients not wanting any strong narcotics.”</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.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">Oxycodone 5 milligram tablets.</span>
<span class="attribution"><span class="source">AP Photo/Keith Srakocic, File</span></span>
</figcaption>
</figure>
<p>Despite the inadequate safety information and the lack of warnings about the need for caution reported by the doctors, most said that they were somewhat or very likely to increase prescribing of the drug compared with before the sales visit. In nearly 60 per cent of promotions, doctors judged the quality of scientific information to be good or excellent.</p>
<p>Given the serious harm from overprescribing of opioids, this study highlights the need for doctors to seek out information on medicines from sources that are independent of the pharmaceutical industry, and to avoid relying on sales representatives.</p>
<h2>The fox guarding the henhouse</h2>
<p>Health Canada has largely turned over regulation of sales representatives’ activities to IMC, which waits for complaints before it acts. Complaints are adjudicated by representatives of member companies. Even if companies are found guilty of violating the Code, the <a href="http://innovativemedicines.ca/wp-content/uploads/2018/06/Code-Formatted_Regular_EN-2.pdf">maximum penalty is $100,000</a>, small change for a multinational company.</p>
<p>Relying on the pharmaceutical industry to regulate its own marketing of medicines is a classic case of the fox guarding the henhouse. We know from the experience with opioids that there are serious consequences for public health when doctors rely on misleading information about the benefits and harms of medicines.</p>
<p>If we want to stop the next round of deaths from misleading promotion, Health Canada needs to start actively regulating drug promotion, including imposing meaningful sanctions.</p><img src="https://counter.theconversation.com/content/132732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2016-2019, Joel Lexchin was a paid consultant on two projects: one looking at developing principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a second 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 at the American Diabetes Association, for a talks at the Toronto Reference Library, for writing a brief in an action for side effects of a drug for Michael F. Smith, Lawyer and a second brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. 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. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p><p class="fine-print"><em><span>Barbara Mintzes is a member of Health Action International (HAI-Europe Association), a non-profit organization that supports public interests in pharmaceutical policy. She was a member of Health Canada’s Expert Advisory Group on the Marketing of Opioids in 2018 and 2019. She has no other interests to declare and receives no funding from pharmaceutical companies. </span></em></p>Aggressive marketing of prescription opioids by pharmaceutical companies provided doctors with scant information about potential harmful effects.Joel 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 TorontoBarbara Mintzes, Senior Lecturer, Faculty of Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1269812019-12-04T13:31:25Z2019-12-04T13:31:25ZThe company that makes OxyContin could become a ‘public trust’ – what would that mean?<figure><img src="https://images.theconversation.com/files/303852/original/file-20191126-180279-1368u6o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Calif. Attorney General Xavier Becerra, discussing the lawsuit his office has filed against Purdue Pharma.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Lawsuits/6ef74907ff3a4cffaab428b56b7ca8c1/2/">AP Photo/Rich Pedroncelli</a></span></figcaption></figure><p>Purdue Pharma, which makes OxyContin and other potentially addictive prescription opioids, has <a href="https://www.vox.com/policy-and-politics/2019/9/16/20868487/purdue-pharma-oxycontin-bankruptcy-opioid-epidemic">declared bankruptcy</a>. It’s also facing <a href="https://theconversation.com/why-companies-file-for-bankruptcy-and-how-it-protects-both-debtors-and-creditors-113101">thousands of lawsuits</a> for its leading role in creating the <a href="https://theconversation.com/us/topics/opioid-crisis-41093">opioid crisis</a>.</p>
<p>The company is trying to reach a broad settlement with the many jurisdictions now suing. The settlement it’s proposing would transform the company from a profit-seeking privately held company into a “<a href="https://www.npr.org/2019/08/28/755177086/purdue-pharma-considers-converting-to-a-public-trust-amid-lawsuits-over-opioid-c">public beneficiary trust</a>” that serves the public good.</p>
<p>I study the <a href="https://www.davidherzberg.com/">history of prescription drugs</a>. Although there are some recent efforts to <a href="https://theconversation.com/nonprofit-drugmaker-civica-rx-aims-to-cure-a-health-care-system-ailment-104744">establish nonprofit drugmakers</a> to help make <a href="https://theconversation.com/theres-a-way-for-modern-medicine-to-cure-diseases-even-when-the-treatments-arent-profitable-122294">certain pharmaceuticals</a> more readily available, I know of no historical precedent for a big drugmaker like Purdue becoming a nonprofit public health provider.</p>
<p>But two similarly ambitious efforts to build alternatives to the profit-driven pharmaceutical model during and immediately after World War II suggest the potential limits of how well this arrangement might work.</p>
<h2>Antibiotics</h2>
<p>Penicillin was <a href="https://www.sciencehistory.org/historical-profile/alexander-fleming">discovered in 1928</a> but <a href="https://www.pbs.org/newshour/health/the-real-story-behind-the-worlds-first-antibiotic">did not come into use until World War II</a>. It was the first antibiotic: a genuinely revolutionary class of drugs that vanquished previously incurable infectious illnesses.</p>
<p>Because of penicillin’s importance for the war effort, the federal government played an active role in its development. <a href="https://www-jstor-org.gate.lib.buffalo.edu/stable/24623264?seq=24#metadata_info_tab_contents">Federal scientists</a> developed ways to mass produce it, federal agencies persuaded reluctant pharmaceutical companies to manufacture it and the government’s “<a href="https://doi.org/10.1080/08998280.1988.11929660">penicillin czar</a>” decided which patients would receive the precious drug. </p>
<p>Despite the high stakes and the faith in centralized planning, no one at that time appears to have even considered the possibility of non-commercial or nonprofit development of antibiotics.</p>
<p>As was the case with wartime goods such as rubber and tanks, <a href="http://www.pbs.org/thewar/at_home_war_production.htm">private companies with federal contracts</a> made penicillin. As was also the case with other wartime goods, the arrangement was an unqualified success. It dramatically increased production, and allocated the antibiotic so as to best serve the war effort.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A capsule of original penicillin mold from which Alexander Fleming made the drug in 1928.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Britain-Penicillin-Mold/ed84ae41f06145cba41990abd847e6ec/9/0">AP Photo/Alastair Grant</a></span>
</figcaption>
</figure>
<p>For penicillin, as with other goods, federal economic controls quickly faded after the war. Drugmakers, freed from government restraints, unleashed an avalanche of brand-name antibiotics whose high-powered marketing campaigns encouraged the <a href="https://jhupbooks.press.jhu.edu/title/antibiotic-era">overuse and misuse of the new medicines</a>.</p>
<p>Interestingly, as the medical historian <a href="https://ghsm.hms.harvard.edu/faculty-staff/scott-harris-podolsky">Scott Podolsky</a> has observed, the Sackler brothers got their start by <a href="https://www.politico.com/magazine/story/2017/12/28/raymond-sackler-obituary-216185">selling antibiotics</a>. The Sacklers, future owners of Purdue Pharma, were pioneers of medical advertising who abandoned earlier restraints and advised their sales representatives to see physicians as “<a href="http://www.doi.org/10.1056/NEJMp1902811">prey</a>.”</p>
<p>The Veterans Administration and the Public Health Service sought to keep their hands on the steering wheel by undertaking massive studies of the new, even mightier antibiotic <a href="https://www.cambridge.org/us/academic/subjects/history/history-medicine/progress-experiment-science-and-therapeutic-reform-united-states-19001990">streptomycin</a>, to determine how best to use the drug against one of humanity’s deadliest microbial foes, tuberculosis. But their calls for precision and restraint stood little chance against drug marketers who skillfully exploited Americans’ desire for miracles. </p>
<h2>Metopon</h2>
<p>The second precedent involved the semi-synthetic opioid <a href="https://history.nih.gov/exhibits/opiates/docs/3_newDrugs.htm">Metopon</a> discovered during World War II by <a href="https://www.jstor.org/stable/236321?seq=1#metadata_info_tab_contents">pharmacologists working for the U.S. National Research Council</a>.</p>
<p>Since the 1920s, opioids had been much more strongly regulated than other pharmaceuticals to <a href="https://theconversation.com/purdue-pharma-taps-a-gilded-age-history-of-pharmaceutical-fraud-112363">protect consumers</a>. As I explain in my upcoming book “<a href="https://www.davidherzberg.com/">White Market Drugs</a>,” they could only be sold by a licensed pharmacist on a physician’s prescription. For decades, the Federal Bureau of Narcotics, working with <a href="https://tethys.pnnl.gov/institution/national-research-council-national-academies-nrc">National Research Council</a> pharmacologists, imposed tight restrictions on the development and marketing of new opioids.</p>
<p>It was a daily battle for these government agencies to identify and then counteract what they considered to be dangerous marketing hype by drug companies pushing the latest miracle opioid.</p>
<p>So, daringly, in 1946, the two agencies hatched a radical idea: They would take out a patent on Metopon and market it themselves. Instead of trying to achieve maximum profit, they would only serve public health. They would not advertise Metopon at all. Instead physicians would learn about it through sober, informative pronouncements from experts in medical journals. Moreover, sales would initially be restricted to patients suffering from end-stage cancer. </p>
<p>The government believed Metopon would win out over competitors not because of marketing hype but because it was actually superior. But it didn’t work out that way.</p>
<p>Sales were sluggish after Metopon’s launch in 1947, and remained low even after the authorities allowed sales for more types of pain. Even <a href="https://theconversation.com/re-criminalizing-cannabis-is-worse-than-1930s-reefer-madness-89821">Harry Anslinger</a>, head of the Federal Bureau of Narcotics and an otherwise ferocious critic of pharmaceutical opioid advertising, complained about lackluster marketing. While it remained technically available, Metopon never earned more than a minute fraction of the U.S. opioid market.</p>
<h2>New ownership</h2>
<p>The proposed transformation of Purdue differs from these earlier attempts to find alternatives to the profit-driven model of drug distribution.</p>
<p>Rather than attempting to get profit-making companies to do the right thing, or hoping that a single ethically marketed drug can win out, the Purdue settlement would legally require a major pharmaceutical manufacturer to prioritize public health over shareholder profits.</p>
<p>This would, at least in theory, serve two important goals.</p>
<p>First, by legally defining the company’s obligations to public health rather than to shareholders, it would eliminate the kinds of abuses that can result from the pursuit of profit such as marketing that encourages unnecessary or improper use.</p>
<p>Second, by providing addiction treatment at no cost, it would increase access to health care to the sorts of patients – addicted, poor and lacking adequate health insurance – typically ill-served or even ignored in today’s system.</p>
<p>In other ways, however, the Purdue settlement seems less of a departure from standard operating procedures than 1940s-era attempts to reduce or eliminate the influence of profit in pharmaceuticals.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.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">Emergency responders use this drug to treat narcotic overdoses.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Purdue/2fd3d7f1b2ef4266b26dfd57af939e3e/5/0">AP Photo/Keith Srakocic</a></span>
</figcaption>
</figure>
<p>By all accounts, the new trust would be a for-profit entity. Indeed, profits from continued sales of pain medicines like OxyContin and addiction treatment medications like <a href="https://www.drugs.com/mtm/buprenorphine-and-naloxone-oral-sublingual.html">buprenorphine and naloxone</a> – <a href="https://www.washingtonpost.com/business/economy/sackler-legacy-is-at-stake-in-familys-bid-to-reinvent-purdue-pharma-as-a-public-trust/2019/11/05/479ea040-ee91-11e9-b648-76bcf86eb67e_story.html">estimated by Purdue to be up to US$8 billion</a> per year – are crucial as the “payment” Purdue is offering to compensate the public for the company’s share of the costs of the opioid crisis.</p>
<p>In other words, to achieve its mission, the new Purdue would have to pursue profits just like the old Purdue. And since all pharmaceutical companies officially declare themselves to be dedicated to serving the public good, how different would it really be?</p>
<p>Then, too, the new trust would still be Purdue Pharma, a company with a well-entrenched culture of <a href="https://khn.org/news/purdue-and-the-oxycontin-files/">maximizing sales and profits</a> even as the opioid crisis grew. One could make a <a href="https://jhupbooks.press.jhu.edu/title/drug-dealer-md">credible case</a> that Purdue’s innovations – the “value” it brought to the table – were not related to any special therapeutic breakthrough in the drugs it developed but instead lay in its genius with marketing these products.</p>
<p>I can see why it is tempting to be excited about the prospect of a new public-benefit trust devoted to addressing addiction.</p>
<p>But for this proposed arrangement to make sense, Purdue would need the tools and expertise required to pursue a radically different mission than it was designed to serve. And history does not offer much assurance that isolated public-sector and nonprofit drugmakers can make a big difference in a pharmaceutical system designed for and powered by profit.</p>
<p>[ <em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/126981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Herzberg was retained as a non-testifying consultant on the plaintiffs' side in the In re National prescription Opiate Litigation MDL.</span></em></p>The government has tried to harness a profit-driven drug industry to serve public health before.David Herzberg, Associate Professor of History, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1122962019-04-14T14:22:57Z2019-04-14T14:22:57ZThe opioid crisis is not about pain<figure><img src="https://images.theconversation.com/files/268736/original/file-20190411-44776-vnag2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man walks in a back alley in Vancouver's downtown eastside, February 2019. More people fatally overdosed in British Columbia last year compared with 2017 despite efforts to combat the province's public health emergency.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span></figcaption></figure><p>Opioid-related deaths have been <a href="https://www.rollingstone.com/culture/culture-features/opioid-epidemic-american-problem-817756/">rising over recent years in North America</a> and globally. New data released by the Public Health Agency of Canada reveals that <a href="https://www.cbc.ca/news/health/opioids-phac-1.5092387">more than 10,300 Canadians died as a result of an apparent opioid-related overdose between January 2016 and September 2018</a>.</p>
<p>There is no question that this is tragic and requires attention. </p>
<p>The response by Canadian policy-makers, however, has focused largely on the over-prescription of opioids as pain medications. Interventions have included <a href="https://www.cbc.ca/news/health/reducing-opoids-after-surgery-western-university-1.4876092">limiting prescriptions</a>, increasing <a href="http://nationalpaincentre.mcmaster.ca/documents/2017_Opioid_Guideline_Summary_EN_000.pdf">oversight of physicians</a> and providing <a href="https://www.ismp-canada.org/download/OpioidStewardship/Opioid-Prescribing-Skills.pdf">guidance for decreasing or tapering</a> opioid medications.</p>
<p>In January 2019, <a href="https://www.theglobeandmail.com/canada/article-ontario-ottawa-sign-bilateral-agreement-for-opioid-crisis-related/">Ontario announced an agreement with the federal government</a> to inject another $100 million in fighting the crisis. These funds will likely be spent on safe injection sites, naloxone kits for emergency and medical personnel, public education about how to respond to an overdose and task forces to improve pain management.</p>
<p>I fear this focus on pain and overdose is a focus merely on the symptoms of a broader crisis — a crisis of under-managed mental illness and <a href="https://www.thespec.com/opinion-story/9277371-opioids-are-killing-canadians-by-the-thousands-we-need-to-care-more-/">unresolved emotional trauma throughout Canada</a>. Pain and substance use disorder are linked, but they are not synonymous. The opioid crisis is not, at its root, a problem of pain. </p>
<p>Meanwhile, the voices of nearly <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298051/">one in five Canadian adults</a> who live with daily pain seem largely unheard.</p>
<h2>Living with chronic pain</h2>
<blockquote>
<p>“Without pain meds, I cannot walk or accomplish even the simplest of household tasks. Going to the toilet will be beyond my capabilities. I have always employed narcotic pain meds to live as close to a normal life as is possible; without them I am only a burden to myself and others.”</p>
</blockquote>
<p>As a physiotherapist, educator and pain researcher over the past 19 years I have heard this story, shared with me via email, countless times. In the shadow of the alarm over the opioid crisis, an important message seems to have been lost: many people live with daily pain and depend on opioid-based medications to live bearable lives. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=459&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=459&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=459&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268861/original/file-20190411-44802-82bj1r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ramona Poppe, 56, of Onalaska, Wash., is shown at her home in September 2018. Poppe said she understands the risk of using opioids but wants to maintain the option of using them to reduce her chronic pain from medical conditions.</span>
<span class="attribution"><span class="source">(Bill Wagner /The Daily News via AP)</span></span>
</figcaption>
</figure>
<p>Many people find that opioid medications such as codeine, OxyContin, morphine or in some cases even fentanyl, can be effectively used in combination with other therapies like exercise, meditation or psychological counselling to maintain a tolerable quality of life. </p>
<p>Through no fault of their own, these people are now described in the same breath with sufferers of substance-use disorders. And they find themselves in the middle of a largely North American tug-of-war between policy-makers, doctors, pharmaceutical companies and the public. Many of them find themselves unable to access the prescription opioids they need to live bearable lives.</p>
<h2>Record number of opioid deaths</h2>
<p>When alarms were raised in 2015 about the growing rate of opioid overdose deaths, the discourse at the time almost exclusively focused on manufacturers of opioid-based pain medications like Purdue Pharma, and the doctors that prescribe them.</p>
<p>The arguments were that <a href="https://www.nytimes.com/2018/05/29/health/purdue-opioids-oxycontin.html">Purdue Pharma’s aggressive marketing of the powerful opiod painkiller OxyContin as non-addictive</a>, along with lax prescribing standards, was the cause of the crisis. The response was swift — from creating <a href="http://nationalpaincentre.mcmaster.ca/documents/Opioid%20GL%20for%20CMAJ_01may2017.pdf">new prescribing guidelines and limits</a> through to a very real <a href="https://www.statnews.com/2018/08/15/oregon-medicaid-tapering-opioids/">attempt by Oregon lawmakers to eliminate opioid prescription altogether in 2018</a>. </p>
<p>While there is merit to these arguments, making the opioid crisis almost exclusively about pain has given policy-makers license to focus on dangerous metrics. Most notably, many focused on counting the total number of opioid prescriptions. </p>
<p>Prescriptions of opioids have declined — <a href="https://www.cihi.ca/sites/default/files/document/opioid-prescribing-june2018-en-web.pdf">from 21.7 million in 2016 to 21.3 million in 2017</a> — and some may laud this decline. However, opioid-related poisonings, <a href="https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/data-surveillance-research/harms-deaths.html">at least according to available data</a>, have not declined in turn. </p>
<p>Meanwhile, the global burden of chronic pain <a href="https://doi.org/10.1016/S0140-6736(17)32154-2">has increased steadily since at least 1990</a>.</p>
<p>So far it seems we are losing on both fronts — opioid poisoning continues while the burden of pain increases.</p>
<h2>Vending machine opioids</h2>
<p>The opioid crisis needs to be understood in the context of a diagnosable health condition now known as opioid use disorder (OUD). Chronic pain, on the other hand, is best thought of as an umbrella disorder — most commonly defined by the duration of pain — that can take many forms. </p>
<p>OUD is partly a disease of impaired impulse control, characterised by an inability to stop using opioids even when faced by clear evidence of harm. While it can affect people from any background, there are increasingly clear connections between OUD and environmental factors such as homelessness, poverty and interpersonal, intergenerational and childhood traumas. </p>
<p>I recently explored <a href="http://www.mentalhealthamerica.net/issues/ranking-states">data on access to mental health care provided by Mental Health America</a> and compared that to data from the <a href="http://careers.milliman.com/insight/2018/Opioid-use-disorder-in-the-United-States-Diagnosed-prevalence-by-payer--age--sex--and-state/">Milliman Group on OUD prevalence</a> and found that states with greater access to mental health care also had the lowest prevalence of OUD. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268850/original/file-20190411-44773-1wjbuxh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&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 injects drugs in Vancouver’s Downtown Eastside, Feb. 6, 2019. Poverty, homelessness and childhood trauma all play a role in the opioid crisis.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Not surprisingly then, since the introduction of opioid-prescribing guidelines in 2017 we can see a shift in behaviour of those with unmanaged OUD. For example, recent trends have shown that <a href="https://www.theglobeandmail.com/canada/article-the-crisis-is-not-abating-opiod-overdose-kills-more-than-1/">the primary substance in opioid-related overdose deaths is now illicit fentanyl</a>, a drug that was rarely prescribed by physicians even before the crisis started. </p>
<p>In 2018, <a href="https://www.cbc.ca/news/canada/newfoundland-labrador/cocaine-drugs-bruce-hollett-1.4968332">cocaine overtook opioids as the leading cause of overdose deaths in Newfoundland</a>. </p>
<p>In a strange twist, forcing people with unmanaged OUD to riskier street drugs has been so devastating that <a href="https://bc.ctvnews.ca/renewed-calls-for-opioid-dispensing-machines-as-deaths-mount-1.4211708">Vancouver has seriously considering installing opioid vending machines.</a> </p>
<p>This means we are facing a very real situation in which some people can access opioids through a vending machine while those with uncontrolled pain cannot do so through their physician.</p>
<h2>Let’s invest in mental health</h2>
<p>The good news is that Ontario’s $100 million in government funds could have real impact if properly directed. </p>
<p>For example, advances in <a href="https://www.ncbi.nlm.nih.gov/pubmed/28699646">pharmacogenetics towards personalized medicine</a> mean it may become routine care for doctors to prescribe the type and dose of opioids that will be most beneficial based on a patient’s genes. This line of research is also expected to improve doctors’ ability to identify those most vulnerable to substance use disorder through <a href="https://www.ncbi.nlm.nih.gov/pubmed/28226333">routine clinical screening</a>. </p>
<p>This will help us get the right treatment to the right person at the right time and avoid potentially harmful treatments for those who may be at risk. </p>
<p>Other strategies could include <a href="https://cmha.ca/wp-content/uploads/2018/04/Summary-Report.pdf">investing in mental health services</a> especially for at-risk youth. These services could arm them with resources needed to cope with trauma and stress and ensure access to alternative pain-management strategies such as physical therapy, mindfulness or cognitive behavioural therapies.</p>
<p>The focus on opioid prescriptions as a metric of success in the opioid crisis has not been successful. We need to think about a world after the opioid crisis has passed — to ensure that mental health services are available and that those who require opioids for intolerable pain have options. </p>
<p><em>If you or someone you know is experiencing severe distress, <a href="http://www.cmha.ca">the Canadian Mental Health Association</a> or your local distress centre are good resources for help and support</em>.</p><img src="https://counter.theconversation.com/content/112296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Walton is an Associate Scientist with the Lawson Health Research Institute. His research has been funded through arm's length public or not-for-profit entities with the exception of a small research grant through Focus on Therapeutic Outcomes Inc. He provides continuing professional development courses and workshops for primarily rehabilitation providers for which he occasionally receives an honorarium or stipend. He receives no compensation or other benefits from any industry partners who would have an interest in the material discussed herein.</span></em></p>A policy response focused on reducing prescription opioids will not resolve North America’s opioid crisis. And it is hurting many adults who live with otherwise unbearable chronic pain.David Walton, Associate Professor, School of Physical Therapy, Western 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/1052152018-10-25T23:14:18Z2018-10-25T23:14:18ZFamily doctors are overdosing on industry sponsorship<figure><img src="https://images.theconversation.com/files/242348/original/file-20181025-71017-vubra5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Family Medicine Forum, Nov. 9, 2017, the Palais des congrès de Montréal.</span> <span class="attribution"><span class="source">(Twitter/@FamilyMedForum)</span></span></figcaption></figure><p>If Canadian family physicians hope to maintain the trust of our patients, we must reject sales pitches thinly veiled as education at our premier conference.</p>
<p>This week, the College of Family Physicians of Canada (CFPC) hosts its annual meeting, <a href="https://fmf.cfpc.ca">the Family Medicine Forum</a>, in Toronto. I have been a family physician for 12 years, but have only attended the largest conference of its kind in Canada twice. Each time I have gone, I have been turned off by the health products industry’s influence on the meeting. </p>
<p>This year, however, there’s a chance for the college to shake off the golden handcuffs with the introduction of the new <a href="http://www.cfpc.ca/new_CPD_certification_launches_2018/">National Standard for Support of Accredited Continuing Professional Development Activities</a>, which was introduced in Jan. 1, 2018. This new set of rules is supposed to maintain the high standards of quality and accountability in continuing professional development, while keeping accredited learning activities as free as possible from bias and influence.</p>
<p>Though several medical conferences in Canada have recently moved away from <a href="http://policyconsult.cpso.on.ca/wp-content/uploads/2014/05/Ontario-College-of-Family-Physicians.pdf">pharmaceutical industry sponsorship</a>, the CFPC has persisted in including this controversial source of funding in its business model.</p>
<h2>Sponsorship influences prescriptions</h2>
<p>Health product companies sponsor conferences so that they can pitch brand name drugs, devices and remedies directly to doctors. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1049654678969970688"}"></div></p>
<p>The public may hope that doctors prescribe medicine based on unbiased scientific research, rather than information from sales representatives. Sadly, this is not the case. </p>
<p>Studies show that contact with industry <a href="https://doi.org/10.1371/journal.pone.0110130">changes the medications doctors prescribe</a> and that it takes as little as <a href="https://doi.org/10.1371/journal.pone.0186060">US$114 per year in gifts, meals or cash to significantly change a doctor’s prescribing pattern</a>.</p>
<p>The CFPC’s financial statements show that 14 per cent, or roughly $500,000, of the 2017 conference budget came from industry funding. The sponsorship averaged about $120 of funding per conference participant — almost precisely the amount shown to influence prescribing practices.</p>
<p>When prescribing habits are influenced, doctors may recommend medications based on questionable information from manufacturers, rather than peer-reviewed articles. For example, Purdue Pharmaceuticals, the makers of OxyContin, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/">a painkiller once erroneously marketed as being “low risk” for addiction</a>, is now acknowledged to have <a href="https://theconversation.com/how-big-pharma-deceives-you-about-drug-safety-94888">fuelled the current deadly opioid crisis</a> and done little to help patients in pain, to boot. Purdue has been a frequent exhibitor at the Family Medicine Forum.</p>
<p>Further, financial statements show that <a href="https://www.cfpc.ca/uploadedFiles/About_Us/CFPC-FS-2017-18-EN.pdf">Family Medicine Forum 2017 made a profit of almost $250,000, or seven per cent</a>. If it chose to forgo a profit, it could easily choose to decline half its industry sponsorship.</p>
<h2>Speakers with financial conflicts of interest</h2>
<p>Two years ago the organization’s CEO, Dr. Francine Lemire, and then-president Dr. Jennifer Hall <a href="http://healthydebate.ca/opinions/college-of-family-physicians-of-canada-pharmaceutical-industry-funding">pushed back against calls to end health product industry funding of continuing professional development</a>. </p>
<p>They highlighted the changes CFPC had made in 2013 to mitigate the influence of pharmaceutical companies at the Family Medicine Forum, steps such as “clearly articulat(ing) what is education and what is marketing.” Enforcing such steps should mean the forum schedule clearly identifies talks sponsored by companies, but this was not the case last year.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"928756054598602754"}"></div></p>
