The opioid epidemic in Europe and North America should be old news.
Even the U.S. government is starting to pay attention and act on the flood of overdose deaths brought on by over-prescription of the highly addictive painkillers – synthetic drugs similar to morphine such as OxyContin, Vicodin, Percocet and Suboxone – and more deadly black market substitutes.
It is not particularly reassuring, however, that the Trump administration supports new healthcare legislation that would remove the requirement that all insurers cover drug addiction treatments.
The pharmaceutical companies – who downplayed the addictive potential of these new opioids, and persuaded physicians to prescribe them as though they were candy – are dealing with the problem by repeating the same stratagem in the rest of the world, and coming up with new drugs that counter the harmful side effects.
Some of them have been around for a while and have proven useful and lifesaving. Naloxone is a partial opioid antagonist that can stop an overdose. Buprenorphine is a lower dose opioid that can be used as a maintenance medication for recovering addicts. Suboxone, which combines the previous two drugs, can theoretically prevent misuse and diversion because they cancel each other out if crushed and snorted, or dissolved in a solution and injected.
Despite that, Suboxone addiction treatment is still necessary because, even in pill form, Suboxone can get a person high if they are not already addicted to something stronger. Buprenorphine is among the most often confiscated drugs by police. Probuphine, a time-released implant made with buprenorphine, is virtually tamper-proof.
Even aside from the risk of Suboxone addiction, treatment may be needed for other side effects, such as opioid-induced constipation (OIC). It doesn’t sound that serious – and indeed late night comics John Oliver and Bill Maher have mocked the problem – but it can be life-threatening.
According to Credence Research, more than 40% of opioid users will experience constipation or other gastrointestinal (GI) symptoms because of their opioid use, creating a growing market for new OIC treatments. Others sources say as many as 90% may experience OIC at some point.
There are at least six branded OIC drugs, oral and subcutaneous, including Relistor (methylnaltrexone) from Progenics Pharmaceuticals and Valeant, and AstraZeneca’s Movantik (naloxegol). Both drugs are “indicated” for patients with chronic non-cancer pain who don’t have a gastrointestinal blockage.
Marketing OIC Treatments
The first time most consumers – and many doctors – ever heard of opioid-induced constipation was when AstraZeneca spent $5m on an unbranded TV advertisement during the Super Bowl. David Kroll points out that is a low cost to raise awareness – and sales – of OIC prescriptions.
Despite some backlash – including from critics accusing Big Pharma of trying to profit further from the problems caused by the opioids they falsely claimed were non-addictive – and the fact that no specific product was named, Movantik prescriptions increased by 35%.
In clinical registration trials, 40% benefited from Movantik, compared to 30% for Relistor and placebos. That is even more impressive given that the test subjects were already highly tolerant of opioids.
Neither drug seems to be a panacea, so the search for more drugs continues. There are other ways to reduce the need for OIC drugs, however, including not prescribing so many opioids in the first place. Long-acting opioids such as Suboxone are more likely to cause constipation than even heroin or OxyContin. Some users have to choose between a bowel movement and Suboxone: addiction treatment or prevention by proxy.
Analyst Claire Gibson of GlobalData predicts the market for such OIC products will grow nearly tenfold – from $67m in 2016 to more than $652m by 2019 – in just six nations: France, Germany, Italy, Spain, the UK, and the US. The US is responsible for 80% of the world’s opioid consumption, but it is expected to account for an even larger 86% – $563m – of the total OIC treatment market by 2019.
Another source estimates the worldwide OIC market will be worth almost $2bn some time this year. The opioid market is worth $10bn in the US alone.
There are ways to treat OIC is without additional pharmaceuticals, but according to AstraZeneca, these treatment alternatives – including exercise, drinking a lot of water, changing your diet to include more fibre and prune juice, stool softeners and over-the-counter laxatives – only help about a third of OIC sufferers.
The National Alliance of Advocates for Buprenorphine Treatment (NAABT) also warns against stimulative laxatives and suggests a warm enema – mineral oil, saline or other – or manual manipulation with a latex glove and petroleum jelly.
Cannabis also is an alternative, medically available in 29 US states (provided President Trump does not start enforcing federal marijuana laws; he might, just to disrupt his critics or reinforce his base, as Nixon did). In fact, relief of constipation reputedly was one of the original uses of cannabis or hemp in ancient China and India. Cannabis has natural antiemetic and antispasmodic properties.
Cannabis, based on small studies and anecdotal reports, also has painkilling properties without the problems of addiction, overdose or constipation. Because of the lack of studies, and political tunnel vision, Big Pharma can plausibly argue against – and finance – campaigns opposing cannabis legalisation, except for its own problematic synthetic version.
President Trump said he wants to speed up the release of new drugs. The problems caused by the rapid endorsement of the new opioids should give him pause. And the fact that new drugs can counter some of the negative effects is merely a palliative, not a palatable solution.