The stigma is not hard to understand: magazine features, books, and movies for two decades now have chronicled America’s drug problems, including the rapacious role of drug manufacturers like Purdue Pharma, which made OxyContin a household name and enriched the Sackler family in the process. The publicity of their misdeeds led lawmakers on a campaign against opioid prescribing. Yet the crackdown had an unintended consequence, one little examined today: it has increased the suffering of patients who experience chronic pain, as medications that were once heavily promoted have since been restricted. And it has added to the needless agony of those like Marshall at the end of life. I told the story of Marshall and others like him in my 2016 book, The Good Death. Since that time, the double-sided problem has only seemed to worsen. Even morphine, which has long been used to ease the final days and hours of patients in hospice care, is only available to the fortunate ones, as supply chain problems have combined with fears of overuse, leading to vast inequities as to who dies in terrible pain.
This unequal access to pain medications is part of a worldwide problem, stretching far beyond the privileged precincts where hospitals are well-stocked with the latest in medications. Last summer, the World Health Organization released “Left behind in pain,” a report that zeroes in specifically on lack of access to morphine, which it notes is “the most basic requirement for the provision of palliative care.” Worldwide, about half of all deaths each year occur while patients are experiencing “serious health-related suffering,” due to poverty, racial bias, limited access to health care—including palliative care—and laws that restrict opioid distribution.
International respondents to the WHO survey pointed to policies or laws that “overly focused on preventing illicit use and unduly restrictive administrative requirements for prescribing or dispensing morphine.” One survey respondent noted, “The regulatory controls are so many that the pharmaceutical industry doesn’t find [morphine] worth manufacturing as the profit is low and regulation is high. The regulators are more concerned about misuse than easing the pain of patients.” (...)
Inaccurate understanding of morphine’s properties is common around the world. Sixty-two percent of the respondents from the Americas believed that morphine was only “suitable for use in people near the end of life.” Such “negative attitudes and perceptions” regarding morphine and other opioids suggest a misunderstanding of how addiction works and how the medical profession should balance the benefits of opioid use for pain with the dangers of powerful drugs. These negative attitudes include “associating opioid use with imminent death” and believing “that opioids can immediately and definitely cause dependence and that opioids are always harmful or even lethal.”
Today there are more than five hundred drugs that are derived directly or synthetically from opium, a product of the poppy plant. They are used to treat a vast range of ailments including congestion or cough, post-surgery pain, chronic pain, addiction, and end-of-life pain. “Opium and its derivatives are all things to all men and have been so for centuries,” Martin Booth wrote in his 1999 book, Opium: A History. Today, not just in the United States but around the world, opium and its derivatives are part of two huge markets, delivered either by the pharmaceutical industry or the illicit drug trade. And perhaps more than ever before, the extraordinary power of opium products to alleviate pain is complicated by the language of addiction.
The Power of Myth
Some addiction experts offer a counternarrative about today’s much-discussed opioid crisis. In the late 1990s, there was a movement in the medical community to better address the pain that patients were experiencing, especially in the final weeks of life. With roots in the palliative care movement, which began with the establishment of hospice programs in the UK in the 1960s and the United States in the 1970s, this focus on pain relief emphasized better training for medical professionals: fear of addiction and biases within medicine were preventing doctors from prescribing adequate pain medication, even to those who were dying. But soon, at intake, patients were being asked what level of pain they were experiencing on a scale of one to ten, or to identify themselves on simple diagrams of faces ranging from a frown to a smile. And savvy pharmaceutical manufacturers rushed to develop medications that could supposedly treat pain without the addictive aspects.
OxyContin was patented in 1996 and aggressively marketed to doctors and the public, along with other new opioid drugs. This resulted in a surge of prescriptions, sometimes in large quantities. About two-thirds of those prescriptions were never fully used, so the country’s medicine cabinets were suddenly awash in prescription pills. These pills were often found by curious teenagers or family members, those experimenting with drug use, or those with prior drug experience. “Prescribing increased massively, and a lot of that increase did not go to people with pain,” Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, told me. “If they were so horribly addictive,” Szalavitz said of those unused prescriptions, “how could this even be true?” In other words, the majority of those with legitimate prescriptions were not getting hooked. And as many as 80 percent of those using prescription opioids for a high were not getting them from a doctor.