<p>In Montréal last year, doctors were inundated with industry messaging. Physicians attended lunchtime “ancillary” sessions without realizing they were sponsored by drug manufacturers because they were not labelled as such in the program. </p>
<p>Doctors attended talks by speakers who had multiple financial conflicts of interest relating to the topic and complained that the speakers did not provide balanced information about the risks, benefits and indications for products. </p>
<p>Doctors also received pitches, and samples, for products from salespeople while attempting to get food in the giant room that housed both sponsors’ booths and food. According to the <a href="https://fmf.cfpc.ca/wp-content/uploads/2017/09/FMF-Policies-Guidelines.pdf">pre-2018 CFPC guidelines</a>, none of these things should have happened.</p>
<h2>Family doctors must complain loudly</h2>
<p>The latest rules are designed to maintain the high standards of quality and accountability in continued professional development, while keeping learning activities as free as possible from bias and influence. </p>
<p>They state that sponsors, such as pharmaceutical companies, will no longer have direct or indirect influence on the content of an accredited continuing professional development activity, and that product-specific advertising will not be allowed to appear in educational slides or programs. </p>
<p>The new standards mean that lunchtime talks at the forum that are directly sponsored by industry should no longer be allowed.</p>
<p>These new guidelines are stricter than the old ones, but they will only make a difference if the CFPC chooses to enforce them and if family doctors complain loudly when the standards are breached. </p>
<p>Family doctors like myself must demand that our premier conference provides evidence-based information rather than sales pitches. Organizers must prevent the sampling of products and must crack down on presenters who have financial conflicts of interest about the subjects on which they are presenting. </p>
<p>Anything less is a breach of duty to our patients.</p><img src="https://counter.theconversation.com/content/105215/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Giles is a board member of Canadian Doctors for Medicare.</span></em></p>This week’s annual Family Medicine Forum is an opportunity for your family doctor – to cave or resist in the face of Big Pharma sponsorship and marketing.Sarah Giles, Lecturer in Family Medicine, Faculty of Medicine, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1051142018-10-16T23:42:30Z2018-10-16T23:42:30ZNow that cannabis is legal, let’s use it to tackle the opioid crisis<figure><img src="https://images.theconversation.com/files/240880/original/file-20181016-165897-jjfcpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A employee holds pre-rolled joints at Buddha Barn Craft Cannabis in Vancouver, Oct. 2, 2018. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span></figcaption></figure><p>The legalization of cannabis for adult use in Canada is one of the biggest national public policy shifts that many of us will ever witness in our lifetimes.</p>
<p>This historic change in drug policy was proposed by the Canadian government as a way to promote public health, as the country grapples with some of the highest <a href="http://www.ccsa.ca/Resource%20Library/CCSA-Canadian-Drug-Summary-Cannabis-2018-en.pdf">cannabis consumption rates</a> of the developed world, including among adolescents.</p>
<p>Meanwhile, Canada is struggling to contain an entirely different substance-related problem: The opioid overdose epidemic.</p>
<p>Fuelled by the <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf">contamination of the illicit drug supply with fentanyl</a> and its analogues, the opioid epidemic is Canada’s gravest public health crisis since the emergence of HIV in the 1980s. Experts agree on the need for creative responses based on scientific evidence.</p>
<p>Increasingly, scientists from the fields of public health, medicine and economics are aiming to figure out if cannabis legalization could be part of the solution.</p>
<p>The possibilities are multiple — from the use of cannabis to treat chronic pain to the <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0373-7">potential of cannabis to reduce opioid cravings</a>.</p>
<p>We published a new study last month showing that <a href="https://doi.org/10.1111/add.14398">highly marginalized patients on “opioid agonist therapy,” with the drugs methadone or suboxone, were more likely remain on their treatment six months later if they were using cannabis on a daily basis</a>.</p>
<h2>Opioids, cannabis and pain</h2>
<p>Almost <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298051/">one in five Canadians</a> live with some form of chronic pain. In the 1990s, pharmaceutical companies began to develop <a href="https://theconversation.com/oxycontin-how-purdue-pharma-helped-spark-the-opioid-epidemic-57331">slow-release formulations of opioids</a> (e.g. OxyContin) and marketed them as safe and effective medications for the treatment of chronic non-cancer pain.</p>
<p>Opioids are now known to carry a high risk of dependence and overdose and yet <a href="https://www.theglobeandmail.com/news/national/sales-of-opiod-drug-prescriptionsskyrocketing/article26008639/">more than 20 million opioid prescriptions</a> are still filled each year in Canada. </p>
<p>Drug overdoses are now the <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">leading cause of death</a> among Americans under the age of 50, and prescription opioids are <a href="https://www.cdc.gov/drugoverdose/data/overdose.html">involved in nearly half of these deaths.</a> </p>
<p>It is also becoming apparent that opioids might be less effective than initially thought in treating certain types of chronic non-cancer pain (<a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006146.pub2/abstract;jsessionid=F7C9469935C456F6BDD34331871E1FEA.f03t01?systemMessage=Wiley+Online+Library+will+be+unavailable+on+Saturday+01st+July+from+03.00-09.00+EDT+and+on+Sunday+2nd+July+">for example, neuropathic pain</a>).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/240892/original/file-20181016-165909-u3bzk7.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">These 2,224 wooden stakes represent the number of confirmed overdose deaths in British Columbia over the three years prior to Sept. 29, 2017. Many of them painted with names of overdose victims, they were placed on the ground at Oppenheimer Park in Vancouver, B.C.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Cannabis, derived from the Cannabis sativa plant, contains several compounds. These include tetrahydrocannabinol (THC, the primary psychoactive component of cannabis) and cannabidiol (CBD). Beyond the well-known psychoactive effects of cannabinoids, new research has shown that they also interact with <a href="https://doi.org/10.1093/bja/aen119">systems in the body involved in the regulation of pain</a>.</p>
<p>This discovery has led researchers to investigate the potential for cannabis to treat various pain conditions for which opioids are currently first- or second-line therapies. </p>
<p>Although high-quality clinical research involving cannabis has been <a href="https://www.theatlantic.com/politics/archive/2014/06/its-hard-to-study-marijuanas-medical-benefits-when-its-illegal/373603/">stunted by its prohibited legal status</a> and the quality of the experimental studies in question ranges from <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012182.pub2/full">low to moderate</a>, recent extensive reviews of experimental research on cannabinoids for chronic non-cancer pain generally agree that they offer <a href="http://www.nationalacademies.org/hmd/Reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx">modest relief of pain</a>. </p>
<p>This begs the question: if cannabis becomes more available, do people switch from opioids to cannabis?</p>
<h2>Ground-breaking findings</h2>
<p><a href="https://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.4005">In a landmark 2014 study</a>, a team of researchers analyzed data from across the United States over a 10-year period. They found that states with legalized medical cannabis saw 25 per cent fewer opioid-related deaths than states where medical cannabis remained illegal.</p>
<p>These findings broke ground for others in the field to find associations between U.S. medical cannabis laws and reduced state-level estimates of opioid <a href="https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2676999">prescriptions</a>, <a href="https://doi.org/10.1016/j.jhealeco.2017.12.007">misuse and dependence</a>, as well as <a href="https://doi.org/10.1016/j.drugalcdep.2017.01.006">opioid-related hospitalizations and non-fatal overdoses</a>. </p>
<p>Opioid overdose trends have also changed in the aftermath of recreational cannabis legalization in some U.S. states. For example, <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2017.304059">a recent study</a> found that opioid-related deaths in Colorado were reduced (albeit modestly) relative to two comparison states in the short term following recreational cannabis legalization.</p>
<p>Although it’s tempting to conclude that increasing access to cannabis is an effective intervention against the opioid crisis, there are several reasons to be cautious when interpreting these study findings.</p>
<p>First, not all cannabis laws are created equal. For example, Colorado and Washington followed a commercialized approach to cannabis legalization with fewer restrictions around things like marketing and product sales compared to Canada’s public health framework. </p>
<p>These regulations are likely to impact the ways in which people access and use cannabis products, which could create different shifts in other substance use trends.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/240894/original/file-20181016-165924-snjeas.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">Prescription pills containing oxycodone and acetaminophen are shown in Toronto, Dec. 23, 2017.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graeme Roy</span></span>
</figcaption>
</figure>
<p>Indeed, a study led by leading drug policy economists in the U.S. found that <a href="https://doi.org/10.1016/j.jhealeco.2017.12.007">the passage of a medical cannabis law on its own was not associated with changes in opioid-related outcomes</a>.
Only after the authors accounted for access to cannabis through legal provisions for retail dispensaries did they find a 25 per cent reduction in opioid-related deaths. </p>
<p>This suggests that if there’s a causal link between the law change and opioid overdoses, access to cannabis through retail outlets could be a driving factor.</p>
<p>Second — and this is the <a href="https://doi.org/10.1111/add.14236">subject of ongoing discussion</a> among substance-use researchers — these population-level studies are limited by their inability to observe <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2210572">individual-level changes in cannabinoid and opioid use</a>. </p>
<p>As a result, it’s impossible to conclude whether it was actually the change in law that created these shifts in opioid outcomes. To better understand this, we need to take a closer look at different sub-populations of opioid users.</p>
<h2>Pain patients and illicit users</h2>
<p>Findings from surveys with medical cannabis users across North America demonstrate a clear preference for cannabis over opioids. For example, roughly one-third of a sample of patients enrolled in Health Canada’s Marijuana for Medical Purposes Regulations (MMPR) program in B.C. <a href="https://doi.org/10.1016/j.drugpo.2017.01.011">report substituting cannabis for prescription opioids.</a> </p>
<p>For chronic-pain patients using medical cannabis, this substitution effect appears even more prominent, with cannabis substitution occurring in roughly <a href="https://doi.org/10.1016/j.jpain.2016.03.002">two-thirds of a sample of former prescription opioid patients in Michigan</a> who started using medical cannabis. </p>
<p><a href="https://doi.org/10.1089/can.2017.0012">In another recent study</a>, 80 per cent of medical cannabis patients in California reported that taking cannabis alone was more effective for treating their medical condition than taking cannabis with opioids. More than 90 per cent agreed they would choose cannabis over opioids if it were readily available.</p>
<p>However, two recent high-impact studies challenge our understanding of this complex topic. <a href="https://doi.org/10.1016/S2468-2667(18)30110-5">A four-year study</a> of Australians on opioid therapy for chronic pain did not find significant reductions in use of prescribed opioids or severity of pain among cannabis users. </p>
<p><a href="https://doi.org/10.1176/appi.ajp.2017.17040413">A second study</a> analyzed a large U.S. dataset and found that individuals who reported cannabis use at baseline were actually more likely than non-users to start using prescription opioids non-medically and have an opioid use disorder three years later. </p>
<p>This discrepancy in findings points to a need for research exploring why this substitution effect is seen in some patient populations but not others.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/240886/original/file-20181016-165894-ttz3zd.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">An officer displays bags containing fentanyl as Ontario Provincial Police host a news conference in Vaughan, Ont., in February 2017.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chris Young</span></span>
</figcaption>
</figure>
<p>But what about the relationship between cannabis and opioids among some of those most affected by the opioid crisis — people with long-term experience using illicit opioids?</p>
<p>Untreated pain and substance use have a high degree of overlap. Pain was reported by almost half of people who inject drugs surveyed in a recent <a href="https://doi.org/10.1186/s13011-017-0112-7">San Francisco study.</a> </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962749/">Research from our colleagues in Vancouver</a> found that under-treatment of pain in this population is common and results in self-management of pain using heroin or diverted prescription opioids. This is becoming increasingly more dangerous, as almost <a href="https://www.theglobeandmail.com/canada/british-columbia/article-pilot-projects-initial-results-show-fentanyl-other-substances-found/">90 per cent of the heroin</a> found in Vancouver is contaminated with fentanyl or fentanyl analogues.</p>
<p>Could there be a role for cannabis as an opioid substitute even among individuals with extensive experience using illicit opioids? <a href="https://doi.org/10.1016/j.drugalcdep.2015.05.014">A study from California</a> of people who inject drugs found that those who used cannabis used opioids less often. We need more research, to know whether this is a direct result of cannabis use.</p>
<h2>Cannabis as an addiction treatment</h2>
<p>There is growing evidence for the use of cannabis in treating opioid addiction. CBD, the non-psychoactive component of cannabis, is known to interact with <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0387-1">several receptors involved in regulating fear and anxiety-related behaviours</a>. It shows potential for the treatment of several anxiety disorders.</p>
<p>Research is also investigating CBD’s role in modulating cravings and relapses — behaviours that are tightly linked to anxiety — among individuals with opioid addiction. <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0373-7">Recent preliminary studies</a> suggest that CBD reduces opioid cravings. A <a href="https://clinicaltrials.gov/ct2/show/NCT02539823?lead=Hurd&cntry1=NA%3AUS&rank=1">larger clinical trial</a> is now under way in the United States. </p>
