Substance abuse prevention is everybody’s problem, but it’s not everybody’s business. It is the business of pharmaceutical companies and pharmacies. Maybe they should do more.
The Cost of Substance Abuse
The United States Centers for Disease Control and Prevention (CDC) estimates that in 2015 opioid abuse cost the US economy $78.5bn related to healthcare, lost productivity, and criminal justice. The US Surgeon General’s 2016 report estimates the total annual costs, including alcohol, at $442bn a year. (The United Kingdom’s costs are a more modest £36bn/$51bn.
During his State of the Union Address Jan. 30, President Donald J. Trump spoke about the record number of opioid overdose deaths, and what he proposed doing about it. (He already had declared the opioid epidemic a public health emergency, a mostly bootless action, since no money was attached to it.)
The Law Enforcement Solution
Mostly Trump talked about getting “tougher” on drug dealers and pushers (longer prison sentences, more police, and border patrol agents) and building a wall on the southern border with Mexico. This would not affect demand. In addition, 95 % of illegal drugs cross the border in vehicles or vessels that a wall would not stop, and more than half of overdoses are due to use of legal and legally obtained drugs.
Trump also has made some vague noises about helping addicts get into treatment. So far he has done little in this regard, other than trying to repeal the Patient Protection and Affordable Care Act (ACA or “ObamaCare“), which would eliminate substance abuse being covered by most health insurance plans as an “essential health benefit.”
Aside from the costs of opioid or heroin addiction treatment, there is the problem that there aren’t enough beds for everybody who wants treatment, let alone everybody who needs treatment.
Well, Trump has said that big government cannot solve problems anyway. Maybe private business should try to solve addiction and overdose deaths. And no private businesses have more incentive to keep drugs legal and available than the pharmaceutical companies and pharmacies.
So, what are they doing?
Big Pharma did not get big by giving away its products for free. Most of its solutions to addiction are to introduce new drugs or new delivery systems, sometimes said to be less addictive or tamper-proof, but always more expensive.
New opioids, such as OxyContin, were said to be less addictive than opiates such as morphine and heroin. A letter in the New England Journal of Medicine seemed to support this—though it was narrowly focused on patients in a hospital setting and was by no means a scientifically rigorous study — leading doctors to prescribe them for chronic pain.
When the new opioids turned out to be highly addictive as well, Big Pharma said people were using them other than as prescribed—in larger quantities and more often—reducing Big Pharma’s legal liability.
In Canada, America’s supposedly more enlightened neighbour to the north, evidence that OxyContin was addictive was introduced in the courts in 2005 by rival pharmaceutical companies—not to ban OxyContin, just to allow the rivals to produce their own generic knockoffs.
New Delivery Systems
Sometimes abuse is not just the drug or dose, but how it is administered. To prevent abuse, new forms of the drugs were created.
To restrict how many pills a patient takes, long-acting versions of pills such as buprenorphine were developed. Addicts soon discovered they could get a more intense high if they crushed the pill and inhaled it, or dissolved and injected it. So the opioid agonist naloxone was added, to cancel out the buprenorphine if injected. A Suboxone film for placement under the tongue also was devised, which addicts still tried dissolving.
However well these abuse-deterrent methods work, they are expensive. Such opioids can cost 10-to-20 times more than an equally effective dose of generic morphine. If the US Department of Veteran Affairs were forced to switch, the $100m it spent on opioids in 2016 would balloon to $1bn or more.
Sometimes these new delivery systems are created not because they are harder to abuse, but because the company’s patent is about to expire, and this is a way to hold on to the patent profits for a while longer. OxyContin’s patent has been extended in this way 13 times.
With the regulatory wagons circling, Big Pharma is again looking into safer alternatives. NGF (nerve growth factor) inhibitors are a non-narcotic analgesic that looks promising, but they do have some unwelcome side effects. They were previously abandoned because, during 2010 trials, they worked so well at capping pain that patients overexerted themselves until they needed a hip or joint replacement.
Big Pharma needs to make sure NGFs are safe and continue looking for new alternatives.
The Pharmacist Solution
If Big Pharma cannot be trusted, neither can all pharmacists. Some have taken advantage of the opioid epidemic by becoming pill mills, distributing many times more prescriptions than their communities have residents. Sometimes they team up with unscrupulous rehab clinics to supply drugs to their patients, allowing them to remain junkies.
(Pharmacist Glenn Chin of the New England Compounding Center was just sentenced to eight years in prison for producing tainted steroids for injection and shipping them to physicians around the United States, resulting in dozens of deaths—though he was not convicted of murder, just racketeering and mail fraud. The motive: profit. It was cheaper and faster to produce the steroid in unsanitary conditions.)
Some pharmacies, at least, are trying to fight opioid abuse and overdoses, including some US chains.
Disposing of Leftover Pills
One way people first become addicted to prescription pills is by stealing pills from friends and family, often leftover or forgotten pills from a past injury. It’s not safe to flush them, put them down the drain or throw them out. While most pharmacies (and some cities) will safely dispose of them for customers if they bring them in, people either forget or cannot be bothered. Now the Walmart retail chain, which includes 4,700 pharmacies, is offering customers a DIY solution: DisposeRX packets that, when added to the pill bottle and combined with water, will reduce the pills to a safe gelatinous mess. Just toss the result in a rubbish bin.
Pharmacies in the US and the European Union also are beginning to use digital means to keep track of prescriptions and monitor for abuse. The European Medicines Agency is looking into a smartphone-compatible information system, allowing for “continuous updates“, though it still is only part of a long-term vision. In the US, many states already have similar electronic databases – prescription drug monitoring programmes – that show some promise in lowering rates of opioid overdose and even prescription.
Finally, pharmacies—including the Rite-Aid, Walgreens, and CVS chains in the US, as well as drug treatment services in the United Kingdom, and pharmacies in Canada—are saving lives by following Italy‘s lead and distributing the overdose-reversal drug naloxone without an individual prescription. Often carried by first-responders to revive overdosers, naloxone can save more lives if all opioid users, legal and otherwise, keep it on hand for emergency use.
Surprisingly, some American politicians—including Maine’s Gov. Paul LePage – object to this, feeling that if people know there is an antidote, they will be more likely to use drugs. There is no evidence that this is true.
The problem of substance abuse – alcohol, legal prescription painkillers, illegal drugs – has no single or simple solution. Every person and institution needs to do their part. It’s time for those profiting from the abuse to do more.
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