I recently finished reading the book Empire of Pain, by Patrick Radden Keefe. This best seller is an exhaustive chronicle of the Sackler family, the owners of Purdue Pharma and creators of the highly addictive painkiller Oxycontin. The publication details 3 generations of the family and provides a vivid picture of a lineage that, time and time again, chose profits over public health. It is a riveting read that I highly suggest.
The book concludes with Purdue filing for bankruptcy in the face of thousands of lawsuits brought by states and private citizens affected by the opioid crisis. The plan agreed upon last year by most parties in bankruptcy court called for Purdue, the company, to pay $4.5 billion and shutter the business. As part of that settlement, however, the Sackler family and their $11 billion in assets would be protected from further litigation. It hardly seems just that their fortunes could be protected when that wealth was accumulated on the backs of an American society that has seen nearly 1 million opioid related overdose deaths since 1999, and was responsible for the catalyst of an epidemic that has been estimated to cost the country’s economy $1.3 trillion a year. And while some states continued to hold out until just a few days ago (netting an additional $1.5 billion), it seems likely that the Sackler’s will ride into the sunset on their yachts headed to some regal private estate.
One Step Forward, Two Steps Back
When I first entered the work comp industry around 2010, opioids were public enemy number one. Largely driven by the deceptive marketing practices and pseudo-science developed by Purdue, the opioid crisis in this country had already been building for a decade at that point, but in comp we had just begun to examine the issue under a microscope. Now in 2022, the perception is that we have largely wrapped our arms around this problem by acting through intervention programs, legislation, and a consciousness of how highly addictive and thus inappropriate painkillers are as a first line of treatment. So why am I beating a dead horse, as they say, and what does this all have to do with the here and now?
Well, the CDC, an organization that is great at research and promoting academia but proven to be flat out terrible at making real-time lifesaving decisions, decided to update the opioid prescribing guidelines they developed back in 2016. The new version of the guidelines would essentially ease patient access to opioid painkillers by not recommending any set dosage limits. On one hand, the guidelines have always been and will remain “suggested best practices” as they are not now and have never been mandatory. Additionally, most states have instituted more stringent guidelines and practices via legislation than anything that was ever in the guidance provided by the CDC. But on the other hand, state lawmakers and public health officials still look to the CDC for direction on these issues. While many states will likely keep their current practices intact, new, less stringent “best practices” from the CDC can and will be used as leverage for change by politicians and advocacy groups with varying interests in the companies that continue to produce and distribute these medications.
Because it’s not just Purdue.
Other companies are now also paying billions for playing a part in the deaths of hundreds of thousands of Americans. Johnson & Johnson, AmerisourceBergen, Cardinal Health, and McKesson recently settled lawsuits for their roles in the opioid epidemic to a tune of $26 billion. This is nothing new for the pharmaceutical industry, however. There is a history of bad actors dating back to Arthur Sackler, that excludes virtually no one from the list of billion-dollar settlements.
So what gives? Why is it that the CDC, amidst a worsening epidemic that saw 101,260 drug overdose deaths in 2021, would decide to ease their grip?
One word: shortsightedness. The acting director of the CDC’s National Center for Injury Prevention and Control, Christopher M. Jones, recently noted that “the vast majority of overdose deaths now involve illicit drugs such as fentanyl, methamphetamine, and cocaine.” This may be true, but the statement ignores the fact that over 70% of drug overdoses are still caused by synthetic opioids, and that oftentimes, those using drugs illicitly are doing so after their introduction to these medications under the care of a treating physician.
Who’s Driving This Thing?
It seems that the CDC is caving to pressure from organizations such as The American Academy of Pain Medicine (AAPM), not to be confused with the “other” AAPM, the American Academy of Pain Management, as both of which are heavily funded by opioid manufacturers and have been staunch critics of the guidelines since their inception.
The American Medical Association (AMA) has continued to pile on as well, joining the AAPMs and dozens of other advocacy groups calling dosing thresholds “arbitrary pseudo-science”. While it is true that there is a lack of peer-reviewed medical studies on the accuracy of a measurement such as morphine equivalent dosing, there are hundreds of statistical evaluations that conclude a simple fact: more opioids lead to more addiction and death. It’s well known that the more opioids you take, the more you need for pain relief, a condition known as hyperalgesia, which is a main factor in the need to limit opioid dosing as well as the length of time patients should be prescribed opioids.
Another issue at play here is the fact that the overwhelming majority of physicians practice medicine in the right way, adhering to the Hippocratic oath and doing no harm to their patients. These physicians pine for the good ol’ days of practicing medicine where they could be left to treat their patients at their discretion. Simply put, however, one bad apple spoils the bunch, and because there are physicians sitting in jail for their indifference to human life, and because every step of the opioid manufacturing supply chain is writing 10 figure checks for their part in an epidemic that has affected millions, the CDC is not justified in paring down safe prescribing parameters.
It does seem unlikely, however, that state regulators, whether in the realm of public health or our little world of workers compensation, will roll back the controls that have already been put in place to combat the opioid epidemic. At least not immediately…
Regardless, this change would leave the door open to do so, and if that makes you feel the same way it does me, there is something you can do. The CDC is taking public comment on these changes until April 11, 2022. Click on this LINK for your voice to be heard. Collectively, perhaps we can persuade the CDC to be the leader in public health that it was intended to.