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The lethal side effects of greed...

The opiate epidemic had its origins in the mid-1990s when there were assertions that doctors were inadequately addressing pain and opiates – which were previously reserved for end of life care and acute pain.

Various pharmaceutical companies seized upon that opportunity by marketing medications aggressively.

Between the mid-1990s to 2010, there was a 5-10-fold increase in opiate prescribing.

Unlike previous drug problems in the past, this epidemic did not begin on the streets via narcotic traffickers or illegal laboratories. It began at the heart of America’s corporate and medical establishment.

Many Americans start out on prescription medications for pain relief. But when they can no longer get them via their doctor, they move onto illegal drugs.

These include opiate pills being sold on the street and heroin. These drugs are often laced with fentanyl, a powerful synthetic opioid that’s behind the sharp rise in overdoses.

"We go see the doctors to get our pills…It’s easily accessible. If you just show up down there and say ‘hey I have a back injury’, they pretty much prescribe you whatever you want." — Anonymous, Huntington, West Virginia.

The initial promotion and marketing of OxyContin was an organized effort throughout 1996–2001, to dismiss the risk of opioid addiction.

Purdue Pharma hosted over forty promotional conferences at three select locations in the southwest and southeast of the United States.

Coupling a convincing "Partners Against Pain" campaign with an incentivized bonus system, Purdue trained its salesforce to convey the message that the risk of addiction was under one percent, ultimately influencing the prescribing habits of the medical professionals that attended these conferences.

Purdue Pharma published a video titled "I got my life back" stating that Oxycontin is a safe, non-addictive long-term chronic pain reliever.

Of the six featured patients in this video, two are now deceased for reasons relating to their opioid addiction.

             

"It all started with the pills. I was in a motorcycle wreck and I then started with the doctor first. I was on Roxi 15s, two a day, and I eventually ended up taking heroin"

In 2007, Purdue Pharma, the company that makes the painkiller OxyContin and three of its current and former executives pleaded guilty in federal court to criminal charges that it had misled doctors and patients when it claimed the drug was less likely to be abused than traditional narcotics.

That claim became the linchpin of an aggressive marketing campaign that helped the company sell over $1 billion worth of OxyContin a year.

Purdue Pharma, based in Stamford, Conn., heavily promoted OxyContin to doctors like general practitioners, who often had little training in treating serious pain or in recognizing signs of drug abuse.

By 2000, parts of the United States, particularly rural areas, began to see soaring rates of addiction and crime related to use of the drug.

John L. Brownlee, the United States attorney for the Western District of Virginia, said the impact of Purdue’s marketing of OxyContin had resulted in rising crime rates, teenage drug addiction, deaths and other problems.

OxyContin abuse became so widespread that the drug was dubbed "hillbilly heroin."

The three men — Michael Friedman, the president; Howard R. Udell, its top lawyer; and Dr. Paul D. Goldenheim, its former medical director — led Purdue at the time of the crimes.

perdue-execs

Prosecutors decided to investigate Purdue Pharma after bringing cases against drug addicts as well as local doctors accused of illegally prescribing the drug.

In 2007, Purdue paid $600 million in fines after being prosecuted for making false claims about the risk of drug abuse associated with oxycodone.

Today, the largest distributors are Cardinal Health, McKesson and Amerisource Bergen.

 

In 2010, there was a rapid increase in deaths from heroin abuse.

As early efforts to decrease opioid prescribing began to take effect, making prescription opioids harder to obtain, the focus turned to heroin, a cheap, widely available, and potent illegal opioid.

Deaths due to heroin-related overdose increased by 286% from 2002 to 2013, and approximately 80% of heroin users admitted to misusing prescription opioids before turning to heroin.

Heroin is commonly injected, which puts users at risk for injection-related diseases like HIV/AIDS, hepatitis B and C, skin infections, bloodstream infections, and infections of the heart.

In 2013 as an increase in deaths related to synthetic opioids like fentanyl. The sharpest rise in drug-related deaths occurred in 2016 with over 20,000 deaths from fentanyl and related drugs.

The increase in fentanyl deaths has been linked to illicitly manufactured fentanyl (not diverted medical fentanyl) used to replace or adulterate other drugs of abuse.

"The opioid crisis was allowed to spread aided by Congress, lobbyists, and a drug distribution industry that shipped hundreds of millions of pills to rogue pain clinics providing the rocket fuel for a crisis that has claimed 200,000 lives" — Joe Rannazzi, ex head of the DEA’s Office of Divisional Control.

