Last Month Purdue Pharma, the producer of synthetic opiate Oxycontin, pleaded guilty to criminal charges. Purdue Pharma have entered into a $8.3bn (£6.3bn) settlement with the DoJ; which will see the company reorganised and managed by a public trust, for the benefit of the public. The company will continue to manufacture Oxycontin, as well as drugs used in drug treatment. This settlement has been heavily criticised, with many calling for criminal sentencing of those involved, namely some members of the Sackler family.
It is undoubtedly important that those culpable take responsibility, and are held accountable for the detrimental levels of harm their addictive opiates have caused across America. The issue of prescription drug dependency needs to be addressed through a nuanced discussion, which encompasses the innate complexity of this public health issue and is intrinsically linked with illicit drug misuse, deprivation, mental health and criminalisation. This settlement alone certainly cannot make up for the loss of life, livelihood, families and community caused by widespread opiate dependency in America. After 50 years of the war on drugs we know that arresting a single drug supplier barely makes a dent in the supply chain; nor does it do anything pragmatic to support people who are experiencing problematic drug use. Comparatively entering a settlement with a single pharmaceutical company does very little to address the national scale of opiate dependency, let alone the global scale.
The opioid epidemic
In 2017 The US department of health and human services declared the opioid crisis as a public health emergency, in turn implementing a 5 point plan to tackle the epidemic.
In 2019 The US Department of Health and Human Services found that:
- Over 130 people die everyday from opioid related deaths.
- 10.3 million people misused opioid prescriptions.
- 2 million people had opioid misuse disorder.
Provision data for 2019 shows there were:
- 70,980 deaths relating to drugs in the United states.
- 70% of these deaths involved an opioid.
- 57% of these deaths involved synthetic prescribed opiates.
It is also estimated that:
- 20% – 30% of people prescribed opiates for chronic pain misuse them.
- 8%-12% of those prescribed opiates will develop opioid use disorder.
In 2020 a study from the BMJ open journal found that between 2012 and 2017 the rate of prescribing opiates was 72% higher in the most deprived counties; and drug related death was 36% higher in the most deprived counties.
Root causes
The opioid epidemic is rooted in the preexisting and entrenched social, political and economic conditions of the United States. ‘Big Pharma’ has played a major role in fuelling this epidemic, but it is likely that their role has been exacerbated by the ultra-liberal political economy, and the high levels of socio-economic inequality found in the United States. The extent of opioid related dependency, harm and death in America cannot be explained without acknowledging the profit driven nature of the private healthcare sector. Whilst the United States is one of the wealthiest countries in the world, it also is home to high rates of deprivation and inequality. Unlike Brits, Americans do not have a publicly funded healthcare system, based on the principle of health equality. Instead, the American private healthcare sector is entrenched in neo-liberal principles, driving profits through a growth business model.
The medical understanding regarding the risk of opioid addiction was propagated by the popular, but inaccurate, narrative that patients without a history of addiction could not become dependent on prescription drugs. Purdue Pharma, in particular, have had considerable influence over the prescribing practises of medical practitioners; having funded over 20,000 educational programmes around pain. There is a clear link between opioid dependency and opiate use for long term chronic pain management. This phenomena is understood as a major contributing factor to the opioid epidemic in the United States. Comparatively this phenomena is also understood to be driving opioid dependency in working class deprived areas in England and Wales, such as Middlesbrough. The University of Manchester notes this phenomena is common in more deprived areas because of the prevalence of manual workers, who are more likely to incur injury, and in turn be prescribed opiates for pain management.
Prescription drug dependency in the UK
This issue is not endemic to America. In 2019 Sunday Times found that 4 in 5 heroin users in the UK began using prescription drugs. This threat of over prescribing medications with high abuse potential has been a concern since the late 60’s. When the Wotton committee recommended the government decriminalise cannabis, and investigate the growing issue of prescription drug dependency. It is 2020 and this debate still persists.
- 1 in 4 adults had been prescribed an addictive prescription drug
- Higher rate of prescription dependency in the most deprived areas
- ‘for opioids and gabapentinoids, the prescribing rate in the most deprived areas was 1.6 times the rate in the least deprived’ areas
- Rates of opioids and benzodiazepines being prescribed for long periods is falling, but despite benign against guidelines long term prescribing of these drugs is still an issue
The recommendations set out by PHE and HHS to manage the issue of prescription drug dependency in England and Wales, and America are uncanny, with these exceptions:
- PHE’s recommendation to improve ‘information for patients and carers on prescribed medicines’ and ‘increase informed choice and shared decision making between clinicians and patients’
- HHS’s recommendation to promote the ‘use of overdose-reversing drugs’
The 2019 ONS statistical bulletin failed to highlight the prevalence of prescription drugs in drug related deaths in England and Wales. Through our own analysis we found that:
- 49% of total drug related deaths in 2019 were related to any opiate.
