The opioid disaster has been with us for over 20 years. While it keeps getting worse, the few successful steps against it have dealt with symptoms, not causes. When most governments regard even safe-injection sites as dangerously radical, we're a long way from a real solution.
That said, an avalanche of recent bad news might just exasperate Canadians into taking a truly radical step to stop addiction at its source.
Consider the following reports:
- The B.C. Coroners Service has published its latest grim tally of overdose deaths (125 in January).
- The Canadian Medical Association Journal published guidelines on " Management of opioid use disorders" to help physicians deal more effectively with a rapidly growing public health disaster.
- At the same time, the U.S. Centers for Disease Control and Prevention (CDC) reported that emergency department visits for opioid overdoses rose 30 per cent nationwide between July 2016 and September 2017 in 45 states.
- Overdoses increased by 70 per cent across the Midwest (peaking in Wisconsin with a 109 per cent increase).
So far, so routine. We've been hearing a growing roar of such statistics for years now, and these recent reports don't seem to add much that's new.
A war on drug makers
One report, however, has dropped not just a bombshell but a nuclear warhead on the whole opioid debate. It means Canada and the U.S. should declare an end to the war on drugs — and declare a new war on their makers.
A study published in the Journal of the American Medical Association found that, for many kinds of chronic pain, the kind that doctors prescribe opioids for, over-the-counter painkillers work just as well if not better.
A year-long randomized trial involved 240 patients suffering severe chronic back pain or hip or knee osteoarthritis pain. One group received immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. The other group got acetaminophen or a non-steroidal anti-inflammatory. Those taking non-opioids saw a clear improvement in pain intensity and suffered only half the medication-related symptoms of the opioid takers.
In other words, some simple over-the-counter drugs like Tylenol and ibuprofen were better for such chronic pain than expensive and addictive opioids.
The JAMA report said nothing about other kinds of chronic pain, but that's beside the point. Since 1995, a privately held corporation, Purdue Pharma, has made billions of dollars manufacturing and promoting varieties of oxycodone with a slow-release formula that was originally touted as preventing addiction.
A long article in The New Yorker last year describes how the Sackler family tweaked the formula of oxycodone (first made in Germany a century ago) and turned it into OxyContin. Skilled marketers, the Sacklers pitched doctors on OxyContin's merits, rewarded their top salespeople, and kept close track of "whales" — doctors who were writing huge numbers of OxyContin prescriptions. Those doctors received handsome bonuses.
Much of OxyContin's success was thanks to marketing that presented it as the remedy for relatively minor forms of chronic pain. It might be fine for terminal cancer patients, but they were short-term customers. Someone who'd suffered a back injury on the job would want OxyContin for a long time. If they became addicted, that was their problem. And it was certainly their problem if they crushed the slow-release pills to get an instant hit.
Belated efforts to crack down on over-prescribing quickly backfired: If OxyContin wasn't available, newly created addicts soon turned to the street and to heroin. They created such a huge new demand that fentanyl and then also carfentanil emerged to deliver hits that even heroin couldn't match.
Purdue Pharma has paid hundreds of millions of dollars to settle lawsuits; given the billions that it's raked in, those settlements look like an acceptable cost of doing business.
Counting the human costs
But consider the cost to others, both in the U.S. and Canada. Thousands of doctors have been ethically compromised, duped or bribed into harming their patients and turning those patients into an enormous market for drugs even worse than OxyContin.
Thousands of first responders — firefighters, paramedics, and cops — have endured stress, burnout and PTSD trying to save people addicted to opioids. Taxpayers are covering the costs of caring for both addicts and first responders, not to mention their very stressed families.
Opioids also drive the need for more funding for courts and jails and prisons and detox centres and rehab programs as well as the people who staff them. Money that might have gone into housing or transit or job training goes instead into trying to keep people alive until the next overdose.
In effect, we are subsidizing the profits of families like the Sacklers, who use those profits to defend themselves against still more lawsuits from states, counties and cities.
A generation lost to deaths of despair
It's even worse than that. Starting 20 years ago, life expectancies of white Americans born in the 1960s levelled off and even began to fall. Meanwhile, the same cohort of Canadians was continuing to thrive, living longer than anyone but their Swedish and Australian contemporaries.
Anne Case and Angus Deaton, the researchers who tracked this strange decline, identified the causes: "Suicide, drug and alcohol poisoning… and chronic diseases and cirrhosis." They called it an "epidemic of pain, suicide, and drug overdoses," a surge in "deaths of despair."
In effect, Big Pharma has gorged itself at the expense of millions of Americans' lives, as well as those of 125 Vancouverites this recent January alone. Lawsuits, fines and even convicting a few senior executives don't begin to balance the scales or even to deter other drug companies.
But we in Canada might obtain some kind of justice, forestall the harm the U.S. has suffered and temper the greed of Big Pharma, by expropriating Purdue Pharma (Canada) and making it a Crown corporation.
In the Second World War, the Canadian and U.S. governments effectively took over the whole economy. They set prices, rationed goods and told corporations what to make (tanks, not cars, for example). And that was early in the war before either country had suffered anything like the casualties we now endure year after year due to opioids.
A nationalized Canadian pharmaceutical producer would develop drugs under much closer inspection and would sell them for much lower prices. It could invest in medicines based on the need for them, not for their profitability. Working closely with health care experts, the Crown corporation would spot adverse effects and take prompt steps to deal with them.
Other drug companies would have to compete on the Crown corporation's prices while meeting its standards. Failure to do so would mean rapid expropriation.
Drugs like heroin and cocaine would be produced solely by the Crown corporation. This monopoly would continue in the event of decriminalization or legalization, ensuring uncontaminated drugs at reasonable prices.
Profits would go chiefly to funding prevention and rehabilitation programs in an effort to help those presently addicted while discouraging others from getting started.
Such a measure would not solve all our addiction problems. But it would be a step in the right direction. Fewer Canadians would become addicted and fewer would die. First responders could go back to fighting fires and saving heart-attack cases. The economic and social burdens of addiction would begin to lift.
So far, all we've done is to reward Big Pharma while criminalizing and imprisoning many of its customers (half a million in the U.S.). The U.S. is unlikely to change this state of affairs, no matter how many deaths of despair it inflicts. But Canadians should have the good sense and political will to ditch such a futile policy and cut off the real source of our opioid disaster.
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