It was a perfect confluence of events today. At one point or another I heard or read about somebody's theory of why there was an opioid epidemic, deaths from drug use, and who was to blame. Although some of the discussants were quite heated they all had one thing in common - they were all dead wrong.
Let me start with the lead story - the Attorney General of the State of Ohio suing drug manufacturers for the massive opioid problem in that state. I say massive because there are an estimated 200,000 opioid users in the state and an associated mortality. If you listen to the story (1) many local coroners and morgues are overwhelmed by the body count. I heard the story on Minnesota Public Radio on the drive home tonight. Ohio Attorney General Mike DeWine is suing Purdue Pharma, Johnson & Johnson, Teva Pharmaceuticals, Endo Health Solutions and Allergan for their role in the opioid epidemic. Apparently the state of Mississippi filed the first law suit in the area. The AG alleges that these companies basically convinced physicians through their questionable marketing efforts that these drugs were much safer than they really were and more effective for the conditions that they were supposed to treat. Robert Siegel the reporter made an attempt to blame physicians instead and asked why they were not named in the law suit. The AG's position was that the culture of medicine was affected by the false promotion and that it will take a while to change things around. See the press release here for the exact position of the AG. A copy of the entire complaint by the AG is available here.
The second story (2) came to my attention on my Facebook feed. This was a case of Ross Ulbricht - who was apparently convicted and sentenced to life in prison based on operating a darknet market that he created called Silk Road. The conviction was apparently for money laundering, conspiracy to traffic narcotics, and computer hacking. My interest in this case has nothing to do with the charges, the defendant himself, the conviction or the sentencing but the reaction on various web sites about the case. There is a consensus on some of these web sites that he was offering valuable service for adults who want to come together and freely exchange items that it might be difficult for them to exchange in other places. The associated arguments are that competent mature adults should be able to do this, that any interest the state has in suppressing such activity is an inappropriate intrusion on individual rights, and that in fact a service like this was essentially competing against cartels and may put them out of business. Some suggested that there was a conspiracy between the state and cartels to put sites like this out of business.
All of these arguments fall flat to an addiction psychiatrist like me. They seriously underestimate the effect that an addiction has on the brain and conscious state of an addicted individual. Imagine what it is like to get out of bed in the morning and the very first conscious thought is: "How can I score some dope today so that I can function?" At that stage you are no longer a competent adult able to weigh decisions and make them in your best interest. All of your decisions are weighted in the direction of ongoing drug use and addiction. That is true if you are on the darknet looking for drugs or standing on a street corner in Ohio. That is true if you are sitting in a physician's office and telling them what you think they need to hear to enable them to prescribe you more opioids.
The second aspect of opioid addiction that is difficult to understand is the genetic predisposition to addiction. There are still a lot of pop psychology theories about addiction being just a bad habit or a lack of moral character that seem to explain the differences between people with addiction and people without addictions. The fact is a substantial part of the population is genetically vulnerable to addiction and it is just a matter of whether or not they are exposed to a highly addictive drug. If I had to estimate, my best guess would be that number is at least 40% of the population. By that I mean that 40% of the population will get an extremely euphorigenic response to opioids (whether or not they work for pain). They will remember that response and if exposed to more opioids are much more likely to use them than not use them.
That is what makes it so hard to stop this epidemic. Without those two basic features of addiction there is no unlimited demand for addictive medications from pharmaceutical companies. There is no need to go to a part of town that a person would never typically travel in to purchase diverted prescription opioids or heroin. There is no need to search out opioids or other addictive drugs on the Internet or the dark net.
Doctors don't get off the hook. All physicians are taught about controlled substances and the schedule of controlled substances. All physicians know that opioids are scheduled according to their addictive potential. The problem is that most physicians do not know how to interact with people who have significant addictions, and even experts can be fooled. Most physicians have an incredibly naive approach to addiction and how they can prevent it or approach it once it is established. The cultural norm that physicians help people by prescribing them medications, combined with the fact that physicians are trained to help people, creates a powerful force to continue to prescribe addictive pain medications. The absence of competent detox facilities is another.
Pharmaceutical companies, doctors, judges and prosecutors - the pro and anti-blame rhetoric around this issue is intense and unrelenting. It is not any easier to stop the current opioid epidemic when lawyers, libertarians, and reporters are spreading the blame around to anyone or anything other than the real cause of the problem - the addiction itself.
Start there - treat it as a public health problem and start to make progress.
George Dawson, MD, DFAPA
2: Brian Doherty. Ross Ulbricht Loses His Appeal Over Conviction and Sentencing in Silk Road Case. Hit and Run Blog. Reason.com May 31, 2017.
A reminder about the Ross Ulbricht case. I am not focused on the case per se or the War on Drugs. I am solely focused on the argument that anything can be openly traded on a market between consenting adults. I do not dispute the argument that the sentence was excessive or any other arguments for that matter.