- 30% of these deaths related to any opiate involved heroin and morphine; of which 21% involved alcohol, 57% involved other drugs
- 26% of total drug related deaths for 2019, and 52% of opiate related drugs involved prescribable (synthetic) opiates inc methadone; of which 19.7% of those deaths involved alcohol, 77% of deaths involved other drugs
- 9% of total drug related deaths involved benzodiazepines: of which 27% involved alcohol, 94% involved other drugs
- 12% of total drug related deaths involved Anti-anxiety medications i.e pregab: of which 17% involved alcohol, and 88% involved other drugs
- 4.2% of total drug related deaths involved any amphetamine, including MDMA
- 0.7% of total drug related deaths involved cannabis
These statistics show that some prescription drugs, e.g. benzodiazepines, were related to more death than some illicit drugs, e.g. cannabis. The issue at hand is far more nuanced and complex, as the data reveals that these deaths often involve other drugs and alcohol. Here at Volteface we have previously raised the issue of an overly medicated society. Clearly there are still groups being treated with medication, whose harmful drug use remains unmanaged.
Root causes in the UK
The UK doesn’t have the same level of corporate influence as the States when it comes to public health. Therefore the well trodden path of pharmaceutical companies exploiting vulnerable communities through profit driven dependency doesn’t quite fit the situation here. In 2018 The Evening Standard highlighted the widespread availability of addictive prescription drugs through unregulated online pharmacies. Other sources of these medications without having a prescription are both through the online and traditional blackmarkets. This highlights the complexity of ‘tackling’ prescription drug dependency, and the meaninglessness of addressing this as an isolated issue caused by doctors overprescribing. Although, like Big Pharma, there has to be some accountability and change in practise to ensure doctors are not accelerating the issue, as in the United States.
Our analysis highlights that we cannot address the issue of prescription drug dependency separately to that of illicit drug dependency. Whilst dependency can be the result of prolonged opiate prescription for pain management. Addiction is also fuelled by unmanaged mental health; which may be persistent and pervasive, or sudden and temporary. Both illicit and prescription drug dependency impacts the most marginalised and vulnerable groups in society, in most deprived areas of the country. The link between drug dependency and deprivation is clear, and this nuanced issue will require an equally nuanced solution, which offers more than data collection and a 24 hour helpline.
Decriminalisation
Whilst decriminalisation has it’s limitations, it can drive effective harm reduction, this is evident by the positive outcomes in Portugal. Last week Peter Krykant was cautioned by police whilst volunteering at the drug consumption van in Glasgow. Despite being an effective harm reduction strategy for injecting users, drug consumption rooms operate in conflict with The Misuse of Drugs Act. In the United States Oregon is the first state to decriminalise all ‘hard’ drugs. Along with the proposal for drug treatment funded by taxes from the legal cannabis industry.
Multifaceted solution for a multifaceted problem
Often poly-substance users are a difficult group to engage in effective harm reduction. The prevalence of this dangerous combination of alcohol, prescription drugs and illicit drugs involved in drug related deaths shows that non-pharmaceutical, psychosocial intervention needs to be prioritised.
A plant based solution?
This year has been a landmark victory for drug reform in the United States. We are in a new wave of plant medicine, across the world we’re seeing patients replace prescription opiates with prescription cannabis for the management of long term chronic pain. Recently N.I.C.E issued draft guidance which aims to reduce NHS prescription of addictive medications. Moreover, the former chair of the BMA has issued a statement supporting the replacement of opiate medications with cannabis medications on the NHS.
One Canadian study found that 87% of medical cannabis patients surveyed quit other substances (prescription medications, illicit drugs and alcohol). Another American study showed that opiate prescribing rates were around 6% lower in states with legalised medical, and recreational cannabis. Showing that medical cannabis has the potential to address prescription drug dependency in patients who: have long term chronic pain conditions; a history of drug dependency; are experiencing ongoing mental health problems, or circumstantial factors which could increase risk of abuse or dependency.
Ibogaine is psychoactive plant based medicine, which is used around the world to break cycles of opioid dependency. In 2010 Ibogaine became available for prescription and use in clinical practice in New Zealand. Ibogaine has been shown to effectively reduce withdrawal effects, improve self-rated mood, and ultimately reduce cravings after treatment. Ibogaine works by resetting the neuro pathways which have in essence ‘taken over’ by opioid receptors. Those dependent on opioids are unable to achieve reward satisfaction from their environment without the opiate. Ibogaine is described as proving a ‘window of sobriety’, which motivates recovery. The conclusions of one study found that a single dose of Ibogaine led to either total opioid abstinence, or maintained reduced usage over a 12 month period. Whilst the long term efficacy of this drug is yet to be established, the current research looks promising.
This piece is an opinion piece and may not reflect the views of Volteface as an organisation.
This piece was written by Ella Walsh, Tweets @snoop_ella.