The Opioid Tragedy, Part 1: ‘We’ve Addicted an Entire Generation’

How pharma greed, government subsidies, and a push to make pain the “fifth vital sign” kicked off a crisis that costs $80 billion a year and has killed hundreds of thousands of Americans

Oxycodone pain pills prescribed for a patient with chronic pain lie on display
Oxycodone pain pills prescribed for a patient with chronic pain. Photo: John Moore/Getty Images

The U.S. is in the throes of a full-blown crisis of opioid overuse, abuse, damage, and death. As far back as 2006, federal health institutes flagged what they called “disturbing data about a spike in opioid addictions. But the message didn’t seem to get through. Prescriptions for opioids continued to rise, and during the Obama administration, opioid abuse was declared an epidemic. The crisis has persisted under the Trump administration.

The good news is that overdose deaths have finally stopped increasing, for the first time since 1990. Still, tens of thousands of people each year are dying from opioids — especially the street drugs heroin and synthetic fentanyl but also prescription painkillers like Oxycontin, Percocet, and Vicodin. Aside from the loss of life and the broken families, consider the economic cost of prescription-opioid abuse. The Centers for Disease Control and Prevention recently put that number at nearly $80 billion a year, once you add up the costs of health care, addiction treatment, lost productivity, and policing and imprisonment.

How did we get here? And what does the complicated dance between supply and demand have to do with the opioid crisis?

When it comes to opioid addiction, Dr. Jeanmarie Perrone of the University of Pennsylvania is one of the most active researchers and practitioners around. Perrone runs a medical toxicology and addiction department in the University of Pennsylvania’s medical system, which means she’s an ER doctor as well as a professor and researcher.

The University of Pennsylvania medical center is in Philadelphia, which has a particularly high rate of opioid abuse. In one recent year, for instance, twice as many people died in Philadelphia from drug overdose — most involving opioids — as from homicide. The city’s health department estimates that some 75,000 Philadelphians are addicted to heroin or other opioids: That’s nearly 5% of the population. Perrone has seen the opioid crisis happen in real time.

“In the beginning, between 2000 and 2008, what we saw was the result of doctor overprescribing,” Perrone says. “And then as a result, in the emergency departments, we would see patients coming in for something like a migraine headache requesting IV doses of an opioid, and not just requesting IV doses but repeated doses. And we were operating under this paradigm that if they still said they had 10 out of 10 pain, we still needed to give them intravenous opioids.”

According to Perrone, that pain paradigm was the result of medical advisory boards and the Joint Commission, the medical-accreditation agency, pushing doctors to adopt pain as a new vital sign. In retrospect, this is an obviously problematic idea. For one thing, it’s hard to reliably measure pain, and especially hard to measure it consistently across patients, the way you can measure the standard vital signs like blood pressure or heart rate. There’s also the fact that painkillers are, by their nature, a desirable medication — they literally make your pain stop — so you can imagine patients demanding them a bit more adamantly than they’d demand, say, a statin or an ACE inhibitor.

Advocacy organizations like the American Pain Foundation and the American Pain Society, funded by the pharmaceutical industry, were also pushing for a more liberal use of opioids. It was the American Pain Society that trademarked the phrase “Pain: The Fifth Vital Sign.” In one of the many opioid lawsuits now underway, the American Pain Society was called a “front group defendant” — that is, a front group for the pharmaceutical companies whose products they promoted, even though the Society presented itself as a professional medical membership organization with an academic thrust.

One of the pharmaceutical companies funding these groups was Purdue Pharma. It was Purdue that brought Oxycontin to market in the 1990s, when pain was being pushed as the fifth vital sign. Oxycontin, a time-released version of an older opioid called oxycodone, was aggressively marketed as a potential solution to the problem that had plagued older opioids like oxycodone, hydrocodone, and synthetic fentanyl: They are addictive and therefore potentially dangerous. Purdue suggested that Oxycontin “might” be less addictive than other opioids, a claim the FDA allowed despite a lack of evidence. And the claim worked, at least from a sales perspective: In 1996, Purdue sold $48 million worth of Oxycontin; just four years later, they sold $1.1 billion worth.

But Oxycontin did not turn out to be non-addictive. According to Alicia Sasser Modestino, a health economist at Northeastern University in Boston, the opioid crisis has occurred in three distinct waves.

“The first wave began with the increased prescribing of opioids in the 1990s, with overdose deaths that involve prescription opioids increasing since at least 1999 [or] 2000,” Modestino says.

Wave number two consisted of heroin-overdose deaths. As doctors realized how dangerous prescription opioids were and started de-prescribing, some users who’d become addicted started to buy heroin. It turns out that roughly 80% of Americans who use heroin started down the path with prescription opioids. And that path was laid by the promiscuous dispensation of prescription opioids in hospitals and doctors’ offices.

Jeanmarie Perrone at UPenn did one study, starting in 2011, that looked at patients who’d gone to the ER for a sprained ankle. She and her collaborators found that 40% of those patients got an opioid prescription of 10 to 30 tablets. Patients prescribed a 30-day supply had a 30% risk of still being on opioids six months later; those who got 10 to 12 pills had a 6% chance.