Current effects to prevent overprescribing have been met with a lot of pushback from the pharmaceutical industry.

They rationalize that the billions of dollars they are making means that they are helping more people than they are harming.

They insist that only those who are diverting and misusing their drugs to get high are responsible for the epidemic and not those that are legitimately prescribed the drugs.

"I would just wish the pharmaceutical companies would say ‘we’ll come in and we’ll partner with you to fight this epidemic’, rather than spending their time saying ‘it’s not our fault’." — Steve Williams, Mayor of Huntington City, West Virginia.

Bigphama - one of the most powerful lobbying groups in Washington, hands out millions to politicians on each side of the political divide.

"The structure of the US healthcare system, in which people not qualifying for government programs are required to obtain private insurance, favors prescribing drugs over expensive therapies. Most insurance, especially for poor people, won't pay for anything but a pill." — Professor Judith Feinberg from the West Virginia University School of Medicine.

When legal sources of opiates dry up, addicts turn to street heroin. North America's dominant trafficking group is Mexico's Sinaloa Cartel, which has been linked to 80 percent of the fentanyl seized in New York.

In 2016, over 64,000 Americans died from overdoses, 21 percent more than the almost 53,000 in 2015. By comparison, the figure was 16,000 in 2010, and 4,000 in 1999.

Over 500,000 Americans have died from an overdose.

More than have died on the battlefield since World War II.

Every day 140 people in the U.S die from an opiate overdose.

Life expectancy in 2016 fell 0.1 years to 78.6, according to the National Center for Health Statistics. It was the first consecutive drop since 1962-63. The last two-year decline before that was in the 1920s.

A "pill mill" is a clinic that dispenses narcotics to patients without a legitimate medical purpose.

This is done at clinics and doctors offices, where doctors examine patients extremely quickly with a purpose of prescribing painkillers.

These clinics often charge an office fee of $200 to $400 and can see up to 60 patients a day, which is very profitable for the clinic. Pill mills are also large suppliers of the illegal painkiller black markets on the streets.

250 pill mills in Florida were shut down in 2015. Florida clinics also are no longer allowed to dispense painkillers directly from their clinics, which has helped reduce the distribution of prescription opiates.

Since the implementation of pill mill laws and drug monitoring programs in Florida, high-risk patients (defined as those who use both benzodiazepines and opioids, those who have been using high opioid doses for extended periods of time, or "opioid shoppers" that obtain their opioid painkillers from multiple sources) have shown significant reductions in opioid use.

The opiate epidemic has ravished the workforce in the US. There have been over 63,600 deaths from overdoses in 2016.

Numbers increase as addicts switch to opiates from unreliable sources.

US Midwest states saw the highest jump in misuse – including Wisconsin, Indiana, Missouri and Ohio.

This has had a huge impact on the economy – because this problem is found mostly in Americans of prime working age.

Addiction is now keeping significant numbers of them out of the workforce. It’s costing the country dearly in lost wages and productivity.

Between 90,000-170,000 people abuse opiates in Ohio. This costs the economy around $6.6-$8.8 billion annually. The cost to the entire US has reached £500 billion.

Much of that is because opiate addiction is highest amongst people of working age.

The labor pool is shrinking. Even when people are hired, many lose their jobs because they are testing positive for opiates after undergoing a random drug test.

Huntington, West Virginia has 10 times more overdose deaths than the national average.

More than 1 in 10 babies in Huntington are born suffering from the symptoms of opiate withdrawal.

"Huntington is a town of just 50,000 people, yet over a 5 year period, there were over 40 million doses of opiates that were distributed across this county alone. Rather than going to the taxpayer of my community and saying ‘we need to raise your taxes so that we can fight this epidemic’, we need to go to those who are complicit in causing the epidemic, and they need to be held accountable" — Steve Williams, Mayor of Huntington City, West Virginia.

Huntington Fire Department is under strain because of the opioid epidemic.

"Most of our callouts now are for drugs. They probably make up around a third of our calls. Fires generally make up around 10-15 percent of our calls" — Michael Smith – Lutenant at Huntington Fire Department.
"One of the truly terrifying things is the pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, that is an overdose waiting to happen. Each of those pills is a potential overdose death."
— Carole Rendon, the acting US attorney for the northern district of Ohio in Cleveland.

Fentanyl, a newer synthetic opioid painkiller, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin, with only 2 mg becoming a lethal dose.

It is pure white, odorless and flavorless, with a potency strong enough that police and first responders helping overdose victims have themselves overdosed by simply touching or inhaling a small amount.

As a result, the DEA has recommended that officers not field test drugs if fentanyl is suspected, but instead collect and send samples to a laboratory for analysis.

Over a two year period, close to $800 million worth of fentanyl pills were illegally sold online to the U.S. by Chinese distributors.

The drug is usually manufactured in China, then shipped to Mexico where it is processed and packaged, which is then smuggled into the U.S. by drug cartels.

As overdose deaths involving heroin more than quadrupled since 2010, what was a slow stream of illicit fentanyl, a synthetic opioid 50 to 100 times stronger than morphine, is now a flood, with the amount of the powerful drug seized by law enforcement increasing dramatically. America is awash in opioids; urgent action is critical.

Those taking fentanyl-laced heroin are more likely to overdose because they do not know they also are ingesting the more powerful drug.

The most high-profile death involving an accidental overdose of fentanyl was singer Prince.

According to the DEA, one kg of fentanyl can be bought in China for $3,000 to $5,000, and then smuggled into the United States by mail or Mexican drug cartels to generate over $1.5 million in revenue.

The profitability of this drug has led dealers to adulterate other drugs with fentanyl without the knowledge of the drug user.

Lethal doses of Fentanyl and Carfentanil relative to a lethal dose of Heroin.

In 2013, a new threat surfaced on Capitol Hill. With the help of members of Congress, the drug industry began to quietly pave the way for legislation that essentially would strip the DEA of its most potent tool in fighting the spread of dangerous narcotics.

Distributors are required under the Controlled Substances Act to report and stop what the DEA calls "suspicious orders" -- such as unusually large or frequent shipments of opioids.   But many distributors ignored that requirement. One example: a pharmacy in Kermit, West Virginia, a town of just 392 people, ordered nine million hydrocodone pills over two years.   The companies cried foul and complained to Congress that DEA regulations were vague and the agency was treating them like a foreign drug cartel.

A parade of DEA lawyers switch sides and jump to high-paying jobs defending the drug industry. Once they'd made the leap, they lobbied their former colleagues.

The bill that stripped the DEA of its ability to stop distributors was introduced in the House by Pennsylvania Congressman Tom Marino and Congresswoman Marsha Blackburn of Tennessee.

The pretence of the bill was that it aimed to ensure that patients had access to the pain medication they needed.

What the bill really did was strip the agency of its ability to immediately freeze suspicious shipments of prescription narcotics to keep drugs off U.S. streets.

"I just don't understand why Congress would pass a bill that strips us of our authority in the height of an opioid epidemic in places like Congressman Marino's district and Congressman Blackburn's district.

Why are these people sponsoring bills, when people in their backyards are dying from drugs that are coming from the same people that these bills are protecting?

Because I think that the drug industry -- the manufacturers, wholesalers, distributors and chain drugstores -- have an influence over Congress that has never been seen before. "

— Joe Rannazzi, ex head of the DEA’s Office of Divisional Control.
In Oct 2017, President Trump called the opiate epidemic a ‘national shame’ and declared it a public health emergency.

Trump previously promised to declare a state of national emergency.

Instead, he has merely declared a public health emergency, which is seen by many as a short-term measure that doesn’t allocate enough money.

More investment is needed for rehab and treatment.

Many are now looking a Congress to secure more money to deal with this crisis.

Experts urged Trump to use powers under the Stafford Act to declare a national emergency. States could then gain access to the Federal Disaster Relief Fund – which is used to rebuild areas affected by fires or hurricanes.

Trump's declaration merely relies on shifting existing funds, rather than putting up the extra money that state officials say is critical for a comprehensive response to the drug epidemic.

Drug overdoses now kill more people than traffic crashes or gun-related deaths. Also, there are fears this epidemic could set off a wave of new HIV/AIDs infections.

Many are concerned because Trump’s move means funding will be redirected away from other programs such as those that are set up to prevent HIV, and it’s ironically those affected by the opioid crisis who are most likely to benefit from HIV-prevention initiatives.

"It’s not even robbing Peter to pay Paul anymore. It’s robbing Peter to pay Peter"
— Tiffany Kaszuba, deputy director of the Coalition for Health Funding.

Trump's pick for drug czar – Tom Marine – withdrew his nomination because he pushed the bill outlined above through that stripped the DEA of its ability to seize suspicious painkiller shipments. He also helped force out a DEA official who was taking on distributors of opiate pills.

"Millions depend on Medicaid for opiate treatment. Trump’s solution is to cut Medicaid by $1 trillion. That’s a disgrace."
— Senator Bernie Sanders.

