What an 1890s opioid epidemic can teach us about ending addiction today

By HAIDER J. WARRAICH

In the ’90s, chronic pain was rampant in America. Opioids, which had previously been taboo, were suddenly being prescribed by doctors. A supposedly safer opioid had been developed which, as a physician wrote in the New England Journal of Medicine, was “not a hypnotic” and carried no “danger of acquiring the habit.”

This movement created a monster, addicting millions of Americans to opioids. Global overproduction fueled even more demand and, as authorities clamped down, many of those addicted to these medicines turned to more potent ones, making an overdose only a minor miscalculation away.

I’m referring, of course, to the eighteen nineties, which eerily echo how the modern opioid epidemic emerged a century later.

The 1890s and 1990s were both characterized by unopposed amplification of the benefits of opioids, the transformation of physicians into unabashed cheerleaders, and the central role of China — first as a global consumer of opium and later as a manufacturer of fentanyl. In the 1890s, the compound marketed by Bayer to supposedly treat morphine addiction was heroin, while in the 1990s, the drug made by Purdue Pharmaceuticals and marketed as a painkiller with low potential for abuse and addiction was OxyContin.

In his 1932 book, “Brave New World,” Aldous Huxley foresaw the modern opioid crisis by depicting a society addicted to a drug called soma, which mirrored the effects of opium, instantly overcoming pain while providing a sense of well-being. Soma was provided free to citizens, and its characterization predated our modern inclination to look to pills to overcome our ills.

The current opioid epidemic is a huge tragedy, albeit one that could have been mitigated, had we learned from the epidemic of yore. While the pharmaceutical industry has been singled out for retribution — and it does carry the greatest burden of responsibility — other groups have largely escaped accountability. This includes physicians as well as the regulators who spectacularly failed to protect the public. If we focus only on punishing pharmaceutical companies, this won’t be the last time opioids infest our society.

Americans constitute 5% of the world’s population but use an estimated 30% of the world’s prescription opioids. This disproportionate use of prescription drugs in the United States is not an accident but arises from a culture deliberately crafted by the pharmaceutical industry. The United States and New Zealand are the only countries that let drug makers directly advertise their claims to consumers.

 

Their sales pitches have been so potent that, over time, Americans’ responsiveness to placebos has increased while that in other countries remains the same. This sustained marketing blitz means that when the average American takes a pill — any pill — for pain or depression, his or her expectation of relief is greater than it is for someone living in another country.

The pharmaceutical industry had help in pushing opioids. The other recurring aspect of these cyclical opioid crises has been the role played by physicians in propagating them. At the end of the 19th century when heroin was first marketed, it could be acquired only with a prescription from a physician. Many of them fell over themselves to praise opioids like heroin.

One doctor wrote in the Journal of the American Medical Association in 1915, “I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.” Decades later, in 1980, a five-sentence, 101-word letter in the New England Journal of Medicine concluded — incorrectly — that “the development of [opioid] addiction is rare in medical patients with no history of addiction.” That letter would be cited hundreds of times to make more false claims about opioids. While the senior physician who wrote the letter now regrets doing so, the damage has been done.

Every prescription opioid that killed an American had a physician sign off on it. That’s why it is essential for the medical community to examine itself to see how it contributed to this tragedy.

When I was a young resident in the early 2010s, I struggled with balancing the need to alleviate my patients’ pain but also make sure they avoided becoming dependent on opioids. Yet “Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education, and Research,” a Congress-mandated report published by the Institute of Medicine (now known as the National Academy of Medicine) read more like a marketing brochure for narcotics. Subsequent investigations revealed that almost half of those who wrote this guideline had undisclosed financial conflicts of interest and they used grossly exaggerated estimates of how many Americans suffered from chronic pain. I felt betrayed when I learned they weren’t the only offenders: Other physician-led organizations that advocated for opioids were being heavily supported with funding from pharmaceutical companies.

The biomedical industry holds broad sway over not just what physicians do but what they are taught, shaping them throughout their careers. Most training materials about opioids have been funded and developed by opioid manufacturers themselves.

Unless we make wholesale changes in how the biomedical industry can manipulate patients and physicians, we will surely find ourselves back in this quagmire at some point down the road. Training materials need to be vetted for bias, and physicians with financial conflicts of interest should be restricted from medical journal editorial boards as well as from FDA and medical guideline committees.

The FDA should be strengthened by expanding its budget and the approval process for new drugs, and post-market surveillance of approved drugs must be made more stringent. The desperate need to develop better medications to treat pain should not lead to lowering the regulatory threshold for approving new treatments. Until the FDA revamps its mechanisms to ensure opioid safety, it should heed the moratorium on additional opioid approvals filed by Public Citizen, a consumer protection group.

We should also expand how we address chronic pain, not by writing more prescriptions but by focusing on and developing nonpharmacologic approaches. A good place to start reversing our pill-popping culture is banning direct-to-consumer pharmaceutical advertising.

Unless we learn from the past and focus only on punishing opioid producers and distributors while ignoring the role of physicians and regulators, it is inevitable that the wheels of time will keep churning, and this tragedy will recur.

Haider Warraich, M.D., is a physician and researcher at the VA Boston Healthcare System and Brigham and Women’s Hospital, and an instructor at Harvard Medical School.

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