By Arvind M. Dhople, Ph.D., Professor Emeritus, Florida Tech
As the COVID-19 pandemic in the U.S. had eased well, the extent of devastation caused during this period by the opioid epidemic is no longer obscured. Data by the National Center for Health Statistics showed 2020 marked the deadliest year yet in its opioid epidemic: more than 100,000 drug overdoses were recorded, nearly 76,000 of them attributed to opioid, an increase of approximately 30% over 2019. The exceptional circumstances of the COVID-19 pandemic may have contributed to many overdose deaths by disrupting treatment programmes and access to life saving medications such as naloxone, and by limiting support networks. Yet the opioid epidemic has been a constant, complex, and decades-long crisis, since its inception in 1995 when OxyContin was approved and erroneously marketed as a safe and low-risk extended-release opioid analgesic.
Over 600,000 deaths have been attributed to opioid since the mid-1990s, fueled by economic recession, corporate greed, and shifting attitudes about pain management. Identifying the underpinning of the opioid crisis has often focused on the unique confluence of factors within the US. Much has been written about the series of dubious decisions made by the U.S. Food and Drug Administration, which failed to enforce proper pain indication labelling on packaging, and the vast increases in the quotas of manufactured opioid approved by the Drug Enforcement Agency. Early warnings by public health workers and emergency services about the potential lethality of opioids went unheeded. As investigative journalist Patrick Radden Keefe suggested in his book, Empire of Pain, “The opioid crisis is ——- a parable about the awesome capability of private industry to subvert public institutions”.
In February 2020, the Stanford University Medical College convened to identify cohesive, evidence-based information about opioid crisis, led by Dr. Keith Humphreys. The report was completed and published towards the end of 2021. Modelling performed by this University group provided a bleak outlook: by the end of this decade, an additional 1.2 million people are predicted to die from opioid without substantial policy reform.
The Biden Administration nominated Dr. Rahul Gupta, former health commissioner of West Virginia, as head of the Office of National Drug Control Policy, and quickly confirmed by the Senate on October 28, 2021. It will be the first physician to take a role, signifying less focus on legal and law enforcement approaches to drug policy and an increased emphasis on addiction treatment and expanded health-care services.
Dr. Gupta’s appointment comes at a vital time. The Stanford Group data suggested that the COVID-19 pandemic has been a potent accelerant of opioid-related overdose deaths. The mechanisms were unclear, but it was likely that disruptions in available treatment services and reduced access to harm reduction practices, such as closures of safe injection sites, will have played a role. The data also was highlighted important demographic points. West Virginia, the epicenter of the crisis, continues to have the highest number of overdose deaths, but urban areas have overtaken rural areas for age adjusted death rates. A major test for Dr. Gupta will be how to increase financing of addiction prevention and treatment services within the often fragmented infrastructure funded by public health insurance. He will need to reinforce resources in the regions that have been hardest hit by COVID-19, and equitably target emerging regional and group vulnerabilities, to opioid use.
Since 2011, ushered in by prescription opioids, expanding heroin markets, and illicit opioids such as fentanyl, there has been a cruel repositioning in the “deaths of despair” narrative – opioid overdose deaths. In addition to describing demographic changes, the Study calls for a major shift in the treatment of opioid use disorder (OUD), by characterizing addiction as a chronic condition. Doing so has major implications for addiction treatment models by providing consistent funding for regional specialty addiction centers with additional, localized medication assisted treatment services, such as offering methadone and buprenorphine.
Innovation and transformation in the approach to ending the opioid epidemic must be met with reinforced regulation. US institutions were subverted through failures in post-marketing surveillance and physician education and by permitting financial conflicts of interest between regulatory agencies and industry. But the moral of the opioid crisis is not that it could happen only in the US. Without reigning in deceptive marketing and prescribing practices and international funding for subsidized generic morphine for low-income countries, the possibility of other opioid crisis remains.