Wednesday, May 31, 2017

Lawyers, Libertarians, and Journalists On the Opioid Epidemic

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      


1:  Ohio Sues Drug Companies Over Role In Creating Opioid Epidemic.  All Things Considered; may 31, 2017.  Transcript and audio clip.

2:  Brian Doherty.  Ross Ulbricht Loses His Appeal Over Conviction and Sentencing in Silk Road Case.  Hit and Run Blog.  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.


  1. Blame doesn't work, and neither does prohibition, which causes more harm than good. Nicotine and alcohol kill far more people than opiates. The solution is to make all drugs (with the possible exception of antibiotics) including heroin available over-the-counter WITHOUT a prescription. Physicians should be advisers, not gatekeepers.

  2. Could not disagree more.

    History shows that widespread availability of Schedule I and II drugs leads to an increasing proportion of the population addicted to these drugs. If anything your example of alcohol and nicotine are examples of that problem. People seem to forget why the Harrison Act was passed in the first place and it was the direct result of availability of OTC opioids and cocaine and then later "dope doctors" who were maintaining large numbers of patients in addiction in order to make money or because they did not know what they were doing.

    Physicians advisers are superfluous if people are purchasing OTC heroin. There is no heroin addict in the world who is interested in a physicians advice.

    The liberalization argument also fails to recognize the line from con men in the 19th century: "There is a sucker borne every minute." Many proponents of the "legalize everything" argument suggest that black markets and drug cartels will disappear. There is a strong profit motive for anyone without a conscious to sell any product to the suckers. The argument also assumes that any willing buyer of these products is able to assess the risk and use them accordingly. Addiction by itself rules that out.

    A secondary argument that is currently being applied to Colorado cannabis is that there will be a windfall from taxing these products. A windfall can be reasonably expected anytime there is broad marketing and sales of an addictive product like alcohol or tobacco. The societal question is whether it is morally acceptable to profit from addiction, particularly when society clearly does a poor job of addressing that problem. There is no evidence that I am aware of that the taxes generated apply to the direct and indirect losses from the addiction.

    The problem is that widespread chaos, death, disability, and economic loss that occurs with addiction on a large scale. The best example ever is the current opioid epidemic. As barriers to access were lowered, the number of addicts and deaths increased rapidly to the point it is a major public health concern. Small towns everywhere suddenly started seeing heroin overdoses, where heroin had never existed before. Increasing access to the drug and a significant number of people are risk is the dynamic here not some legal or economic constraint.

    There would be far less damage if antibiotics were available OTC for the basic reason that antibiotics don't reinforce their own use.

  3. I don't know how the AG lets the worst KOLs off the hook for this.

    I'd start with the most flagrant and title the motion, "Portenoy's Complaint."

    If for no other reason that he has been untouched and still working the pharma connections.

    "I meant well" is an excuse that first graders use. My standard is you should have known better.

    I recognize this type of academic and I never could stand them. A theorist with a well rehearsed line of BS devoid of any real world clinical judgment backed by a mountain of special interest money.

  4. Why is the US such an outlier though? That to me is an interesting question, and surely the addiction itself is not the only answer...

    1. The equation is very simple.

      Biology + Access = Addiction

      All of the naysayers have a mystical explanation for what is happening and tend to overemphasize/deemphasize the importance the disease concept and the impact that addiction has on the conscious state.

      Keeping that arithmetic in mind - the US is only an outlier in terms of access. If my theory is correct - human biology is about the same everywhere and therefore everyone is susceptible to addiction. I think that the current opioid epidemic in the US is basically the story of how increased access leads to epidemics of addictive drugs.

      That is as true now as it was at the turn of the century in the US, when controlled substances were all OTC. It is as true now as it was in China in the mid-19th century at about the time of the Opium Wars.

  5. Curious as to your take on Portugal which decriminalized drug use. My understanding is that they are seeing overall benefits from this, both in reduced drug use and reduced crime and morbidity/mortality.

    I would point out that decriminalization can be very different from legalization.

    Also curious as to your take on the movement in Canada to decriminalize cannabis, as their model looks a lot different to me than the model here, which seems mostly about maximizing income and letting the public fend for itself.

    1. A couple of responses based on this analysis:

      Societal cost (direct/indirect) is always difficult to estimate. In the US, the estimates of substance use are based on a national survey (NSDUH) and total cost estimates by various agencies like the NIAAA and CDC. The policy implemented in Portugal seems to be a pragmatic one with expected results. For example clean needle exchanges result in less cost for treatment of hepatitis and HIV. An emphasis on treatment results in longer inpatient stay and more lost productivity to inpatient stay. The authors themselves point out that their estimates may not capture total societal cost - but they proceed to analyze the costs in detail.

      Looking at the actual policy as they describe it there are a couple of key features:

      "The decriminalization of illicit drug acquisition and possession for personal use (understood as that which does not exceed the quantity needed for an average individual consumption for a period of 10 days) was approved in November 2000 (via Law no. 30/2000) and entered into force on the 1st July 2001."

      I see no problem with that policy at all. They point out the societal savings in terms of not paying for all of the associated legal costs of incarcerating this group of offenders. However the analysis of the problem is more complex due to the fact that at least some of these users are holding much greater quantities because they are financing their own use by selling drugs. I think there is a misconception that an ideal decriminalization statute will cleanly separate the users into a group that merit leniency and treatment and a group that don't and that is not the case (using their own law to make that determination).

      "(xii) to reinforce the combat against drug trafficking and money laundering and to improve the cooperation between different national and international authorities;"

      It appears that even a most enlightened policy, still recognizes the fact that criminal activity will continue to be present and needs to be suppressed. This is another aspect of policy that is actively denied in the USA. Most people supporting decriminalization or legalization believe that will lead to an enlightened pattern of use, tax revenues (for legalization) that will benefit all of society, and and even statements like "all of the drug cartels will be put out of business". I find all of those statements to be incredibly naive.

      Their policy also focuses on primary prevention. I consider this to be the best public health appraoch because it seeks to avoid exposure to addictive drugs in the first place. That is the concluding remark in my post.

      Another significant problem in the USA comes down to the managed care non-system of health care. I would be very interested in a side by side comparison of the USA to Portugal in terms of length of stay in detox and treatment facilities, availability of services, etc. According to recent OECD data Portugal has three times as many psychiatric beds per 1,000 residents as the US:

      Even if the USA were to implement the same policy - policy makers here seem oblivious to the fact that their rationing policies have greatly diminished the infrastructure necessary for carrying out the necessary treatment of even severely affect individuals. Managed care physician reviewers continue deny people access to care or throw them out at various stages of detox and treatment. There is no way that LOS in the USA would increase as long as those policies are in place and supported by Congress.

      That is my brief take. Interested readers can find the full text paper on Portugal at the above link or at this reference:

      1: Gonçalves R, Lourenço A, Silva SN. A social cost perspective in the wake of the Portuguese strategy for the fight against drugs. Int J Drug Policy. 2015 Feb;26(2):199-209. doi:10.1016/j.drugpo.2014.08.017. Epub 2014 Sep 6. PubMed
      PMID: 25265899.

    2. On the issue of Canada versus the US on cannabis legalization I will only say that I am on record predicting that American regulators will eventually come up with a system that facilitates Big Cannabis and there is accumulating evidence for that. I make this argument in the following posts from a political forum. They also contain some of my concerns about the way medical care is managed in this country: