Someone you know uses opioids to manage their pain. You probably don’t know who they are, because the use of these drugs carries a stigma almost as strong as the American aversion to pain and illness.
One out of every five American adults lives with a chronic pain condition. For many of these patients, the arrival of effective, safe, opioid-based treatments like OxyContin was a lifesaver, allowing them to continue to hold down a job, enjoy their families and experience life in ways otherwise impossible. Without these drugs, life with chronic pain tended to be lonely, impoverished and short.
These drugs are highly addictive. For chronic pain patients, the risk of addiction was of little concern. How much do we worry about diabetics becoming “dependent” on insulin? A drug that restores the capacity of millions of pain patients to resume something approaching a normal life is a miracle.
In America, miracles aren’t free. Unfortunately, OxyContin and related drugs weren’t merely prescribed to chronic pain patients. The Sackler family and their company, Perdue, lied about the addictive properties of their new product to reach the broadest possible market. They bribed doctors and deceived regulators to push their drug to injured high school athletes, people recovering from minor surgeries, even to patients with ordinary aches and pains.
What followed has been a classic American story of grift, inspiring a campaign of righteous zealotry. A lifesaving breakthrough for chronic pain patients quickly became an epidemic of addiction. Our uniquely American attitudes toward illness, drugs and addiction turned that epidemic into needless carnage that hasn’t yet peaked.
Who is bearing the brunt of this nightmare? Chronic pain patients who briefly saw some hope are now treated like criminals, struggling to maintain the most basic access to health care in a system where their doctors have been replaced with glorified probation officers. The slightest misstep and they will be plunged back into persistent pain, combined with the horrors of withdrawal; effectively routing them into the arms of America’s health care black market.
How did we get here and why has opioid addiction been such a uniquely American disaster?
In general, Americans are very sick people. Access to health care here depends on access to a good paying job. Illness or injury regularly cuts off or degrades that access, creating an accelerating cycle of illness and associated pain. Struggling to maintain a job through a health condition can turn a treatable acute issue into a chronic one. Our exclusionary, for-profit healthcare system, the only one in the world, is set up to treat empirically identifiable illnesses that fit a “standard of care” flowchart. It will only do this for people fortunate enough to maintain good quality insurance.
Chronic pain conditions often elude empirical “proof.” Pain doesn’t show up on a CAT scan. It can’t be quantified and compared. Pain can’t be validated or invalidated with a blood test or exam. Our system is biased to disregard pain, because that system struggles to deal with conditions for which no known empirical detection or clear treatment exist. This is a nightmare for patients with a chronic pain condition.
Making matters worse, roughly 20% of Americans suffer from an auto-immune disorder, many of which like lupus, fibromyalgia, interstitial cystitis and rheumatoid arthritis, cause terrible pain. No curative treatments are available, only a collection of drugs with worrisome side effects and questionable effectiveness. Diagnosis of these conditions is murky and subjective. The very definition of many of these illnesses is open for debate. A cancer patient can point their doctor to a mass on a CAT scan to prove their “worthiness” for treatment and explain their pain. Auto-immune or chronic pain patients have no such empirical flag to wave to validate their claims.
For many of these patients, a new class of opioid based painkillers opened their lives in ways never before possible. Contrary to the popular narrative, drugs like OxyContin were safe and remarkably effective, allowing many of these patients to resume life activities they’d imagined were lost.
Perdue and the Sacklers weren’t satisfied with the money they could make selling to patients who needed their pills. They aggressively lied about the addictiveness of OxyContin while bribing doctors to prescribe as much as possible. What followed was a wave of addiction. When doctors recognized what was happening to their patients and withdrew treatment, millions of former OxyContin users were left with a problem more persistent than their pain, addiction. With no formal treatment available they turned to the only relief they could find, illegal heroin or fentanyl.
When the harm became apparent, the American public responded with its usual War On Drugs narrative. The Sacklers have been shamed and punished. New state and federal regulations have made the process of prescribing opioid drugs a career-threatening gamble for doctors and a misery for patients. The results?
By last year the volume of opioids prescribed had plummeted by half from its peak around 2012. Meanwhile, deaths from opioids more than doubled. More than 50,000 Americans died from an opioid overdose in 2019. That same year, 31,000 died from car accidents and 45,000 died in gun incidents. Last year, opioid overdose deaths topped 70,000, a 23% increase from the previous year.