On January 17, 2018, several senators, including New Hampshire Senator Maggie Hassan, wrote a letter to President Trump expressing extreme concern regarding his lack of commitment to the White House Office of Nation Drug Control Policy (ONDCP).

The ONDCP plays a critical role in coordinating the federal government's response to the fentanyl, heroin, and opioid epidemic.

"You show me in the past a national public health emergency declaration with no accompanying funding or even request for funds and I’ll be surprised" — Andrew Kessler, Slingshot Solutions.

The letter states that the ONDCP and DEA (Drug Enforcement Administration) have both been without permanent, Senate-confirmed leadership since Trump took office.

Trump has not presented the Senate with qualified candidates for these positions.

The senators requested that Trump provide their offices with a list of his political appointees to key drug policy positions and those appointees' relevant qualifications, including appointees at ONDCP; the Department of Justice, including the DEA; the Substance Abuse and Mental Health Services Administration (SAMHSA); and elsewhere in his administration.

"The lack of resources is concerning to us since the opioid epidemic presents lots of challenges for State budgets – we hope people will realise that with no money the ball is going to be in Congress’s court" — Michael Fraser, executive director of the Association of State and Territorial Health Affairs.

The Department of Labor will be able to give funding to states for workers affected by the epidemic if funds are available.



However, the Trump Administration is proposing to cut dislocated workers grants by 40%

Trump's measures do not address access to emergency overdose treatment naloxone. The price of naloxone has soured, meaning it is difficult for cash-strapped emergency departments to stock it

Additional funding to address the opioid epidemic has widespread bipartisan support among the electorate. Sixty-nine percent of all registered voters said they support increasing funding to help solve opioid abuse, while 17 percent said they oppose additional money.

Broken down by political party, 77 percent of Democrats, as well as 65 percent of independents and Republicans said they support more funding to address opioid abuse.

Acting on the opioid epidemic could have been an easy win. It’s an issue that crosses partisan lines, with both Democrats and Republicans angling to do something about it. There’s evidence it’s very relevant to Trump’s own base.

"Recommendations and declarations on their own don’t save lives." — Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse.

The opioid commission released two sets of proposals in 2017. Trump reacted to the first set of preliminary proposals by declaring a public health emergency over the crisis, which was the commission’s top recommendation at the time.

But the Trump administration has done very little, at least publicly, about the broader final set of 56 proposals — which generally focused on expanding access to addiction treatment by, for example, streamlining federal funding for drug addiction.

Trump announced a vague plan to confront the opioid crisis in March 2018. But instead of taking up the commission’s largely public health-oriented proposals, Trump’s plan focuses largely on harsher criminal justice measures, including a scheme to use the death penalty more often for drug traffickers — which the commission did not recommend.

Experts are deeply skeptical that any effort to beef up border security, including Trump’s wall, would do much, if anything, to stop the flow of drugs into the US.

Trump’s plan also made some ambiguous promises to encourage fewer opioid painkiller prescriptions and scale up addiction treatment.

If you ask experts, they have a fairly good idea of what’s needed to combat the opioid crisis: more treatment (particularly medications like methadone and buprenorphine), more harm reduction (including better access to the opioid overdose antidote naloxone), fewer painkiller prescriptions (while ensuring the drugs are available to those who really need them), and policies that can help address the root cause of addiction (like mental health issues and socioeconomic despair).

"In the 20-year conflict in Vietnam we lost 44,000 Americans. We’re losing that number every year from opioids. Trump’s response is kind of like pointing at a burning building and then not calling the fire department and watching it burn to the ground." — Andrew Kolodny, Co-Director, Opioid Policy Research, Heller School, Brandeis University.

In his proposals, Trump has also tried to cut the budget for the Office of National Drug Control Policy by 95 percent — a move that his team initially walked back after facing bipartisan opposition during last year’s budget talks but reportedly may try again this year.

And the administration supported the repeal of the Affordable Care Act, which experts credit with expanding access to addiction treatment.

"Because we can have all the blue ribbon committees we want, but if we don’t get tough on the drug dealers, we’re wasting our time. Just remember that. We’re wasting our time. And that toughness includes the death penalty."
— President Donald Trump.

"Greater criminalization would be not only ineffective but actually harmful."

— Sarah Wakeman, medical director at the Massachusetts General Hospital Substance Use Disorder Initiative.

STAT forecast that as many as 650,000 people will die within the next decade — the equivalent of the entire population of Baltimore.

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