<p>Our own research suggests that <a href="https://doi.org/10.1111/add.14398">patients are more likely to stay in opioid agonist therapy during periods of intensive cannabis use</a>. </p>
<p>These findings suggest we need rigorous experimental research into the use of cannabinoids as an adjunct treatment to opioid agonist therapy.</p>
<p>Meanwhile, the opioid overdose crisis is so dire in some regions that community harm reduction groups, like the High Hopes Foundation in Vancouver’s Downtown Eastside, are starting <a href="https://www.cbc.ca/news/canada/british-columbia/high-hopes-foundation-1.4265850">cannabis-based substitution programs</a> that provide free access to cannabis products for drug users.</p>
<h2>Harnessing a unique opportunity</h2>
<p>Canada is the first country in the G-20 to introduce a legal framework regulating the use of cannabis by adults.</p>
<p>Legalizing cannabis will break down historic barriers to understanding its clinical and public health impacts. </p>
<p>Certain measures like rates of youth use and impaired driving will no doubt be top priorities for evaluating the new law’s impact on population health and safety. But we should also be prepared to monitor indirect public health gains, especially against the backdrop of the ongoing overdose crisis. </p>
<p>Canada should harness this opportunity to understand if, and how, cannabis legalization could fit into a multi-faceted opioid prevention and response strategy.</p><img src="https://counter.theconversation.com/content/105114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephanie Lake is supported by funding from the Canadian Institutes of Health Research and the Pierre Elliott Trudeau Foundation. She is affiliated with Canadian Students for Sensible Drug Policy.</span></em></p><p class="fine-print"><em><span>M-J Milloy is supported by funding from the United States National Institute on Drug Abuse, the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research. His institution has received an unstructured gift from NG Biomed Ltd., a private firm seeking a licence to produce medical cannabis, to support him.</span></em></p>Cannabis legalization in Canada is a public health strategy. Let’s harness this opportunity to understand how cannabis could fit into a multi-faceted opioid prevention and response strategy.Stephanie Lake, PhD student in Population and Public Health, University of British ColumbiaM-J Milloy, Research Scientist, BC Centre on Substance Use and Assistant Professor in the Division of AIDS, UBC Department of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1032802018-09-20T10:37:41Z2018-09-20T10:37:41ZHow many Americans really misuse opioids? Why scientists still aren’t sure<figure><img src="https://images.theconversation.com/files/236980/original/file-20180918-158225-hnfyl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Defining opioids.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/injectable-drug-loaded-into-syringe-while-1138870511?src=mPH3Tzt8lnRo-MWj6YYDaQ-1-6">Darwin Brandis/shutterstock.com</a></span></figcaption></figure><p>With rates of <a href="http://doi.org/10.1001/jama.2015.11859">prescription opioid use disorder</a> and <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">opioid-involved overdose deaths</a> on the rise, the U.S. opioid crisis appears to be continuing unabated.</p>
<p>Data on overdose and death are pretty reliable. But there’s still much that’s unknown about opioid misuse that doesn’t lead to an adverse outcome such as overdose. </p>
<p>Drug surveys are reseachers’ main method of collecting data on opioid misuse. I’ve been in drug survey research for almost two decades, but in recent years I’ve learned that collecting accurate data on opioid misuse in particular is difficult. Why? Because many people underreport misuse, while others unintentionally overreport misuse.</p>
<p>Colleagues have been asking me how to ask about opioid misuse on surveys. I’m finding that there’s no easy answer. But one thing I’ve learned in my <a href="https://www.tandfonline.com/eprint/qS4yA2y2mMfPsAI2qXMy/full">research</a> is that many people may misunderstand the basics about opioids, preventing researchers like myself from understanding the full scope of the epidemic.</p>
<h2>Medical use and misuse</h2>
<p>Drug surveys are already difficult to conduct, as <a href="https://archives.drugabuse.gov/sites/default/files/monograph167_0.pdf">many people lie</a> about use. For example, some people deny use to appear more socially desirable, and others simply try to finish the survey quickly without really reading it. But opioid surveys are especially challenging. </p>
<p>A friend of mine recently took my drug survey. She texted me the next day, saying she believed she incorrectly answered my opioid questions. Even though my survey asked only about using to get high or using without a prescription, she admittedly didn’t read the directions and reported misuse of dilaudid, a pain medication.</p>
<p>Situations like this lead some researchers to distrust reportedly high rates of opioid misuse. For example, a few years ago, <a href="https://www.drugabuse.gov/news-events/nida-notes/2017/04/nonmedical-opioid-heroin-use-among-high-school-seniors">my colleagues and I estimated</a> that 12 percent of high school seniors have ever misused prescription opioids. However, some of my reports focusing on such national data have (perhaps rightfully) been <a href="http://doi.org/10.1080/00952990.2016.1208211">questioned</a>, but we are limited by what people report. </p>
<p>On surveys, opioid misuse is <a href="http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2016.pdf">sometimes defined</a> as using without one’s doctor telling you to do so. Other times, it’s <a href="https://www.cdc.gov/mmwr/volumes/65/ss/ss6506a1.htm">defined</a> as using without a prescription. The most accurate <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm">definition</a> is use not directed by a doctor, including using opioids without a prescription or using greater amounts, or more often or longer than directed.</p>
<p>It’s important to include definitions of opioids and misuse on surveys. However, such definitions are meaningless if those taking the survey refuse to read them.</p>
<p>Misuse is also a confusing concept, as it is possible to use as prescribed and still enjoy the feeling resulting from use.</p>
<h2>Lack of knowledge</h2>
<p>Even though the public is now largely familiar with the term “opioids,” many people still don’t appear to know which drugs are opioids and which are not. For example, my colleagues and I discovered that a <a href="https://doi.org/10.1080/00952990.2016.1178269">over a third of high school seniors</a> who reported nonmedical Vicodin or OxyContin use denied using opioids nonmedically overall. This suggests many users may be unaware that these drugs are opioids.</p>
<p>Opioids are commonly referred to opiates, painkillers, pain relievers, narcotics and analgesics. While “opioid” now appears to be the most common term, an individual familiar with the term may become confused when asked about different terms such as prescription painkillers or narcotics. The term “narcotics,” for example, can lead to confusion, as the <a href="https://www.deadiversion.usdoj.gov/21cfr/21usc/802.htm">Controlled Substances Act</a> also includes cocaine as a narcotic.</p>
<p>Confusion may also arise regarding drug names. For example, OxyContin misuse may be overreported by individuals who used weaker oxycodone formulations. Codeine misuse may also be <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm">overreported</a> by those claiming misuse of Tylenol III, which contains codeine, when they only used regular Tylenol.</p>
<p>I’ve also noticed that many people also don’t know the difference between methamphetamine, a potent stimulant, and methadone, an opioid. I learned about such confusion firsthand, after receiving multiple questions about methadone from social workers during a presentation I was giving about about methamphetamine.</p>
<p>Concoctions that contain opioids, such as “Sizzurp” (also known as “Lean” or “Purple Drank”), typically contain codeine cough syrup in a soft drink such as Sprite. Many users of this concoction likely deny codeine misuse.</p>
<p>It’s difficult to determine whether estimates of U.S. opioid misuse are too high or too low. Accuracy of these statistics is important, as they guide research, prevention, harm reduction and policy. </p>
<p>Researchers can use surveys to help educate people about opioids while collecting data. But first we need to figure out how to get people to read the questions.</p><img src="https://counter.theconversation.com/content/103280/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Palamar receives funding from the National Institute of Drug Abuse (K01DA038800)</span></em></p>Many people may misunderstand the basics about opioids. That prevents researchers from understanding the full scope of the epidemic.Joseph Palamar, Associate Professor of Population Health, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/994312018-07-04T23:04:04Z2018-07-04T23:04:04ZWhat Big Pharma pays your doctor<figure><img src="https://images.theconversation.com/files/226187/original/file-20180704-73300-b65hpd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows that money and meals from the pharmaceutical industry do increase the amount doctors prescribe the drugs being marketed.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Members of <a href="http://innovativemedicines.ca/">Innovative Medicines Canada (IMC)</a>, the lobby group for the large pharmaceutical companies, <a href="http://innovativemedicines.ca/ethics/voluntary-disclosure-of-payments/">recently released their voluntary reports of payments</a> to health-care professionals and health-care organizations. </p>
<p>Altogether, the 10 reporting companies paid out more than $75 million in 2017. </p>
<p>This is the second year of these disclosures. When they started, Russell Williams, then the IMC president, said on CBC’s <em>The Current</em>: “<a href="http://www.cbc.ca/radio/thecurrent/the-current-for-april-4-2016-1.3519317/apr-8-2016-episode-transcript-1.3520603#segment1%22%22">We’re open to continually improving and monitoring</a>” the disclosures. According to the new president, Pamela Fralick, the 2016 <a href="https://www.theglobeandmail.com/news/national/canadian-drug-makers-assailed-for-lack-of-transparency-over-payments/article35392284/">revelations were only a first step</a> and she expected more companies to disclose payments in 2017.</p>
<p>Come the 2017 disclosures, and there are still the same 10 companies. Moreover, the disclosures are actually not on the IMC website, they are on the individual companies’ websites and are not easy to find. It takes at least a couple of mouse clicks to locate the material. Nor is there any more detail this year than last year about how the money is used.</p>
<p>IMC touts these disclosures as “<a href="http://innovativemedicines.ca/ethics/voluntary-disclosure-of-payments/">part of our commitment to high ethical standards and enhancing trust</a>.” </p>
<p>But all that the companies have disclosed are gross figures — with no information about what they paid for. </p>
<h2>Paid to promote opioids?</h2>
<p>Why did Purdue Pharma, <a href="https://theconversation.com/how-big-pharma-deceives-you-about-drug-safety-94888">makers of OxyContin</a> and a host of other opioid products, <a href="http://purdue.ca/wp-content/uploads/2018/06/Purdue-Disclosure-2017-FINAL.pdf">give almost $1.9 million to health-care professionals</a> in 2017? </p>
<p>All Purdue’s website says is that the money was for “services.” Were some of those services speeches made by doctors on behalf of Purdue? In the past <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">Purdue has paid doctors $2,000 a talk</a>. </p>
<p>Amgen Canada <a href="https://www.amgen.ca/%7E/media/amgen/full/www-amgen-com/www-amgen-ca/pdf/amgen-canada-voluntary-disclosure-of-payments-to-hcps-and-hcos--january-to-december-2017.ashx?la=en-CA">gave more than $6 million to health-care organizations</a>, but we don’t know what these organizations did with that money. </p>
<p><a href="https://www.novartis.ca/en/about-us/corporate-responsibility/transparency-voluntary-disclosure-payments-healthcare#ui-id-1=2">Novartis spent $350,000 on travel expenses</a> so that doctors and possibly other professionals could go to international congresses and/or global stand-alone meetings. </p>
<p>Who were these health-care professionals? What meetings did they go to? Where were the meetings?</p>
<h2>Canada lags behind</h2>
<p>Big Pharma here in Canada is far behind the curve when it comes to disclosing where the money is going. The federal government doesn’t seem to be in any hurry to force the companies to make more information public either. </p>
<p>Just over a year ago, then Health Minister Jane Philpott’s position was that <a href="https://www.theglobeandmail.com/news/national/canadian-drug-makers-assailed-for-lack-of-transparency-over-payments/article35392284/">forcing the disclosure of payments to individual doctors was, “in principle…an important concept” but should be left to the provinces</a>.</p>
<p>In the United States, companies have had to disclose <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001754">any payment of more than $10</a> to a doctor since 2013. The doctors are named. </p>
<p>In Australia, an analysis of information that companies must disclose found that, from October 2011 to September 2015, <a href="https://bmjopen.bmj.com/content/7/6/e016701">42 companies sponsored 116,845 events</a> for health professionals. </p>
<p>In <a href="http://www.ijhpm.com/article_3478.html">nine European countries, disclosure is either mandatory or voluntary</a>. Many of the European voluntary codes allow doctors to opt out of having their names disclosed. </p>
<p>IMC justified not linking doctors’ names to payments on the grounds of <a href="http://www.cbc.ca/radio/thecurrent/the-current-for-april-4-2016-1.3519317/apr-8-2016-episodetranscript-%201.3520603#segment1">Canadian privacy laws</a> but <a href="https://www.theglobeandmail.com/news/national/ontario-law-to-require-drug-firms-to-reveal-funds-paid-to-doctors-groups-patient-advocates/article38061619/">Ontario’s recently passed legislation</a> will require disclosures to include the names of all health-care professionals who receive money or any other “transfer of value.” </p>
<p>Later this summer, <a href="https://www.theglobeandmail.com/canada/british-columbia/article-bc-considers-forcing-drug-companies-to-disclose-payments-to-doctors/">British Columbia will hold public consultations</a> about the same type of legislation.</p>
<h2>Free meals increase prescriptions</h2>
<p>Disclosure is only the first step. Payments made to doctors can be linked to how they prescribe. </p>
<p>In the U.S., this has been analyzed using the Medicare database. The links show <a href="http://www.dx.doi.org/10.1001/jamainternmed.2016.1709">an association between the amount of money doctors get and their prescription of brand-name statins</a> (cholesterol-lowering drugs) rather than much less expensive generic versions. </p>
<p>Receipt of industry-sponsored meals with a value of less than $20 is associated with an <a href="http://www.dx.doi.org/10.1001/jamainternmed.2016.2765">increased rate of prescribing the brand-name medication</a> that is being promoted. </p>
<p>Receiving money from opioid makers in one year is associated with <a href="http://www.dx.doi.org/10.1001/jamainternmed.2018.1999">prescribing more opioids</a> the next year.</p>
<p>Perhaps this is why IMC doesn’t want to take disclosures any further. This lobby group is afraid that Canadians will realize the perverse effects of all the payments its member companies make.</p><img src="https://counter.theconversation.com/content/99431/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 payments 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 and for a talk at the Toronto Reference Library. 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>Big Pharma in Canada is far behind the curve when it comes to disclosing what payments to health-care professionals are for.Joel 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/948882018-04-12T21:28:05Z2018-04-12T21:28:05ZHow Big Pharma deceives you about drug safety<p>The recent decision of a Saskatchewan judge to <a href="https://www.theglobeandmail.com/canada/article-saskatchewan-judge-rejects-proposed-settlement-between-opioid-patients/">reject the proposed settlement between the provinces and Purdue Pharma, the maker of OxyContin,</a> should raise serious questions. </p>
<p>Purdue introduced the prescription drug OxyContin in 1996 and marketed it as safer and less addictive than other opioids. This is now seen by many as the beginning of <a href="https://theconversation.com/uk/search?utf8=%E2%9C%93&q=canadas+opioid+crisis">the opioid crisis in Canada</a>. The settlement in question was meant to compensate patients who were victims of the opioid epidemic and the provinces for some of their additional health-care costs in dealing with the epidemic.</p>
<p>The decision should raise questions not just about how Purdue marketed OxyContin, but also about how Health Canada regulates — or more accurately does not regulate — the promotion of prescription drugs in Canada.</p>
<p>Since at least as far back as the mid-1970s, Health Canada has not fined a single drug company for the way that it promotes prescription drugs. </p>
<p>A reporter for <em>the Toronto Star</em> asked Health Canada why it had never prosecuted drug companies for illegally marketing drugs in Canada despite the same companies being fined for doing so in the United States. </p>
<p>The <a href="https://www.thestar.com/news/canada/2014/06/26/dangers_of_offlabel_drug_use_kept_secret.html">response from Health Canada</a> was that it “has not been made aware of any specific similar issue in Canada and has not received complaints concerning these companies promoting off-label uses of their products in Canada.”</p>
<h2>Regulation by industry</h2>
<p>In theory, the <a href="http://laws-lois.justice.gc.ca/eng/acts/f-27/">Food and Drugs Act</a> and <a href="http://laws.justice.gc.ca/eng/regulations/c.r.c.,_c._870/index.html">its regulations</a> give Health Canada the ability to directly regulate promotion. </p>
<p>In practice, the agency has turned over the day-to-day regulation of promotion to a combination of industry, as represented by its lobbying arm Innovative Medicines Canada (IMC), and an independent external group with strong industry representation, the Pharmaceutical Advertising Advisory Board (PAAB).</p>
<p><a href="http://www.paab.ca/about.htm">The PAAB is governed by a 14-person board</a>, with representatives from five organizations that directly benefit from drug advertising: IMC, BioteCanada, Association of Medical Advertising Agencies, Canadian Association of Medical Publishers and Consumer Health Products Canada.</p>
<p>Its <a href="http://code.paab.ca/">Code of Advertising Acceptance</a> is deeply flawed. </p>
<p>This code requires a “fair balance of risk to benefit” but there is no specific requirement that equal space in the ads be devoted to harms and benefits, and there is no provision for the font size used to describe benefits and harms to be equal in size. </p>
<p>The generic name does not have to be used each time that the brand name is given, despite evidence that <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352">use of the generic name leads to better prescribing</a>. </p>
<p>The most serious penalty that the PAAB can impose where <a href="http://code.paab.ca/make-an-appeal.htm">“information may cause inappropriate product use or constitutes an imminent and/or significant health hazard”</a> is that the head of the organization may require letters of correction, published notices or the immediate withdrawal of the advertisement. </p>
<h2>‘Drug abuse is not a problem…’</h2>
<p>One example of how Purdue misled Canadian doctors about OxyContin was an ad that appeared in <em>Canadian Family Physician</em> in 2000. </p>
<p>The ad featured the World Health Organization “pain ladder” — <a href="http://www.who.int/cancer/palliative/painladder/en/">a guideline for administering the right drug in the right dose at the right time for cancer pain relief</a> — that Purdue had adapted. New drugs were added to the ladder as part of the adaptation, one of which was oxycodone, the generic name for OxyContin, and there was no mention that the original pain ladder was only for people with cancer. </p>
<p>The same ad also had the statement that, “drug abuse is not a problem in patients with pain for whom the opioid is appropriately indicated.” </p>
<p>The provenance for that quote can be traced back to a <a href="http://www.nejm.org/doi/pdf/10.1056/NEJM198001103020221">five-sentence letter in <em>the New England Journal of Medicine</em></a> in January 1980. </p>
<p>The patients referred to in the letter suffered from acute pain, not chronic pain, were in hospital, not outpatients, and there was no long-term follow-up. </p>
<p>The ad had been approved by the PAAB.</p>
<h2>Health Canada an advisor</h2>
<p>The Oct. 18, 2016, issue of the <em>Canadian Medical Association Journal</em> had an ad for another opioid, Targin, also made by Purdue. </p>
<p>The ad prominently featured the statement: “Demonstrated reduced drug liking relative to oxycodone, when administered intranasally or intravenously.” Drug liking refers to the risk that a drug will be abused because of its addictive potential.</p>
<p>Below this statement, in barely visible print, was the acknowledgement that “the likely clinical significance of these results has not yet been established.” </p>
<p>The ability of companies to insert claims where the clinical significance is unknown is allowed by the PAAB code. How much reduction in liking was observed was not stated. </p>
<p>Intranasal and intravenous administration was tested because those are routes likely to be used by recreational drug users. Targin is only available in an oral formulation, but there was nothing in the ad about potential for abuse by people who had been legitimately prescribed this dosage form. </p>
<p>Buried deep in the fine print was the warning about “addiction, abuse and misuse.” This ad was also approved by the PAAB. </p>
<p>In 2012, OxyContin was replaced by OxyNeo, a new formulation that couldn’t be crushed and injected. The following year Purdue <a href="http://imsbrogancapabilities.com/YIR_2013_FINAL">spent more than $3 million promoting OxyNeo</a>, took out 143 pages of advertising in Canadian medical journals and its sales representatives made 17,000 office visits to doctors.</p>
<p>When the PAAB was subjected to public criticism in an academic forum, the organizers of the forum, of whom I was one, were <a href="http://shpm.info.yorku.ca/files/2018/04/Joel-Lexchin-Letter-of-complaint-from-Rosser.pdf">asked to send an apology to all of the audience members</a>, an apology that would be first reviewed by the organization’s lawyer.</p>
<p>Health Canada presumably approves of how the PAAB operates since it acts as an adviser to the organization.</p>
<h2>No information on drug harms</h2>
<p>Despite the visibility of journal ads, the amount spent on them is dwarfed by the amount spent on visits by sales representatives. In 2016, pharmaceutical companies in Canada spent <a href="http://imsbrogancapabilities.com/YIR_2016_FINAL/mobile/index.html">$12.5 million on ads versus more than $400 million on sales reps</a>. </p>
<p>The actions of these men and women are regulated through the Code of Ethical Practices of IMC. The code states that: “Members must provide full and factual information on products, without misrepresentation or exaggeration. Statements must be accurate and complete. They should not be misleading, either directly or by implication.” </p>
<p>This claim was tested in 2009-2010 in a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785667/">project lead by Dr. Barbara Mintzes</a>, then a faculty member in population and public health at the University of British Columbia, that I was involved in. </p>
<p>We asked general practitioners in Vancouver and Montreal who saw sales representatives to fill out questionnaires after each visit to record what they heard. </p>
<p>Claims about benefits of drugs were made twice as often as the harms from those drugs were discussed. </p>
<p>There was no oral or written information about harms between 36 to 40 per cent of the time. </p>
<p>Contraindications to use of the drug were mentioned about 15 per cent of the time. And for serious adverse side effects it was even worse — the sales reps talked about them only five to six per cent of the time.</p>
<h2>Penalties are lunch money</h2>
<p>The validity of complaints about code violations is decided by the Industry Practices Review Committee (IPRC). The permanent members of the IPRC are two company representatives, two external health-care professionals all appointed by the IMC Board of Directors, a representative appointed by the IMC president and IMC’s general counsel. </p>
<p>The maximum financial penalty after a fourth violation in a 12-month period is $100,000. After the third violation, the chief executive officer of the company is required to appear before the R&D Board of Directors to provide a detailed explanation of the violations and a comprehensive written action plan to ensure remediation. </p>
<p>When companies are spending <a href="http://imsbrogancapabilities.com/YIR_2016_FINAL">upwards of $14 million promoting a single product</a>, $100,000 is lunch money.</p>
<p>The way in which companies promote their products should be no surprise; they are in the business of making a profit for their shareholders. </p>
<p>What is surprising is that Health Canada condones their marketing practices. It’s time for that to change.</p><img src="https://counter.theconversation.com/content/94888/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2015-2017, Joel Lexchin was a paid consultant on two projects: one looking at indication-based prescribing (United States Agency for Healthcare Research and Quality) and a second 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). 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.</span></em></p>Prescription drugs are policed by industry and Health Canada has never prosecuted a drug company for illegally marketing a drug.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University and Associate Professor of Family and Community Medicine, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/890102018-02-06T11:35:45Z2018-02-06T11:35:45ZWhy treating addiction with medication should be carefully considered<figure><img src="https://images.theconversation.com/files/204327/original/file-20180131-157466-1se70eb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vivitrol, a non-opioid medication, is used to treat some cases of opioid dependence. Addiction specialists stress that not all patients need medication, but that many do.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Teens-Opioid-Treatment/84629d2afe8b4857a888c6f3272560cc/241/0">AP Photo/Carla K. Carlson</a></span></figcaption></figure><p>When a patient has diabetes, doctors typically prescribe insulin, along with diet and exercise. When a patient has high blood pressure, we prescribe medication, and we also reinforce the importance of healthy eating, exercise, weight loss and quitting smoking. </p>
<p>When it comes to the disease of opioid addiction, however, some <a href="https://www.nytimes.com/2016/05/29/opinion/sunday/addicted-to-a-treatment-for-addiction.html">critics describe the use of medication</a> as merely substituting one opioid for another, preferring instead total abstinence. Others see pharmacotherapy as the most critical component in treating the current opioid epidemic.</p>
<p><a href="https://www.cdc.gov/drugoverdose/data/overdose.html">More than 2 million people</a> in the U.S. have an opioid abuse disorder, yet only a small fraction actually receive treatment. For those who do, our society uses a specific term to refer to the medication part: “medication-assisted treatment,” or MAT.</p>
<p>The medications currently approved to treat opioid addiction act on the brain’s opioid receptors by either substituting as a less rewarding drug or blocking the euphoric effects of opioids. In either case, the goal is to decrease the use of the more addictive and lethal opioids and stop the cycle of addiction. </p>
<p>As with any illness, the goal should be to have patients on the least amount of medication needed. But sometimes, as with diabetes or heart disease, medications are needed in concert with other treatment. </p>
<p>To me, even the name “medication-assisted treatment” is problematic: We’re treating addiction differently than other diseases, due to the stigma that’s always surrounded it. </p>
<p>As medical director of the UF Health Florida Recovery Center, I consider medication to often be part of a multi-pronged treatment approach for many patients suffering from opioid addiction. Each person is different, and we need to individualize treatment. While using medicine is often important, it is not a panacea. Here’s why we need to carefully consider how and when we use medications, for all types of addiction and mental health issues.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/TYFxPG_MYK8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr. Scott Teitelbaum discusses opioid addiction.</span></figcaption>
</figure>
<h2>A nation with a long history of opioid use</h2>
<p>Prior to the Civil War, <a href="http://www.history.com/topics/history-of-heroin-morphine-and-opiates">morphine was synthesized</a> to treat pain. This, combined with advancements in anesthesia, exposed a great number of soldiers to opioids. Following the war, addiction was called <a href="https://www.newyorker.com/news/amy-davidson/the-soldiers-disease">“the soldier’s disease”</a> or “the Army’s disease.” </p>
<p>Soldiers said the drug not only relieved physical pain, but also the <a href="https://www.newyorker.com/news/amy-davidson/the-soldiers-disease">emotional pain </a>of their wartime experience. Even then, the wounded and those who treated them recognized that opioids relieved both physical and psychic pain.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204326/original/file-20180131-157481-c11tss.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Civil War casualties after the battle at Antietam Creek, Md., Sept. 17, 1862. The war claimed more than 700,000 lives and left thousands more disabled, damaged and disfigured.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Associated-Press-Domestic-News-Maryland-United-/6adfb37c97e5da11af9f0014c2589dfb/116/0">AP Photo</a></span>
</figcaption>
</figure>
<p>Our country’s <a href="https://www.washingtonpost.com/news/retropolis/wp/2017/09/29/the-greatest-drug-fiends-in-the-world-an-american-opioid-crisis-in-1908/?utm_term=.94c9d93799ad">first heroin epidemic</a> began in the late 1800s. This was followed by the Harrison Narcotics Act of 1914, which stated it was not in good faith <a href="http://www.druglibrary.org/schaffer/library/studies/cu/cu8.html">for physicians to treat </a>heroin addiction with morphine, as addiction was not considered a disease then. It was illegal for physicians to use opioids to treat opioid addiction, and many physicians went to prison when they did.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=879&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=879&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=879&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1105&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1105&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204325/original/file-20180131-157473-ubyqmo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1105&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A bottle of heroin, which was legal to purchase in many parts of the world, even after the 1924 Heroin Act banned its sale in the U.S.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Bayer_Heroin_bottle.jpg">Wikimedia.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>In the 1920s and ’30s, people who were caught “doctor shopping” to get opioid prescriptions were sent to “<a href="https://www.ket.org/opioids/lexingtons-narcotic-farm-a-pioneering-institution-in-drug-treatment/">narcotic farms</a>” in Lexington, Kentucky, and Fort Worth, Texas, for treatment. Once released, most relapsed.</p>