Why are more people dying from a drug that’s become less available? Because the drug wasn’t killing people. People rarely die from taking these drugs as prescribed, under the care of a doctor. Contrary to the popular narrative, they are safe and remarkably effective, especially for chronic pain. Opioid patients most commonly die when they lose their access to safe healthcare and are forced to pursue unsafe treatments like heroin or other blackmarket drugs.
In typical American fashion, our paranoid response to the opioid crisis has killed tens of thousands of patients while making life needlessly miserable for those still struggling to maintain legal access to pain treatment. Our popular narrative blames our epidemic of opioid deaths on a deadly drug sold by evil drug dealers. Good, honest people avoid this horror by protecting their bodies from the exotic temptations of mild-altering chemicals. That narrative is a lie. Our response to the mayhem unleashed by the Sacklers has been a completely unnecessary reign of death, premised on bizarre, almost religious myths about “drugs” and “addiction.” It did not have to be this way.
These same opioid painkillers are broadly used across the developed world with nothing remotely approaching the carnage seen in the US. OxyContin is not the problem. Fentanyl is not the problem. “Drug abusers” aren’t the problem. The problem is a broken health care system that rises from increasingly dystopian politics. Politics is always a matter of life and death.
For comparison, opioids, including OxyContin, began to be widely prescribed in Germany at about the same time as in the US, in the late 90’s. By the late teens, Germany was second to the US in the volume of opioids prescribed, with the highly addictive and powerful fentanyl among the most commonly prescribed varieties. In 2016, approximately 800 people died of opioid overdoses in Germany. The figure for the US that year topped 40,000 for the first time.
What’s going on? If opioids like OxyContin can be used safely, why are these drugs killing so many Americans?
One key fact helps explain the death toll from the opioid crisis and the difference in outcomes between the US and the rest of the world. Patients very rarely die from taking a prescribed dose of OxyContin or other opioid drugs. Almost always, deaths occur when patients lose their access to these medications and are forced to treat their pain or manage their addiction without medical assistance. In some cases that means buying and/or misusing pills purchased from street dealers, pills often laced or adulterated. Or in the worst cases, death comes when patients must treat their condition using traditional street drugs like heroin.
While everyone’s story contains some unique features, two main paths to opioid death emerge from the data. The first comes from patients with an acute condition, like a broken bone, who are improperly prescribed powerful painkillers like OxyContin. The second are chronic pain patients who struggle to maintain access to health insurance or prescription access. In both scenarios, death most commonly comes when they can no longer obtain safe prescription drugs.
Cameron Weiss’s story is typical of the first category. He was a high school football player in Albuquerque. After an injury in 2010, he was prescribed the opioid, hydrocodone. His injuries healed, but he was left with an addiction. With a maze of regulatory obstacles to obtaining an effective treatment it was a struggle to fight through withdrawals. His only dependable avenue to fend off devastating withdrawal was heroin obtained illegally.
He died of a heroin overdose at 18. He bought the drugs that killed him from a dealer he met while jailed on drug charges.
Adam Lovota epitomizes the other main path to addiction. He was diagnosed with the chronic pain condition, lupus, at age 19. Pain from lupus, like that from fibromyalgia, multiple sclerosis and many other chronic pain conditions, doesn’t respond to most common painkillers. Lovota was able to manage his condition with opioids.
Doctors cut off his access to his pain medication when a drug test showed he had once taken a friend’s ADHD medication. Then, racked with both pain and addiction, he was forced to manage his condition with whatever drugs he could obtain illegally, eventually becoming addicted to fentanyl. Twelve years later he’s in rehab, disabled, battling addiction with methadone treatments while still unable to obtain medication to dim his persistent, untreated pain.
One other story demonstrates a troubling dimension of this problem. In January 2020, Joseph Fenner died alone in the cab of his truck of an apparent heroin overdose. He had stopped for the night at a TA truck stop in West Virginia while delivering a load. Fenner is probably the single most representative face of our opioid disaster, its causes and effects. Like the largest bulk of opioid users, he was using the drug to work.
Workers in physically punishing jobs like construction, mining and agriculture face an outsized risk of opioid overdose. Painful, often chronic injuries threaten their livelihood. Stripped of union protections, with only the most tenuous access to health insurance, missing work can not only lead to financial disaster but cut off all access to health care.
