Where does the blame really lie in the Opioid Crisis

Updated: Jul 2, 2020

There is a notion called the 'burden of proof', eloquently covered by Malcolm Gladwell in his Revisionist History podcast. It is the obligation to prove one's assertion, and it involves gathering of evidence to build a case before acting.

A recent case, in the US, found a Minnesota-woman guilty of 3rd degree murder by supplying her own Fentanyl pain patches to her fiance, who subsequently overdosed and passed away. This is the most recent in a spate of legal actions against those who are deemed to supply an illicit drug resulting in death. Particularly important here is the common theme of a close relative providing strong opioid medications, which have been prescribed for pain problems, to the deceased. In the opioid epidemic in general, the drugs may be legally prescribed and often obtained illicitly. But that's besides the point; this litigation is being used to put the blame squarely on the shoulders of each individual in a drug issue far larger and deeper than the sum of individual parts.

As the rates of Australia's opioid use have increased 15 fold from 1992 to 2012 (Ref), Australia has silently slipped into an epidemic of its own. In Australia, however, we call it a crisis - we're not alarmist like the Yanks. Except people are dying, in fact 250% more people are dying from 2000 to 2009 (Ref). So if you think this is an issue that only really affects the US, then you're wrong. I think we should be alarmed.

So where does the blame really lie? Does it rest on the shoulders of individuals, as litigation habits in the States would have you believe? How many more people are going to die from accidental overdose before there is enough evidence - enough proof - in order to act and change the actual root causes? What is our burden of proof as a society?

I'm not going to pretend to have the breadth of the issue covered whatsoever, that would be ludicrous. There are some bigger, more deep-rooted issues that I think contribute to this issues more than most would care to admit.

It's very easy to blame the doctors. But, as you can see with various guidelines here and here, General Practitioner training material is fairly well endowed with the appropriate message on opioids. Consider other therapies for chronic pain, and try all else before opioids in acute pain. I don't blame GPs or other doctors. And I don't think taking the right of GPs to prescribe really solves the problem either. Although I don't agree with much of his reasoning behind why opioid medication has flooded the healthcare system, this (here) is a good read. Taking the right from sensible, generally ethical individuals is a knee-jerk reaction to something deeper. Pain Australia and ScriptWise recommendations on the topic are:

  • better education for doctors and other health professionals;

  • improved access to pain services (especially in regional and remote Australia);

  • improved access to affordable specialised allied health services; and

  • clear pathways for referral using a team-based approach in the primary health care setting.

Makes perfect sense! Improving the alternate means for self-management by those in pain is absolutely gold-standard and it will help right now. But is there a risk that another class of drugs can be misused? Or that this may shift reliance from one thing onto another (expensive multidisciplinary pain services)? Crystal-balling is not a specialty, so I don't know, but perhaps. Because this approach is very appropriate for a pain issue, but in the opioid epidemic issue we are talking about both a pain issue and an addiction issue. Both issues need comprehensive and complex solutions, so again, I don't want to sound too reductionist, but I write about the two following issues a lot in my blog: Money and education.

Addiction may be caused by money, rather the imbalance of this, in society. Where there is social equity issues surrounding money, there will be addiction. If it isn't opioids, it will be something else. The system is funded by pharmaceutical companies and fueled by its profits. 3 of the top 50 companies in the United States are pharmaceutical companies; they make a lot of money out of maintaining the status quo. These companies financialise the most disadvantaged and they are a huge source of profit. It is reductionist, but if you follow the trail of money and power, you generally find a route cause. Until we are alarmed at this fact, addiction won't change.

Pain, in my view, has a lot in common with addiction. Both are more prevalent in the disadvantaged. The disadvantaged position can be financialised by large companies to create a profit machine, but ignorance can also be financialised to create profit. I left off a key recommendation by Pain Australia and ScriptWise above - a public awareness and education campaign for consumers (intentionally so). For pharmaceutical companies to maintain the status quo, this means keeping your consumers ignorant of the risks. Can you picture pharmaceutical companies funding public education campaigns to increase awareness of the highly addictive and side-effect-ridden nature of their products? Not to mention that they generally don't actually impact the thing they are prescribed for (pain)?

Me neither.

We do need more education, because the lack of education around opioids is a route cause. This is where we should start. Bandaids like restricting prescribing rights for GPs are going to plug the dam, but GPs still work in a rigged system. Their training revolves around pharmaceutical management and until the consumer comes to them demanding something other than pharmaceutical management, nothing will drastically change. How does the consumer know to demand something other than a 'pill for every ill'? They need the education that a pill isn't going to impact your pain and that other things (like exercise and changing your mood) are better. Maybe this has to be done by the public system, because as I've said above, we can't really expect Big Pharma to fess up to this. But we can expect Big Pharma to promote opioids for the conditions that they know work (like cancer-related pain and end-of-life care) and be honest in saying when they don't work (like pain conditions - well, a start would be an admission for the lack of efficacy in chronic pain).

So where does the blame really lie? Big Pharma? No, us. The consumer, we need to be alarmed that there are larger issues at play in the opioid epidemic and demand that these powerful companies are honest, that they are scrupulous when it comes to their marketing (to the prescribers and prescribees). We also need to demand public education campaigns, which debunk the 'pill for every ill' sentiment and can re-orient a system fueled by pharmaceutical profits. What is our burden of proof as consumers? How many more people need to die or go to jail for us to act?

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