An Opioid Crisis Foretold

https://www.nytimes.com/2018/04/21/opinion/an-opioid-crisis-foretold.html

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One of the more distressing truths of America’s opioid epidemic, which now kills tens of thousands of people every year, is that it isn’t the first such crisis. Across the 19th and 20th centuries, the United States, China and other countries saw drug abuse surge as opium and morphine were used widely as recreational drugs and medicine. In the West, doctors administered morphine liberally to their patients, while families used laudanum, an opium tincture, as a cure-all, including for pacifying colicky children. In China, many millions of people were hooked on smoking opium. In the mid-1800s, the British went into battle twice — bombing forts and killing thousands of civilians and soldiers alike — to keep the Chinese market open to drug imports in what would become known as the Opium Wars.

That history has either been forgotten or willfully ignored by many in the medical and political establishments.

Today’s opioid crisis is already the deadliest drug epidemic in American history. Opioid overdoses killed more than 45,000 people in the 12 months that ended in September, according to the Centers for Disease Control and Prevention. The epidemic is now responsible for nearly as many American deaths per year as AIDS was at the peak of that crisis.

Experts say that the death toll from opioids could climb for years to come. Millions of people are dependent on or addicted to these drugs, and many of them are increasingly turning to more potent, illicit supplies of heroin and fentanyl, which are cheap and readily available on the street and online. Yet only about 10 percent of Americans who suffer from substance abuse receive specialized addiction treatment, according to a report by the surgeon general.

WE HAVE SEEN THIS BEFORE

As many as 313,000 people were addicted to injected morphine and smoked opium in the United States in the late 19th century, according to David Courtwright, a history professor at the University of North Florida who has written extensively about drugs. Another scholar, R. K. Newman, estimated that as many as 16.2 million Chinese were dependent on opium and smoked the drug daily.

In the United States today, about 2.6 million people suffer from opioid use disorder. But some experts say that data, which is based on a government survey, underestimates the number of pain patients who are addicted to their prescription pills because of how surveyors ask people about drug use; the actual number might exceed five million.

In the 19th century, like today, the medical community was largely responsible for the epidemic. Doctors did not fully appreciate the risks these drugs posed. In the 1800s, many doctors viewed morphine as a wonder drug for pain, diarrhea, nerves and alcoholism. In addition to getting homemakers, Civil War veterans and others addicted, many doctors became addicts themselves. The drug was overused in large part because there were few alternatives; aspirin, for example, didn’t become available until the late 1890s.

In his 2001 book, “Dark Paradise: A History of Opiate Addiction in America,” Mr. Courtwright notes that the use of morphine began declining as younger doctors who had been better trained started practicing medicine and as non-addictive pain treatments became available. He also notes that many local governments across the country set up clinics that sought to help addicts — a forerunner of contemporary methadone clinics — but a hostile federal government forced virtually all of them to shut down by 1923. It did so under the misguided idea that it was wrong to keep supplying drugs to people who had become dependent on them — a view that is, regrettably, still widespread today.

Today’s opioid crisis has its roots in the 1990s, when prescriptions for painkillers like OxyContin and Vicodin started to become common. Companies like Purdue Pharma, which makes OxyContin, aggressively peddled the idea that these drugs were not addictive with the help of dubious or misinterpreted research. One short 1980 letter to The New England Journal of Medicine by Dr. Hershel Jick and Jane Porter said the risk of addiction was less than one percent, based on an analysis of nearly 12,000 hospital patients who were given opioid painkillers. That letter was widely — and incorrectly — cited as evidence that opioids were safe.

Federal regulators, doctors and others were swayed by pharmaceutical companies that argued for greater use of opioids; there was increasing awareness that doctors had become too unresponsive to patients who were in pain. Patient advocates and pain specialists demanded that the medical establishment recognize pain as the “fifth vital sign.”