<p>In the 1950s and ’60s, U.S. doctors began the practice of <a href="https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone">methadone maintenance</a>, initiated in large part to reduce urban crime.</p>
<p>Another shift in opioid usage happened in 2001. The Joint Commission on Accreditation of Healthcare Organizations <a href="https://www.ncbi.nlm.nih.gov/pubmed/11706454">first established standards for pain assessment</a> and treatment. Though the standards did not state that pain needed to be treated like a vital sign, some organizations implemented programs by making pain “the fifth vital sign.” Doctors began to treat pain more liberally, exposing more sufferers of pain to opioids.</p>
<p>Today, the U.S. has about 5 percent of the world’s population, and <a href="https://www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html">we use an estimated 90 percent</a> of the world’s prescribed pain medications. </p>
<p>Today’s opioid crisis has been the deadliest yet. More than <a href="https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf">64,000 Americans</a> lost their lives to drug overdose in 2016 – about two-thirds were from opioids. Most of the other overdose deaths were from central nervous system depressants like Xanax and alcohol, highlighting the importance of not forgetting the risk of other drugs. </p>
<h2>Pain medications as gateways</h2>
<p>For those who become addicted to painkillers, heroin becomes attractive because it is cheaper and widely available. Because of this, <a href="https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-abuse-heroin-use/introduction">overdose deaths from prescription opioids decreased about 2010, </a> while there was a precipitous rise in overdoses of heroin and fentanyl, a synthetic narcotic sometimes sold on the street as heroin. </p>
<p><a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">Fentanyl</a> is extremely potent; it’s used in the operating room to put people under anesthesia. The sharpest increase in number of deaths – an estimated <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">20,000 deaths</a> – was due to fentanyl. </p>
<h2>Undoing the damage a slow process</h2>
<p>Modern-day MAT stems from the 2002 Food and Drug Administration approval of <a href="https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine">buprenorphine</a> for the treatment of opioid withdrawal and maintenance. Buprenorphine is a partial opiate <a href="https://www.ncbi.nlm.nih.gov/pubmed/1711441">agonist</a>, or a drug that operates as an opioid, but with a ceiling effect to help significantly decrease the chance of respiratory arrest from overdose. Unlike methadone, which must be dispensed in a highly structured clinic, buprenorphine can be prescribed in a doctor’s office on an outpatient basis.</p>
<p>According to the National Institute on Drug Abuse, <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">medications are an important element</a> for many patients with opioid addiction. They are especially effective when combined with counseling, other behavioral therapies and 12-step recovery programs like Narcotics Anonymous. </p>
<p>Research shows that MAT results in what we addiction specialists call <a href="https://drugabuse.com/library/harm-reduction/">harm reduction</a>. This means that while some of these patients may not be ready to be opioid-free, we want to keep them alive and achieving the greatest level of functioning. We don’t want them engaging in self-destructive behaviors like relapsing to street drugs, committing crimes, overdosing or acquiring infectious diseases like HIV. And there’s <a href="https://www.medscape.com/viewarticle/891282">good evidence</a>, some of which was presented as recently as Jan. 23, 2018, that medications have helped decrease HIV, hepatitis C and crime, as well as improve function. </p>
<p>It’s not that abstinence is not a goal, but the aim of MAT is rather to stop the devastating consequences of this terrible illness and keep the patient alive and engaged in the process of treatment. Many have serious, co-occurring health problems, such as mental illness and a history of trauma. They may not yet have the ability to deal with the physical and emotional discomfort of being opioid-free.</p>
<p>In the last two years, the FDA has approved new formulations of buprenorphine to treat opioid addiction. One is a <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm587312.htm">once-monthly injection</a> and another an <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm503719.htm">implant</a> that can be effective up to six months. These longer-acting options can stabilize a patient by decreasing cravings, which then discourages use.</p>
<h2>Larger treatment plan important</h2>
<p>It is true, nonetheless, that if not done carefully, these MAT medications can be abused themselves. If taken with other drugs or in larger amounts, these drugs can cause overdoses, too.</p>
<p>In my view, the goal should be prescribing the least amount of medication one needs. Regardless of what medication is used during treatment, we should be pushing patients to be the best versions of themselves and to live their fullest lives possible. I favor scrapping the debate over whether we are abstinence-based or medication-based and instead asking, “What does this individual need?” </p>
<p>Then one day, I hope, we can shake the “medication-assisted” and just call it what it is: treatment.</p><img src="https://counter.theconversation.com/content/89010/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Scott Teitelbaum 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 U.S. has had multiple drug epidemics, and, until recently, has not had evidence-tested ways to help people. That has changed. New medicines can help. But other medical issues should also be addressed.Scott Teitelbaum, Professor of Psychiatry, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/853132017-10-15T22:30:31Z2017-10-15T22:30:31ZSugar in the diet may increase risks of opioid addiction<figure><img src="https://images.theconversation.com/files/190226/original/file-20171013-3561-6uj7xt.jpg?ixlib=rb-1.1.0&rect=122%2C163%2C4939%2C3301&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As North America's opioid crisis worsens, schools across Canada are purchasing naloxone anti-overdose kits. Research suggests that risks of opioid addiction could also be addressed through attention to children's nutrition.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Could a diet high in refined sugars make children and adults more susceptible to opioid addiction and overdose? New research, from our laboratory of behavioral neuroscience at the University of Guelph, suggests it could. </p>
<p>Approximately <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">20,000 people died of fentanyl-related overdoses</a> in the United States last year and in Canada there were <a href="https://www.thestar.com/news/canada/2017/09/14/rising-hospitalizations-due-to-opioid-crisis-puts-a-burden-on-canadas-health-system-report.html">at least 2,816 opioid-related deaths</a>. During 2017 so far, <a href="http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf">over 1,000 people have died</a> of illicit drug overdoses in British Columbia. <a href="http://bc.ctvnews.ca/fentanyl-antidote-should-be-stocked-in-every-high-school-trustee-says-1.3606017">High schools are stocking up on the overdose-reversing drug naloxone</a> and <a href="http://www.cbc.ca/news/canada/montreal/montreal-universities-prepare-for-worst-train-staff-to-administer-fentanyl-antidote-1.4294178">universities are training staff to administer the drug</a>. </p>
<p>Nobody is talking about sugar. </p>
<p>And yet there is substantial experimental evidence that <a href="http://www.nature.com/scientificamerican/journal/v309/n3/full/scientificamerican0913-44.html">refined sugar can promote addictive behaviours</a> by activating the brain’s rewards centres in much the same way as addictive drugs. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109725/">Opioid abuse is also associated with poor dietary habits</a>, including preferences for sugar-rich foods, as well as malnutrition. These connections have led to questions of whether excessive consumption of refined sugar may affect vulnerability to opioid addiction. </p>
<p>To explore the possible role of a sugar-rich diet in opioid addiction, we investigated whether unlimited access to high fructose corn syrup (HFCS) altered rats’ neural and behavioural responses to the semi-synthetic opioid, oxycodone. </p>
<p>Our findings suggest that a diet high in corn syrup may dampen the reward associated with oxycodone and may therefore encourage consumption of higher quantities of the drug.</p>
<h2>Opioids, high fructose corn syrup and addiction</h2>
<p>High fructose corn syrup is a refined sugar that typically includes more fructose than glucose. It is a commonly used food additive in North America, produced by chemically processing corn. Although it is employed in many processed foods, its use in soft drinks appears to have the biggest impact on health. In fact, there is a significant relationship between <a href="https://www.omicsonline.org/open-access/neuroscience-of-reward-implications-for-food-addiction-and-nutrition-policy-2155-9600-1000569.pdf">increased consumption of sugar-sweetened beverages and weight gain, metabolic syndrome and hypertension</a>. </p>
<p>Recently, our laboratory has been exploring the <a href="http://www.mdpi.com/2072-6643/7/5/3869">impact of HFCS on behaviours and brain markers of addiction</a> in laboratory rats. In one study conducted by my PhD student Meenu Minhas, animals had unrestricted around-the-clock access to bottles containing a water solution sweetened by HFCS. After about a month of voluntary drinking, the bottles were removed and, after a few sugar-free days, animals’ behavioural and neural responses to oxycodone were assessed. </p>
<p>Similar to other opioids, oxycodone induces pharmacological effects that include analgesia, euphoria and feelings of relaxation. Some common street names include: “hillbilly heroin,” “perc,” and “OC.” Oxycodone is the active ingredient in a number of formulations which include intravenous injections, immediate release solutions/capsules (Percocet, Percodan, OXY IR, OXY FAST), and extended release preparations (OxyContin). </p>
<p>Oxycodone is also highly addictive and has impacted the lives of numerous North Americans. There are estimates that its consumption <a href="https://c.ymcdn.com/sites/safestates.site-ym.com/resource/resmgr/imported/Jones.pdf">increased by almost 500 per cent from 1999 to 2011</a>. The U.S. <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm">National Survey on Drug Use and Health</a> revealed that approximately 27.9 million people aged 12 or older used oxycodone products. Moreover, 4.3 million people aged 12 or older reported misusing oxycodone-containing products in the past year. </p>
<h2>Dampening drug’s reward may increase use</h2>
<p>At the neural level, HFCS exposure decreased oxycodone-induced release of dopamine, which is a desire-promoting neurotransmitter active in the brain’s reward circuits. </p>
<p>Furthermore, at low doses, sedative drugs like opioids and alcohol normally interfere with inhibition and stimulate a variety of “psychomotor” behaviors — such as sociability, extroversion, talkativeness, sensation seeking and interest in novelty. Our study in rats found that exposure to the high fructose corn syrup reduced this psychomotor stimulation induced by oxycodone.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190059/original/file-20171012-31390-1s923be.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"></span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Our experiments show that chronic exposure to high fructose corn syrup had an impact on both the neural and behavioural responses to oxycodone, resulting in changes likely to affect drug-taking and drug-seeking behaviour. They suggest that a high sugar diet may dampen the reward associated with a given dose of oxycodone. And that this may cause people to consume more of the drug.</p>
<p>These results suggest that nutrition, and high fructose corn syrup intake in particular, can influence responses to opioids — a finding that may be relevant both to clinical uses of opioids and to treatment of addiction.</p>
<p>We can win the war on opioid addiction only if we tackle the problem from multiple angles. Our findings, and those of other laboratories, strongly suggest that prevention of unhealthy diets may not only help reduce the obesity epidemic, but also reduce environmental factors that may predispose to opioid addiction.</p><img src="https://counter.theconversation.com/content/85313/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Francesco Leri receives funding from the Natural Sciences and Engineering Research Council of Canada, and from the Ontario Brain Institute. </span></em></p>High fructose corn syrup in food and drinks has long been linked to rising rates of child and teen obesity. New evidence suggests it increases the risks of opioid addiction and overdose too.Francesco Leri, Professor of Psychology, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816032017-08-13T23:17:38Z2017-08-13T23:17:38ZLegal weed: An accidental solution to the opioid crisis?<figure><img src="https://images.theconversation.com/files/180476/original/file-20170801-28766-1erdw7h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There is growing evidence for the use of cannabis in treating opioid addiction.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>It’s hard to go a day in Canada without hearing about at least one of two types of drugs – but for vastly different reasons. One class of drug — opioids — <a href="https://www.thestar.com/news/canada/2017/04/19/death-toll-reaches-almost-4-a-day-in-overdose-crisis-in-bc-coroner.html">kills four people a day in British Columbia</a>. The other — cannabis — will be legal for adult purchase and consumption <a href="https://www.canada.ca/en/health-canada/news/2017/04/canada_takes_actiontolegalizeandstrictlyregulatecannabis.html">by this time next year.</a></p>
<p>The opioid overdose epidemic is Canada’s gravest public health crisis since the emergence of HIV in the 1980s. With its roots in the over-prescription of high-potency painkillers, sparked by the contamination of the illicit drug supply with fentanyl and related drugs, the crisis has reached across demographic divides. Experts agree on the need for creative responses based in scientific evidence. </p>
<p>Could cannabis legalization be a part of this solution? Increasingly, this is what the latest scientific research indicates. </p>
<h2>Fatal overdoses</h2>
<p>The opioid crisis is a product of the medical system’s <a href="https://theconversation.com/how-to-fix-canadas-opioid-crisis-it-starts-with-pain-and-the-prescription-pad-78512">over-reliance on opioids</a> for pain relief. Almost <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298051/">one in five Canadians</a> live with some form of chronic pain. Twenty years ago, pharmaceutical companies began to develop <a href="https://theconversation.com/oxycontin-how-purdue-pharma-helped-spark-the-opioid-epidemic-57331">slow-release formulations of opioids</a> (e.g. OxyContin) and marketed them as safe and effective medications for the treatment of chronic non-cancer pain. </p>
<p>We know now that these drugs carry an extremely high risk of dependence and fatal overdose. Despite this, <a href="https://www.theglobeandmail.com/news/national/sales-of-opiod-drug-prescriptionsskyrocketing/article26008639/">more than 20 million opioid prescriptions</a> are filled each year in Canada. Drug overdoses are now the <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">leading cause of death</a> among Americans under the age of 50. And prescription opioids are involved in <a href="https://www.cdc.gov/drugoverdose/data/overdose.html">nearly half</a> of these deaths. It is also becoming apparent that opioids might be less effective than initially thought in treating certain types of chronic non-cancer pain (<a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006146.pub2/abstract;jsessionid=F7C9469935C456F6BDD34331871E1FEA.f03t01?systemMessage=Wiley+Online+Library+will+be+unavailable+on+Saturday+01st+July+from+03.00-09.00+EDT+and+on+Sunday+2nd+July+">e.g. neuropathic pain</a>).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180478/original/file-20170801-5515-q7tbo9.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">Canada will soon be the first country in the G-20 to legalize cannabis for non-medicinal purposes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Cannabis, derived from the Cannabis sativa plant, contains several compounds. These include tetrahydrocannabinol (THC, the primary psychoactive component of cannabis) and cannabidiol (CBD). Beyond the well-known psychoactive effects of cannabinoids, new research has shown that they also interact with <a href="https://academic.oup.com/bja/article-lookup/doi/10.1093/bja/aen119">systems in the body involved in the regulation of pain</a>. </p>
<p>This discovery has led researchers to investigate the potential for cannabis to treat various pain conditions for which opioids are currently first- or second-line therapies. High-quality clinical research involving cannabis has been <a href="https://www.theatlantic.com/politics/archive/2014/06/its-hard-to-study-marijuanas-medical-benefits-when-its-illegal/373603/">stunted by its prohibited legal status</a>. But a recent <a href="https://link-springer-com.ezproxy.library.ubc.ca/article/10.1007%2Fs11481-015-9600-6">review of clinical studies</a> involving cannabis-based medicines (including smoked or vapourized cannabis) found strong evidence for relief of chronic non-cancer pain.</p>
<h2>Ground-breaking findings</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/15731502">The substitution effect</a> is an idea from behavioural economics that describes how the use of one product might decrease when the availability of another increases. Substance use researchers have recently <a href="http://www.tandfonline.com/doi/abs/10.3109/16066359.2012.733465">adapted this theory</a> to understand the substitution potential between cannabis and opioids. In other words, does the use of opioids decrease with increasing access to cannabis?</p>
<p><a href="https://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.4005">In a landmark 2014 study</a>, a team of researchers analzyed data from across the United States over a 10-year period. They found that states that had legalized medical cannabis saw 25 per cent fewer opioid-related deaths compared to states where medical cannabis remained illegal. </p>
<p>These findings broke ground for others in the field to find associations between U.S. medical cannabis laws and reduced state-level estimates of <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303426?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed">opioid use</a> and <a href="http://www.nber.org/papers/w21345">dependence</a>. But, because these population-level studies cannot observe <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2210572">individual-level changes in cannabis and opioid use</a>, a closer look at these trends among different sub-populations of people affected by the opioid crisis is needed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180488/original/file-20170801-11176-1lbxy6y.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">Legalizing cannabis will enable researchers to investigate the clinical and public health impacts of the drug.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Not surprisingly, findings from surveys conducted among patients using medical cannabis across North America demonstrate a clear preference for cannabis over opioids. For example, roughly one-third of a sample of patients enrolled in Health Canada’s Marihuana for Medical Purposes Regulations (MMPR) program in B.C. <a href="http://www.sciencedirect.com/science/article/pii/S0955395917300130">report substituting cannabis for prescription opioids.</a></p>
<p>For chronic pain patients, this substitution effect appears even more pervasive, with cannabis substitution occurring in roughly <a href="http://www.sciencedirect.com/science/article/pii/S1526590016005678?via%3Dihub">two-thirds</a> of a sample of former prescription opioid patients in Michigan who started using medical cannabis. </p>
<p><a href="http://online.liebertpub.com/doi/full/10.1089/can.2017.0012">In the most recent study</a>, 80 per cent of medical cannabis patients in California reported that taking cannabis alone was more effective at treating their medical condition than taking cannabis with opioids. More than 90 per cent agreed they would choose cannabis over opioids to treat their condition if it were readily available.</p>
<h2>Illicit opioid use</h2>
<p>But what about the relationship between cannabis and opioids among some of those most affected by the opioid crisis — people with long-term experience using illicit opioids?</p>
<p>Untreated pain and substance use have a high degree of overlap. Pain was reported by almost half of people who inject drugs surveyed in a recent <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-017-0112-7">San Francisco study.</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962749/">Research from our colleagues in Vancouver</a> found that under-treatment of pain in this population is common. It results in self-management of pain by obtaining heroin or prescription opioids on the street.</p>
<p>This means there could be a role for cannabis even among individuals with extensive experience using illicit opioids. <a href="http://www.sciencedirect.com/science/article/pii/S0376871615002501?via%3Dihub">A study from California</a> of people who inject drugs found that those who used cannabis used opioids less often. It’s still unclear if this difference is directly due to cannabis use and more research is needed.</p>
<h2>Potential as anxiety treatment</h2>
<p>Even without chronic pain, cannabis may prove an effective alternative among individuals wanting to reduce or stop their opioid use. There is growing evidence for the use of cannabis in treating opioid addiction. CBD, the non-psychoactive component of cannabis, is known to interact with <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0387-1">several receptors involved in regulating fear and anxiety-related behaviours</a>. It shows potential for the treatment of several anxiety disorders. </p>
<p>Research is also investigating CBD’s role in modulating cravings and relapses — behaviours that are tightly linked to anxiety — among individuals with opioid addiction. <a href="https://link.springer.com/article/10.1007%2Fs13311-015-0373-7">Recent preliminary studies</a> suggest that CBD reduces opioid cravings. A <a href="https://clinicaltrials.gov/ct2/show/NCT02539823?lead=Hurd&cntry1=NA%3AUS&rank=1">larger clinical trial</a> is now underway in the United States.</p>
<h2>A bold response?</h2>
<p>Canada will soon be the first country in the G-20 to introduce a legal framework regulating the use of cannabis by adults for non-medical purposes. This will create a country-wide natural experiment for the world to observe. Legalizing cannabis will break down traditional barriers to understanding the clinical and public health impacts of the drug. </p>
<p>This massive drug policy change could not come at a more desperate time. By increasing access to the drug for therapeutic and recreational purposes, we will have the opportunity to investigate substitution effects within different populations of people who use opioids.</p>
<p>Protection of youth and removal of organized crime aside, the Cannabis Act may just be the unintentionally bold government response to the opioid crisis that our country so desperately needs.</p><img src="https://counter.theconversation.com/content/81603/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephanie Lake is supported by funding from the Canadian Institutes of Health Research and the Pierre Elliott Trudeau Foundation. She is affiliated with Canadian Students for Sensible Drug Policy. </span></em></p><p class="fine-print"><em><span>M-J Milloy is supported by funding from the United States National Institute on Drug Abuse, the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research. His institution has received an unstructured gift from NG Biomed Ltd., a private firm seeking a licence to produce medical cannabis, to support him.</span></em></p>As Canada moves towards legalization of cannabis in 2018, there is growing evidence of the drug’s potential to treat opioid addiction itself, as well as the chronic pain that often drives it.Stephanie Lake, PhD student in Population and Public Health, University of British ColumbiaM-J Milloy, Research Scientist, BC Centre on Substance Use and Assistant Professor in the Division of AIDS, UBC Department of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810192017-08-07T23:07:27Z2017-08-07T23:07:27ZBetter medical education: One solution to the opioid crisis<figure><img src="https://images.theconversation.com/files/179842/original/file-20170726-28585-m2t8ma.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The latest evidence-based treatments for opioid addiction are often under-used, due to inadequate addiction education for doctors and nurses. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>We are in the middle of an <a href="http://www.bcmj.org/bc-centre-disease-control/perspectives-drug-overdose-crisis-bc">overdose crisis</a> in Canada and around the world. Opioid overdose is a complex problem, but opioid addiction can be managed with effective interventions. Nonetheless, many evidence-based interventions are underused, and inadequate medical education is contributing to the problem. </p>
<p>Specialized addiction medicine fellowships for doctors can offer a new and effective way to fight addiction. A recently launched <a href="http://www.bccsu.ca/addiction-medicine-clinical-research-fellowship-overview/addiction-medicine-fellowship/">addiction medicine fellowship</a> — at the University of British Columbia (UBC) and St. Paul’s Hospital in Vancouver — promises to change how addiction is taught in medical schools and beyond. </p>
<p>Historically, treatment of addiction has been in the hands of psychiatrists. Most health authorities <a href="https://doi.org/10.1136/bmj.h4027">have not trained doctors in addiction medicine</a>. But training more doctors more efficiently can help to improve diagnosis and treatment of substance use disorders. It can also help reduce the public health epidemics that can result from <a href="http://www.cfenet.ubc.ca/news/in-the-news/time-confront-iatrogenic-opioid-addiction">improper prescribing of opioid analgesics</a> – an <a href="https://theconversation.com/how-to-fix-canadas-opioid-crisis-it-starts-with-pain-and-the-prescription-pad-78512">ongoing problem</a> in North America. </p>
<p>As a postdoctoral fellow at the University of British Columbia and researcher at the British Columbia Centre on Substance Use, I recently began to study how to improve addiction medicine education for doctors. This <a href="https://doi.org/10.1186/s12909-017-0862-y">research</a> includes a review of best practices that will help inform an <a href="http://dx.doi.org/10.1080/08897077.2017.1355868">international consultation of experts</a> developing standards for teaching doctors in addiction medicine worldwide.</p>
<h2>New treatments, old training</h2>
<p>Over the past few decades, addiction science has advanced in leaps and bounds. We have found innovative ways to treat addiction, especially if it’s diagnosed early and treated promptly. However, most interventions are underused. Early diagnosis and treatment by medical professionals fail mainly due to a <a href="https://www.centeronaddiction.org/addiction-research/reports/addiction-medicine-closing-gap-between-science-and-practice">lack of skills</a> and <a href="http://dx.doi.org/10.1080/08897077.2017.1296055">knowledge in addiction medicine</a>. The result is myriad public health problems that stem from untreated addiction and <a href="http://www.cfenet.ubc.ca/news/in-the-news/wake-doctors-and-teach-them-addictions">untrained doctors</a>.</p>
<p>Not long ago, for example, medical doctors in several provinces were told by representatives of pharmaceutical companies that <a href="https://theconversation.com/roots-of-opioid-epidemic-can-be-traced-back-to-two-key-changes-in-pain-management-50647?sg=835d599f-39ef-42f6-b273-11caeff100e2&sp=1&sr=1">OxyContin was not addictive</a> — a lie that caused a mess to be cleaned up over the next decade.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180081/original/file-20170727-29132-1ae352h.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">Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin).</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>All of this could be prevented with better training and better use of the interventions that we already have. Among them is <a href="http://www.bccsu.ca/wp-content/uploads/2017/05/BupNlx-did-you-know_final.pdf">buprenorphine/naloxone</a> (also known as Suboxone), which is used to treat addiction to opioids. The new <a href="http://www.bccsu.ca/care-guidance-publications/">opioid treatment guidelines</a> now recommend it as the first line of treatment for opioid addiction. In the past, it was not covered by provincial medical plans and only a handful of physicians could prescribe it. They needed to have their methadone licences first. <a href="http://globalnews.ca/news/2806946/b-c-doctors-can-more-easily-prescribe-suboxone/">New regulations and new guidelines</a> removed these barriers so that more people can access it and <a href="https://www.theglobeandmail.com/news/politics/health-canada-to-allow-imports-of-drugs-needed-to-treat-opioid-addiction/article35487648/">other drugs</a> needed to treat opioid addiction.</p>
<h2>Global shifts</h2>
<p>The situation of addiction training in Europe and elsewhere has changed, but not so dramatically. The Dutch created one of the most complete programs in Europe — a whole <a href="http://tandfonline.com/doi/full/10.1080/08897077.2011.555713">masters degree in addiction medicine</a>. It also shaped the <a href="http://tandfonline.com/doi/full/10.1080/08897077.2011.555710">Indonesian national training program</a>. But both the Dutch and the Indonesian models have been inspired by the <a href="http://tandfonline.com/doi/full/10.1080/08897077.2011.555705">Canadian models</a> of addiction training. </p>
<p>Norway has started a <a href="http://dx.doi.org/10.1007/978-88-470-5322-9_69">full medical speciality</a> in addiction medicine that is supported by the government. In the U.K., St George’s medical school at the University of London led a project that <a href="https://www.addiction-ssa.org/images/uploads/SMUGProjectReport.pdf">studied teaching in 19 cities</a> and resulted in national guidelines for medical schools. On the other side of the globe, Australia offers three years of <a href="http://tandfonline.com/doi/full/10.1080/08897077.2011.555718">supervised training</a> in addiction medicine, with regular assessment and a focus on harm reduction and evidence- based interventions.</p>
