Medicalizing the Opioid Crisis: Limitations in Existing Interventions

https://doi.org/10.56927/431965

Christopher Li

ABSTRACT

The opioid crisis has only grown in severity since its most recent rise that began with Purdue Pharma and its misleading advertising of oxycontin in the mid-1990s. The rise in opioid prescriptions corresponded with a large jump in opioid use disorder (OUD). As OUD and OUD-related deaths became increasingly prevalent, solutions towards addressing the crisis became focused on overprescription. These medicalized solutions acting by themselves had the opposite effect, resulting in rises in OUD associated with illicit heroin and synthetic opiates. Medicalized policies were also inconsistent: they did not decriminalize or make more accessible medications for treating OUD (MOUD). Supply-side interventions developed to address this crisis ignore social structures that created and perpetuated a social environment that led to the opioid epidemic, while also creating shifts in the opioid market correlated with movement away from natural opiates and towards increased usage of more potent heroin and synthetic opioids. As a result, this shift has led to rises in overall OUD-associated mortality rate.

ARTICLE

With 70% of the 500,000 drug-use-related deaths in 2017 linked to opioid abuse, the opioid epidemic has developed into a global crisis.¹ With its present roots in Purdue Pharmaceutical’s misleading, damaging, and illegal direct-to-physician and direct-to-consumer advertising of the prescription opioid Oxycontin, policy discourse has often centered around its medicalization: decreasing prescriptions and further regulating prescription opioids. Despite efforts to decrease prescriptions in hopes of decreasing related cases of opioid use disorder (OUD), the problem has now expanded beyond the scope of its medicalized focus. Based on 2006-2019 data specific to the US from the National Center for Drug Abuse Statistics, prescriptions in 2019 hit a 13-year low; in the same year, opioid overdose deaths in the US reached a 13-year high.² The complexity of addressing the opioid epidemic lies in the fact that it is actually “an epidemic on an epidemic”–that is, OUD includes prescription opioids but also more recent increases in heroin and fentanyl usage, which are classified as illicit substances.³ These three forms of the opioid epidemic coexist and perpetuate one another.

While the medicalized approach of bettering prescription guidelines for opioids is important, it is incomplete in the context of how unprescribed opiates like heroin and fentanyl are becoming increasingly present substances in the crisis. In fact, the rise in heroin and fentanyl use may be correlated to the lack of consideration given to the consequences of stringent prescription opioid regulation. Within the last decade, new prescription guidelines for opioids have been established, most notably by the CDC in 2016.⁴ In 2010, likely in pursuit of patent extension and longer market exclusivity, Purdue developed oxycontin that could not be crushed and inhaled, as a means to prevent abuse.⁵ Starting in 2012, the national dispension rate of prescription opiates fell from 81.3 opioid dispensing rate/100,000 people to 43.3 opioid dispensing rate/100,000 in 2020.⁶ These medicalized interventions have been somewhat successful–but only in curbing the effects of prescription opioids, with the death rate linked to prescribed opioids decreasing (in a fluctuating trend) from 4.7 deaths/100,000 in 2010 to 4.2 deaths/100,000 in 2020.

Over the corresponding period beginning in 2010, opioid deaths linked to heroin and fentanyl usage (substances classified as illicit and are not prescribed) increased over 4-fold and 11-fold respectively: heroin death rates rose from 1 death/100,000 in 2010 to 4.4 deaths/100,000 in 2020, and synthetic opioid death rates rose from 1 death/100,000 in 2010 to 11.4 deaths/100,000 in 2020.⁷ The medicalized approach sought and continues to seek, “supply-side interventions”, addressing the opioid crisis by limiting the supply of prescription opioids, operating on the assumption that reducing “legal” supplies does not divert the flow of opioids to illicit markets. The flaw in this assumption draws on a phenomenon termed the “Iron Law of Prohibition” by Richard Cowan: essentially, “the harder the enforcement, the harder the drug.” With illicit markets under pressure to divert product flow from legal sources to illegal sources, the focus becomes on maximizing the efficiency, or maximizing potency per unit.⁸ A study published by Martin et al. seems to confirm this finding. Following the reclassification of hydrocodone from a Schedule III (drugs which may lead to low or moderate physical dependence and high psychological dependence) to a Schedule II (high psychological and physical dependence) drug in 2014, fentanyl went from being the least purchased product on drug cryptomarkets in 2014 to the second-most purchased by July 2016.⁹ Medicalization in and of itself is highly inconsistent. Rises in prescription opioid-related OUD prompted the several interventions made by the CDC and other organizations above to change prescription guidelines, surveil the issue, and change the opiate. However, there was not any associated widespread decriminalization and accessibility to medications treating OUD, like buprenorphine. A review of several studies indicates that most who use buprenorphine illicitly due so to help manage their OUD symptoms, with a substantially smaller portion using illicit buprenorphine to get high.^{10, 11} Contradictingly, medications for treating opioid use disorder (MOUD) are rarely offered in the treatment of OUD: MOUDs were used only about 18% in states with expanded Medicaid and only about 2% in states with no expanded Medicaid.¹² Medicalization of the opioid crisis remains a mechanism of justifying supply-side interventions as sufficient in limiting OUD. While certainly a necessary response to the rampant and misleading advertising by Purdue Pharma that contributed to a rise in prescriptions in the 1990s, a medicalized approach operating by itself merely shifts the problem into other, nonregulated flows of opioids.

The attribution of the opioid crisis as a problem solvable by changes in solely physician or healthcare industry behavior not only exacerbates the crisis in the shifts they create in the legal and illicit opioid market, but also ignores solutions geared towards addressing foundational social structures that allow for such a crisis to occur in the first place. Correlations between social factors like poverty, housing, education, structural racism, and substance use are well-established. Studies indicate that counties with comparatively eroded social capital had higher rates of overdose. All these social structures are then implicated as root causes for the disease OUD, and more generally, substance use disorder, is just as much a product of imbalanced social and economic systems as it is a product of prescription by healthcare.^{13, 14} Medicalized solutions are conspicuously absent of solutions that would address these entrenched social systems defined by their inequality and imbalance. Furthermore, the focus of supply-side interventions in delineating legality thereby establishes illegality: charges like drug possession which result in punitive justice further limit and erode future social capital, reinforcing the root social causes of the crisis.

The most recent cycle of the opioid crisis began in the 1990s with Purdue Pharma and its obsessive advertising campaign to both doctors and consumers, pitching opioids as a safe way to treat pain. The resulting spike in opioid prescriptions and then overdose and deaths would define a long-term, yet incomplete approach to addressing this crisis: that with its beginnings seemingly due to prescription, medicalizing the crisis through limiting prescriptions and legal supply would reverse the path that had been created. The medicalization of the opioid crisis, in its singularity, has only exacerbated the problem by shifting the flow of opioids into illicit heroin and synthetic channels and in its inconsistency, made MOUDs inaccessible and unused. Addressing the opioid crisis requires more than a reductionist approach of focusing on prescription and legal supply. It requires focusing on root social structures and understanding the consequences of medicalization in shifting the composition of the opioid market, in addition to existing medicalized approaches of better prescription practices.

ABOUT THE AUTHOR

Christopher Li is a first-year at Harvard College interesting in studying History of Science and Human, Developmental, and Regenerative Biology.

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