Demand created a market: pill mills. Those dependent on opioids sought out their own prescriptions, while others began to sell their unused pills for extra income. Instead of addressing drug use with treatment—methadone, buprenorphine, abstinence programs—states and the federal government began to respond by limiting the quantity of opioids that doctors could prescribe, hurting legitimate pain patients, who were now unable to get the medication that allowed them to function, and leaving those dependent on or addicted to illicit prescription medication in deep withdrawal.
“Do you really think that’s not going to generate a local street market?” Szalavitz asked. So, in “towns where there was deindustrialization, a lot of despair, long family histories of addiction to things like alcohol,” she said, people were forced to find a new drug source. Heroin and street fentanyl filled the void. Those addicted to or dependent on prescription opioids were now using drugs that were not commercially made, their dosages variable, unpredictable, and often deadly. Between 2011 and 2020, there was roughly a 60 percent decline in opioid prescriptions in the United States. Yet, the overall overdose death rate per capita, across all drug categories, tripled.
This way of looking at the opioid crisis is worlds away from the prevailing narrative that Big Pharma alone was driving up the overdose death rate. Pharmaceutical companies were indeed pocketing billions of dollars. Yet, taking down Purdue Pharma didn’t solve the opioid problem. No laws were passed to change marketing practices, and little effort was made to support those with addiction through treatment and training, or through economic policies and health care access. And hardly any attention was devoted to the people with pain who now had to struggle to find medications that had previously allowed them to live their lives.
When I asked Szalavitz how she made sense of this misleading popular narrative about addiction and overdose, she told me, “You couldn’t say that the people who got addicted to prescription opioids were starting by recreational use because then white people wouldn’t be innocent—and journalists like innocent victims. We had to get it wrong in order to convict the drug companies.” From this vantage point, every story of, say, a high school athlete getting hooked on Oxy after knee surgery is misleading as an average portrait, defying both the data and what experts know about addiction. Most people with addiction begin drug use in their teens or twenties, which means it’s likely that those proverbial student athletes getting hooked on Oxy were already experimenting with drugs. “If you don’t start any addiction during that time in your life, your odds of becoming addicted are really low,” Szalavitz told me. “So, what are we doing? We’re cutting off middle-aged women with no history of addiction, who are not likely to ever develop it, and have severe chronic pain, to prevent eighteen-year-old boys from doing drugs that they’re going to get on the street instead.”
Understanding—and addressing—addiction is what’s missing from current drug policy. Instead, some types of drug dependence are demonized, dependence is conflated with addiction, and the best, most cost-effective treatment for pain to exist at this time is stigmatized and kept from those who rely on it to function. As Szalavitz explains it, dependence is needing an increasing dose of a drug to function normally. Many on antidepressants or other stabilizing drugs are not shamed for their dependency. Addiction, Szalavitz says, is using a drug for emotional not physical pain; it is “compulsive drug use despite negative consequences, so increasing negative consequences does not help, by definition.”
Truly facing and addressing addiction requires a new vocabulary—and accepting that “say no to drugs” is an inadequate response. It also requires an examination of far-reaching economic and social challenges in our culture: lives of despair, racial prejudice, economic insecurity, isolation, inaccessible health care, expanding police forces and prisons, and, of course, politics. For politicians, “drugs are a great way to get elected,” Szalavitz said. They can campaign on tough drug laws, claiming that their policies will decrease overdose deaths. “It’s really infuriating,” she told me, “because our prejudice against pain and our stereotypes about addiction push us toward solutions to the problem of opioids that simply do not work.” (...)
Demand created a market: pill mills. Those dependent on opioids sought out their own prescriptions, while others began to sell their unused pills for extra income. Instead of addressing drug use with treatment—methadone, buprenorphine, abstinence programs—states and the federal government began to respond by limiting the quantity of opioids that doctors could prescribe, hurting legitimate pain patients, who were now unable to get the medication that allowed them to function, and leaving those dependent on or addicted to illicit prescription medication in deep withdrawal.