<p>Few of these programs provide teaching that is necessary for skilled addiction specialists. Better programs should include training in detoxification protocols, inpatient consultation, residential treatment, youth addiction, mental health problems and chronic pain management as well as long-term treatment based in the community.</p>
<h2>A new model for addiction education</h2>
<p>In this respect, new training programs to address these problems have emerged around the globe, including in Canada. The <a href="http://www.bccsu.ca/addiction-medicine-clinical-research-fellowship-overview/addiction-medicine-fellowship/">fellowship</a> at UBC and St Paul’s Hospital teaches addiction science to eight physicians over 12 months of specialized training. They come from family medicine, internal medicine and other disciplines and thus expand the skilled addiction treatment workforce to a community of front-line workers who see people with substance use disorders frequently. </p>
<p>From the very beginning, the <a href="http://www.addictionmedicinefoundation.org/">American Addiction Medicine Foundation</a> accredited the fellowship, and trainees are supported to sit the foundation’s exams. They receive not only training in clinical skills, but also <a href="http://tandfonline.com/doi/full/10.1080/08897077.2014.939802">research skills via intensive work with mentors</a>. They have lots of access to public research articles, participate in academic half-days, conferences and journal clubs. They are trained on how to talk to journalists, how to influence public opinion and how to advocate on patients’ behalf – becoming true leaders in the field.</p>
<p>In recent years, the <a href="http://www.cfenet.ubc.ca/publications/needs-assessment-number-comprehensive-addiction-care-physicians-required-canadian">number of applicants for the fellowship have increased</a> and challenged the program’s capacity to train the next generation of addiction doctors. To respond to this urgent need, and to save more lives of people who overdose, new training pathways have been built around the fellowship program. <a href="http://www.bccsu.ca/addiction-medicine-clinical-research-fellowship-overview/addiction-nursing-fellowship/">Nurses</a> and <a href="http://www.bccsu.ca/addiction-medicine-clinical-research-fellowship-overview/addiction-social-work-fellowship/">social workers</a> are now trained — two from each profession annually. </p>
<p>Another U.S.-funded <a href="http://www.bccsu.ca/addiction-medicine-clinical-research-fellowship-overview/canada-addiction-medicine-research-fellowship/">fellowship program</a> of dedicated research training in Canada teaches science skills to four physicians on a part-time basis every year. These clinician scientists are an important piece in the overdose management puzzle because they deliver the care, know their patients well and can prescribe effective medications.</p>
<p>A new, free <a href="http://www.bccsu.ca/courses/online-addiction-medicine-diploma-program/">online diploma</a> in addiction medicine was also launched in May. Anyone can access it and study just one or all the educational modules on various topics of addiction medicine. In addition, the <a href="http://www.bccsu.ca/provincial-opioid-addiction-treatment-support-program/">Provincial Opioid Addiction Treatment Support program</a> has been moved online to reach a wider audience of prescribers as the program became part of the new British Columbia Centre’s on Substance Use <a href="http://www.bccsu.ca/courses/">portfolio</a>. </p>
<p>With these recent developments, the potential to improve the system of addiction care and prevent people from dying due to overdose has reached unprecedented levels. Lives will be saved.</p><img src="https://counter.theconversation.com/content/81019/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jan Klimas receives funding for research from The Irish Research Council and The European Commission. </span></em></p>Most physicians are unaware of effective approaches to treat opioid addiction. Addiction medicine fellowships offer a new and effective way to save lives.Jan Klimas, Postdoctoral Fellow at Primary Connections, University College Dublin |, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/792432017-06-12T11:06:54Z2017-06-12T11:06:54ZThe opioid epidemic in 6 essential reads<figure><img src="https://images.theconversation.com/files/173219/original/file-20170609-4841-1pp3o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug related deaths are on the rise, but federal funds to programs that mitigate drug abuse are being cut in 2018.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/grumpy-puddin/5161819684/in/photolist-8S8Fa7-6vaLox-635Ju-6veWuj-6vaLnk-cHhoMy-6vaLg4-GsU3t-6veWAd-7MhkvW-jzZsMe-9kC6Km-qznEaT-bXUPx-cHhfjS-SXxwYB-dp5X6i-9sS84N-6vaLpB-8knpCN-6veWC5-efgp16-gXH688-Mqex-54dH9T-9Cg59v-aQ71vK-6QyKwT-6VnSDE-bPuPbV-4xcHp9-ei6szp-8QZM9R-9KRmfw-dFHZpC-7w88Br-8R9Kkm-oW2aQ-9aTME3-49TkM1-aCEmz6-8FJMJJ-dJGAyL-SSga5W-6Q3N14-4wP9QZ-6SbB7V-9vCtht-mA7Hua-aAYbYp">Me/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p><em>Editor’s note: The following is a roundup of archival stories related to opioids.</em></p>
<p>The opioid crisis appears to be getting worse, not better. </p>
<p><a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">According to The New York Times</a>, drug deaths are rising faster than ever, with more than 59,000 overdose deaths in 2016. </p>
<p>The situation has been dire for a few years, with <a href="http://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html">six in 10 drug overdose deaths</a> in 2014 involving an opioid, such as a painkiller or heroin.</p>
<p>In May, Donald Trump <a href="http://thehill.com/homenews/administration/332871-trump-appoints-opioid-commission">appointed a commission</a> on the opioid epidemic, which he’s described as “<a href="http://abcnews.go.com/Politics/donald-trump-sounds-alarm-citing-tremendous-problem-deep/story?id=41309801">a tremendous problem</a>.” However, <a href="https://www.vox.com/policy-and-politics/2017/5/23/15680096/trump-budget-opioid-epidemic">his proposed budget includes cuts</a> to agencies like the Office of National Drug Control Policy and the Substance Abuse and Mental Health Services Administration.</p>
<p>At The Conversation, scholars have been examining the many facets of the epidemic for months. Here are six articles that explain the background of the epidemic and where were might go from here. </p>
<h2>How did we get here?</h2>
<p>Ted Cicero and Matthew Ellis, who study opioid abuse at Washington University in St. Louis, argue that the epidemic is rooted in two events: the introduction in 1996 of OxyContin, an extended-release high-dose opioid, and a 2001 report on pain treatment from the Joint Commission on Accreditation of Healthcare Organizations. </p>
<p>As Cicero and Ellis <a href="https://theconversation.com/roots-of-opioid-epidemic-can-be-traced-back-to-two-key-changes-in-pain-management-50647">write</a>:</p>
<blockquote>
<p>“The change in pain treatment ushered in by the Joint Commission report lead to an increase in the number of opioid prescriptions in the U.S., and the increase in prescriptions for this particular high dose opioid helped to introduce an unprecedented amount of prescription drugs into the marketplace, generating a whole new population of opioid users.”</p>
</blockquote>
<p>Jeannie D. DiClementi, a professor of psychology, points out that the increase in opioid prescriptions led to an <a href="https://theconversation.com/from-the-clinic-to-the-street-how-the-explosion-in-prescription-painkillers-has-created-more-heroin-users-50344">increase in heroin use</a>:</p>
<blockquote>
<p>“[N]early 80 percent of heroin users report having become addicted to prescription pain medications first, while just 3.6 percent had a history of heroin use before beginning prescription pain medications.”</p>
</blockquote>
<p>Fentanyl, a synthetic opioid 100 times more powerful than heroin, was first introduced in the 1960s as a <a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">painkiller during major surgery</a>. Illictly made fentanyl is now found on the street, often in counterfeit drugs. So are novel synthetic opioids that are chemically unrelated to anything used in medicine but act on the same receptors in the body and brain. These drugs are generally manufactured in clandestine labs in China and Mexico. </p>
<p>However, adding these illicitly made versions of fentanyl and other new opioids to Schedule I – the category of the Controlled Substances Act for illegal drugs like heroin – can be a lengthy process. And as Samuel Banister, Roy Gerona and Axel Adams, who study these new synthetic substances, <a href="https://theconversation.com/fentanyl-and-other-synthetic-opioids-sold-as-counterfeits-in-deadly-new-trend-62814">explain</a>:</p>
<blockquote>
<p>“The trouble is that as individual illicit synthetic opioids are added to Schedule I, clandestine chemists in China and Mexico ‘tweak’ molecular structures to circumvent the law by creating new drugs with similar effects.”</p>
</blockquote>
<h2>Treating addiction</h2>
<p>Last year, the federal government passed legislation aimed at expanding access to addiction treatment and took steps to improve treatment options for people in the criminal justice system. </p>
<p>William Greene and Lisa J. Merlo from the University of Florida <a href="https://theconversation.com/some-good-news-on-opioid-epidemic-treatment-options-are-expanding-61483">wrote that</a>: </p>
<blockquote>
<p>“This stepped-up policy response is giving doctors the means to better treat people with opioid addiction. When combined with improvements in public understanding that addiction is a disease requiring treatment, we as a society are creating an environment that supports treatment. We believe this will save many thousands of lives.”</p>
</blockquote>
<h2>We still need opioids</h2>
<p>Pain, <a href="https://theconversation.com/what-is-chronic-pain-and-why-is-it-hard-to-treat-57943">explains Robert Caudle at the University of Florida</a>, is complex and multifaceted, something that we can experience in many dimensions. Opioids can suppress incoming pain signals, prevent those signals from being amplified and improve the emotional states of the patient, all critical things for people with chronic pain. </p>
<p>In many ways, opioids are the most effective treatment we have currently, but Caudle notes out that we aren’t investing much in finding better ones:</p>
<blockquote>
<p>“In 2015 the National Institutes of Health spent US$854 million on pain research, compared to more than $6 billion for cancer. It is no wonder that pain patients muddle through with what amounts to centuries-old therapies.”</p>
</blockquote>
<p>While the opioid epidemic wears on in the U.S., parts of South America, Africa and Asia face a very different opioid crisis: too few of them. People in those parts of the world often cannot access pain medication stronger than acetaminophen. </p>
<p>Luke Messac argues that policies from the International Narcotics Control Board aimed at preventing opioids from being diverted for illict use have wound up keeping these medicines out of the hands of <a href="https://theconversation.com/the-other-opioid-crisis-people-in-poor-countries-cant-get-the-pain-medication-they-need-56205">people who truly need them</a>. “Pain is universal,” writes Messac, “but its relief is still a function of geography.”</p>
<p><em>This is an updated version of <a href="http://theconversation.com/the-opioid-epidemic-in-6-essential-reads-66227">a story that originally ran on October 6, 2016</a>.</em></p><img src="https://counter.theconversation.com/content/79243/count.gif" alt="The Conversation" width="1" height="1" />
Drug deaths are rising faster than ever. How did we get here and what to do about it?Jessie Schanzle, Aviva Rutkin, Data EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/621442016-07-06T19:10:45Z2016-07-06T19:10:45ZOpioid crisis: How did we get here?<p>Lawmakers meet <a href="http://www.nytimes.com/2016/07/07/us/politics/congress-to-hash-out-final-bill-aimed-at-opioid-epidemic.html">today</a> to try to finalize legislation to solve the nation’s opioid crisis. It’s an issue that The Conversation has been covering for many months. </p>
<p>How can it be that nearly half a million people in the U.S. are addicted to heroin and another two million have <a href="https://www.cdc.gov/drugoverdose/">substance use disorders</a> related to prescription drug abuse? In 2014, opioid overdose killed more than <a href="https://www.cdc.gov/drugoverdose/">28,000 people</a>.</p>
<p>Here are three articles from our archives that explain how we arrived at this crisis point.</p>
<ol>
<li><p>Theodore Cicero and Matthew Ellis of Washington University in St. Louis write that the roots of the epidemic can be traced back to changes in <a href="https://theconversation.com/roots-of-opioid-epidemic-can-be-traced-back-to-two-key-changes-in-pain-management-50647">pain management</a>. When pain began to be treated as the “fifth vital sign,” prescriptions to treat it soared. </p></li>
<li><p>Richard Gunderman of the University of Indiana argues we should not let pharmaceutical companies, particularly Purdue Pharma, off the hook. The company aggressively marketed OxyContin, Gunderman says, knowing that it could be easily <a href="https://theconversation.com/oxycontin-how-purdue-pharma-helped-spark-the-opioid-epidemic-57331">abused</a>. Prescriptions for the powerful – and highly addictive – drug for non-cancer pain soared from 670,000 in 1997 to 6.2 million by 2002. </p></li>
<li><p>Jeannie DiClementi, of Indiana University-Purdue University Fort Wayne explains how the abuse of prescription pain drugs spread to <a href="https://theconversation.com/from-the-clinic-to-the-street-how-the-explosion-in-prescription-painkillers-has-created-more-heroin-users-50344">abuse of heroin</a>. It wasn’t a big leap, as the chemical structures are similar. </p></li>
</ol>
<p>Almost everyone agrees we need to stop this scourge, yet there is disagreement over how to do that. Even today, lawmakers are expected to argue rather than agree. Democrats said they would oppose the bill if it did not include more money for treatment.</p>
<p>The Obama administration moved forward Tuesday on its own. It announced a <a href="https://www.whitehouse.gov/the-press-office/2016/07/05/obama-administration-takes-more-actions-address-prescription-opioid-and">new rule</a> that would allow certain doctors to almost triple the number of patients they can treat with buprenorphine. That drug treats addiction, but addicts can abuse it, too. Prescribing rights are therefore limited. To prescribe it, doctors must have a special waiver. And, until now, they could treat only 100 patients. </p>
<p>The new rule increases the prescribing limit to 275. But according to Jeffrey Horn, a policy research fellow at the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania, and Krisda H. Chalyachati, also a Robert Wood Johnson Foundation fellow at the University of Pennsylvania, those rights should be extended even further. In a <a href="https://theconversation.com/why-its-easier-to-be-prescribed-an-opioid-painkiller-than-the-treatment-for-opioid-addiction-60137">recent article</a> they argue that nurses and physician assistants also should be allowed to prescribe buprenorphine, given the scope of the opioid addiction epidemic.</p><img src="https://counter.theconversation.com/content/62144/count.gif" alt="The Conversation" width="1" height="1" />
As congressional leaders today discuss legislation to curb the opioid epidemic, we look at three articles that explain how it happened and one that suggests some solutions.Lynne Anderson, Senior Health + Medicine Editor, The Conversation, USLicensed as Creative Commons – attribution, no derivatives.