Opioid drugs help them continue to function, a detail often overlooked in stories about addiction. Many opioid users depend on the drug to maintain their ability to work. When their access to safe opioids is stripped away, illegal drugs are the lifeline protecting their families’ livelihoods.
Why doesn’t this happen in Germany, France, Japan or other developed countries?
For patients who need access to painkillers, the American public’s sanctimonious response to a wave of opioid deaths has threatened their lives. All Germans have access to health care. No one there gets dropped onto the American Wheel of Pain, in which you need painkillers to continue performing a job which provides the health insurance which protects your access to painkillers.
In Germany or Japan, pharma reps who tried to bribe a doctor on the scale carried out in public by Perdue and the Sacklers would go to prison. The degree of access these pharma reps were granted to US patients would be unthinkable in a developed country. Though Germans use prescription opioids at levels just behind the US, they do not hand them out to acute pain patients. And when a chronic pain patient develops an addiction, they don’t lose their access to medication. Patients who develop a dependency aren’t criminalized and thrown away.
No developed country would pursue policies so stupid as to cut off drug access to patients who need treatment merely because they’ve developed dependence, a move which virtually invites them to become heroin addicts.
Today in the US, millions of patients with painful conditions like lupus, fibromyalgia or the nightmarish bladder condition interstitial cystitis, can no longer be treated under the supervision of their doctor. Their pain medications can only be prescribed through a narrow network of “pain specialists” carefully supervised by the DEA. Ironically, the pain clinic “pill mills” fed by Perdue which the DEA fought so hard to combat have been co-opted into the healthcare system by the DEA. With their care now under the control of the DEA, their doctor now functions as a probation officer. Their pills are closely counted. Prescription refills can be like a visit to a bank vault.
Pain is not empirical. It cannot be measured or proven. Thus all chronic pain patients requesting treatment must somehow prove they are not criminal “drug-seekers.” Where five years ago they could visit a doctor who knew them, their lives and their condition in detail, chronic pain patients must now visit a specialized prescriber each month, pee in a cup to show they haven’t been naughty, and approach their so-called “doctor” like a parole board, hoping to earn one more month of reprieve from their condition. Pain doctors can and do cut off patients for any reason, or none at all.
In most states, if your prescription is lost or stolen it cannot be replaced. Have that happen during the first week of a month’s prescription and a stark choice awaits. Buy drugs illegally so that you can continue to work, risking death from overdose or other issues. Or be plunged into weeks of withdrawals, with no assistance, robbing your ability to work and risking your health insurance.
Strip away the righteous panic over opioids and tens of thousands of dead Americans would be alive in our midst. Replace our utterly bizarre healthcare system in which a job is necessary for access to care with almost any of the dozens of cheaper, successful systems elsewhere in the world, and tens of thousands of dead Americans would still be alive. If pharma reps couldn’t buy Congress, regulators, and local doctors, we would save lives. If medical and scientific expertise was given the power to thwart greed, we would save lives. If our sanctimonious religious panic over “DRUGS!!!” was blocked from distorting medical decisions, we would save lives. We don’t seem to care.
Americans think you solve homelessness by forcing vagrants off the sidewalk. We think you solve drug addiction by harassing addicts and arresting dealers. Americans see the world in terms of good and bad, success and failure, achievers and losers. That approach fails because it’s a poor model of reality.
Illness frightens Americans because it exposes the lie at the heart of our most cherished myth. We see the world in individual terms, assigning success and failure to personal choices and characteristics. But everyone gets sick. Everyone. Health eventually fails everyone. No one recovers from an illness on their own. When we’re sick, weak, sad, compromised or vulnerable, resilience comes from the strength of our community.
Americans see sickness as a failure of personal virtue, a consequence of poor choices. That perverse distortion sits at the root of America’s status as the rich world’s sickest people.
Being sick threatens the ability to contribute to the economy, which undermines the only value cherished in American life. People die in the US from health conditions that would barely merit a thought elsewhere in the world, thanks to our for-profit healthcare system, powerful pharma lobby and public indifference. Hundreds of thousands of completely avoidable opioid deaths demonstrate the reality that the US is the land of No Lives Matter.