“Do you really think that’s not going to generate a local street market?” Szalavitz asked. So, in “towns where there was deindustrialization, a lot of despair, long family histories of addiction to things like alcohol,” she said, people were forced to find a new drug source. Heroin and street fentanyl filled the void. Those addicted to or dependent on prescription opioids were now using drugs that were not commercially made, their dosages variable, unpredictable, and often deadly. Between 2011 and 2020, there was roughly a 60 percent decline in opioid prescriptions in the United States. Yet, the overall overdose death rate per capita, across all drug categories, tripled.
This way of looking at the opioid crisis is worlds away from the prevailing narrative that Big Pharma alone was driving up the overdose death rate. Pharmaceutical companies were indeed pocketing billions of dollars. Yet, taking down Purdue Pharma didn’t solve the opioid problem. No laws were passed to change marketing practices, and little effort was made to support those with addiction through treatment and training, or through economic policies and health care access. And hardly any attention was devoted to the people with pain who now had to struggle to find medications that had previously allowed them to live their lives.
When I asked Szalavitz how she made sense of this misleading popular narrative about addiction and overdose, she told me, “You couldn’t say that the people who got addicted to prescription opioids were starting by recreational use because then white people wouldn’t be innocent—and journalists like innocent victims. We had to get it wrong in order to convict the drug companies.” From this vantage point, every story of, say, a high school athlete getting hooked on Oxy after knee surgery is misleading as an average portrait, defying both the data and what experts know about addiction. Most people with addiction begin drug use in their teens or twenties, which means it’s likely that those proverbial student athletes getting hooked on Oxy were already experimenting with drugs. “If you don’t start any addiction during that time in your life, your odds of becoming addicted are really low,” Szalavitz told me. “So, what are we doing? We’re cutting off middle-aged women with no history of addiction, who are not likely to ever develop it, and have severe chronic pain, to prevent eighteen-year-old boys from doing drugs that they’re going to get on the street instead.”
Understanding—and addressing—addiction is what’s missing from current drug policy. Instead, some types of drug dependence are demonized, dependence is conflated with addiction, and the best, most cost-effective treatment for pain to exist at this time is stigmatized and kept from those who rely on it to function. As Szalavitz explains it, dependence is needing an increasing dose of a drug to function normally. Many on antidepressants or other stabilizing drugs are not shamed for their dependency. Addiction, Szalavitz says, is using a drug for emotional not physical pain; it is “compulsive drug use despite negative consequences, so increasing negative consequences does not help, by definition.”
Truly facing and addressing addiction requires a new vocabulary—and accepting that “say no to drugs” is an inadequate response. It also requires an examination of far-reaching economic and social challenges in our culture: lives of despair, racial prejudice, economic insecurity, isolation, inaccessible health care, expanding police forces and prisons, and, of course, politics. For politicians, “drugs are a great way to get elected,” Szalavitz said. They can campaign on tough drug laws, claiming that their policies will decrease overdose deaths. “It’s really infuriating,” she told me, “because our prejudice against pain and our stereotypes about addiction push us toward solutions to the problem of opioids that simply do not work.” (...)
Today we call the extensive family of opium-derived drugs opioids, but the term obscures the difference between opiates, the alkaloids extracted from the poppy plant or derived from it—morphine, codeine, heroin—and opioids, the more than five hundred drugs fully or partially synthesized from chemical components of opium. The partially synthesized include hydrocodone (Vicodin), hydromorphone (Dilaudid), and oxycodone (OxyContin, Percocet). The fully synthesized include dextromethorphan (NyQuil, Robitussin, Theraflu, Vicks), dextropropoxyphene (Darvocet-N, Darvon), methadone (Dolophine), meperidine (Demerol), and the infamous fentanyl (Sublimaze, Duragesic). The catchall term, then, is a linguistic manifestation of the way that addiction has colored our understanding of an entire class of drugs, some of which remain medically indispensable.
by Ann Neumann, Baffler | Read more:
Image: Valeria Biasin[ed. Exactly. I've been banging on this issue for ages saying exactly the same thing (just type the term opioid into the 'Search' button). When a few pill mills and unscrupulous doctors were initially exposed you could see the hysteria coming from a mile away.]