“The more you get exposed, the more likely you are to create this default in your mind that, you know, acetaminophen or ibuprofen don’t work for me,” Perrone says. “I really do better with oxycodone.”

The medical establishment did eventually start scaling back, and the rate of opioid prescribing has been falling steadily since its peak in 2012. The CDC has issued guidelines that recommend the lowest effective dose of opioids — if any at all; many states and hospital networks now limit the number and potency of pain pills that are dispensed to patients. Deaths from prescription opioids have at least leveled off. And, more recently, heroin deaths have also plateaued. Unfortunately, wave number three had already arrived by the time these changes were implemented

“The third wave began in 2013, when we saw significant increases in overdose deaths involving synthetic opioids,” Modestino says. “And so those are things like fentanyl. And the thing that’s very distinct between heroin and fentanyl is how powerful fentanyl, and how deadly, fentanyl can be.”

Illicit fentanyl is so potent that it’s hard to tell the difference between the amount that will get you high and the amount that will kill you. Medical fentanyl has long been used to treat pain in cancer patients and people who’ve undergone intensive surgery; in those cases, doctors carefully calibrate the dosage. Illicit fentanyl, meanwhile, is often sold over the dark web using cryptocurrencies and shipped to its final destination in the mail.

The opioid epidemic has hit some communities harder than others. Modestino says that in Massachusetts, rural areas, low-income communities, and males aged 25 to 34 have been especially hard hit. This lines up with another startling set of data from the opioid crisis. A recent working paper by three economists found that American military personnel, especially those who’d been deployed to Iraq or Afghanistan, have “an overdose rate twice that of civilians,” having been regularly “exposed … to injury-related chronic pain, psychological trauma, and cheap opium supplies.”

Opioid addiction is not unique to the U.S.: Overdose rates have also risen in Canada, Australia, and Europe. But we are, unfortunately, the world leader and by quite a margin. With just 4.4% of the global population, the U.S. consumes more than 80% of the world’s opioids. “I think demand across the world is probably pretty much the same for addictive types of substances,” Modestino says. “I think in the United States, you know, in particular the way the pharmaceutical industry operates — we have lots of supply-induced demand for medical care, and opioids is a part of that, certainly.”

“Supply-induced demand … for opioids” is an economist’s anodyne way of saying that firms like Purdue Pharma and advocacy groups like the American Pain Foundation and the American Pain Society were for years encouraging doctors and hospitals to pass out pain pills like candy. As far back as 2007, a Purdue affiliate and three executives from the parent company pled guilty to criminal charges for false claims about the addictiveness of OxyContin; they paid more than $600 million in fines. Thousands of state and local governments have sued Purdue and others involved in the legal-opioid trade.

In addition to the pharma manufacturers and distributors and advocates, there’s another institution that played a large role in the massive uptake of prescription opioids: the federal government, in its role as a health-insurance provider.

“Essentially we had an increased government funding of drugs through Part D of Medicare, which also covered the disabled,” explains Tomas Philipson, a health care economist who’s the acting chair of the Council of Economic Advisors in the White House. “Now, what they implicitly did was to subsidize the growth of an addictive substance as opposed to tax it, which is what we’re doing for alcohol and cigarettes and other addictive substances.”

So while it may be tempting to look at every fentanyl overdose and heroin overdose as the result of a poor decision — the decision to use an illegal, dangerous drug — it would be disingenuous to ignore the fact that for many people, that decision grew out of what happened back in the doctor’s office, with a federally-subsidized medicine that was advertised as safe and non-addictive.

The prescription opioids that flooded the U.S. didn’t just affect the people who the prescriptions were written out to. According to Modestino, 50% of users get their drugs from family and friends.

“Often what happens is someone gets prescribed an opioid, they typically have more medication than they need, and they keep that extra medication in their medicine cabinet,” Modestino says. “And it can either become diverted by a family member or a friend who takes that medication, maybe in response to some kind of pain, not knowing what this medication is. Or it could even be diverted and sold explicitly on the black market.”

Even after the movement to deprescribe opioids, Modestino says that more than 20% of Americans still had at least one opioid prescription filled in 2017. And the average daily amount of those prescriptions was higher than the level the CDC has identified as necessary to treat chronic pain.

So, considering how many opioids are still out there, and how many more are still being prescribed, Modestino had an idea to try to sop up some of that surplus. She and some colleagues recently launched an experiment, in Massachusetts, to increase the number of pills brought back to pharmacies: a buyback. Participants who bring unused opioids back to the pharmacy get a $10 gift card.

“The black-market price is about $20 per pill on the street,” Modestino says. “We are not going to get people who are already abusing opioids bringing this medication back, but we will get people who might then have their opioids diverted to a family member who is already addicted or whose opioids might be taken out of their medicine cabinet by a teenager who becomes addicted.”

This column was adapted from the Freakonomics Radio episode “The Opioid Tragedy, Part 1: “We’ve Addicted an Entire Generation.” You can find the full episode at Freakonomics.com. You can also listen on Stitcher, Apple Podcasts, or any other podcast platform.

Stephen J. Dubner is co-author of the Freakonomics books and host of Freakonomics Radio.

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