Mr. Courtwright says that this was not a simple case of historical amnesia. In the earlier epidemic, doctors “made mistakes, but it was a bad situation to begin with,” he said. “There was no equivalent of Purdue Pharma flying you off to the Bahamas for the weekend to tell you about the wonders of these new drugs.”

WHAT SHOULD WE DO NOW?

The AIDS crisis might provide public officials some lessons for how to move forward. Like with opioids, the federal government responded to that epidemic by doing next to nothing for many years. But an organized movement led in part by people with H.I.V. and gay activists eventually forced Congress to create and fund new programs. For example, in 1990 Congress approved the Ryan White Care Act, a bipartisan bill that poured billions of dollars into providing treatment and support to people with H.I.V. By 1995, the federal government was spending $3.3 billion a year (about $5.4 billion today after adjusting for inflation) on AIDS efforts, not including billions spent through mandatory programs like Medicaid and Medicare, according to the Kaiser Family Foundation. That was up from just $116 million in 1985.

Though slow to act, Congress eventually treated AIDS as a complex, multidimensional problem and tackled it by funding prevention, treatment, support services and research. Lawmakers provided money to make expensive antiretroviral drugs accessible to more people and allocated money to help house people infected with H.I.V., recognizing that they needed more than just access to drugs.

Lawmakers so far have fallen far short of such a vigorous effort when it comes to opioid addiction. Congress has taken what can be considered only baby steps by appropriating a total of a few billion dollars of discretionary opioid funding in recent years. This funding amounts to a pittance relative to what is needed: substantial long-term funding for prevention, addiction treatment, social services and research. Andrew Kolodny, co-director of opioid policy research at Brandeis University, says at least $6 billion a year is needed for 10 years to set up a nationwide network of clinics and doctors to provide treatment with medicines like buprenorphine and methadone. Those drugs have a proven track record at reducing overdoses and giving people struggling with addiction a shot at a stable life. Today, large parts of the country have few or no clinics that offer medication-assisted treatment, according to an analysis by amfAR, a foundation that funds AIDS research.

Next, lawmakers need to remove regulations restricting access to buprenorphine, an opioid that can be used to get people off stronger drugs like heroin; its use is unlikely to end in an overdose. Doctors who want to prescribe the drug have to go through eight hours of training, and the government limits the number of patients they can treat. These limits have made the drug harder to obtain and created a situation in which it is easier to get the kinds of opioids that caused this crisis than to get medicine that can help addicts. France reduced heroin overdoses by nearly 80 percent by making buprenorphine easily available starting in 1995. Yet many American lawmakers and government officials have resisted removing restrictions on buprenorphine, arguing it replaces one addiction with another. Some of the same people have also stood in the way of wider availability of naloxone, which can help reverse overdoses, and opposed harm-reduction approaches like supervised drug consumption sites, where users can get clean needles and use drugs under the watch of staff who are trained to reverse overdoses.

To stem the number of new opioid users, lawmakers and regulators need to stop pharmaceutical companies from marketing drugs like OxyContin and establish stronger guidelines about how and when doctors can prescribe them. These drugs are often the last resort for people with cancer and other terminal conditions who experience excruciating pain. But they pose a great risk when used to treat the kinds of pain for which there are numerous nonaddictive therapies available. Doctors have been writing fewer opioid prescriptions in recent years, but even the new level is too high.

Some lawmakers have begun to take this epidemic seriously. Senator Elizabeth Warren and Representative Elijah Cummings, both Democrats, recently proposed legislation modeled on the Ryan White Act that would appropriate $100 billion over 10 years for research, treatment and support. While that might seem like a lot, President Trump’s Council of Economic Advisers said in November that the epidemic cost the economy $504 billion in 2015 alone.

Leaders in both parties are responsible for this crisis. Presidents George W. Bush and Barack Obama and members of Congress did too little to stop it in its earlier stages. While Mr. Trump talks a lot about the problem, he seems to have few good ideas for what to do about it. As we’ve learned the hard way, without stronger leadership, the opioid epidemic will continue to wreak havoc across the country.