For years, America has pursued a war against drugs, but the extensive abuse and misuse of opioids by Americans has created a nation-wide crisis. Few, if any, places have been spared from the opioid epidemic that has ravaged the United States in this decade (cite Rochester business journal some how). According to Vashishtha, Mittal & Werb (2017), death from prescription drug overdose has become the leading cause of preventable death in the United States. An epidemic is an outbreak of disease that spreads quickly and affects many individuals at the same time. When imagining a situation horrific enough to be referred to as an epidemic, many people would picture civilians dying from terrible diseases such as Polio, AIDS, or The Black Death. But how many people would envision a co-worker found dead after overdosing on prescription medicines they bought online? Or the sixteen-year-old boy next-door who gets high off of his parent's prescribed painkillers? How many people would visualize an elderly loved one not waking up the next morning due to an accidental overdose?
The current opioid crisis is a significant national health problem and the socially accepted perception that prescription drugs are generally safe and pose little risk or legal consequence, is cause for alarm (Tunajek, 2009, p. 27). If the current trend of misusing opioids and prescriptions medications does not come to an end soon, the related deaths and overdoses will become a thing of normality. Fixating on an end to the present crisis, Americans are no longer blaming the drugs themselves for the havoc they wreak. The multifaceted blame for creating and continuing to aid the current American opioid epidemic should be placed on all stakeholders of the crisis including pharmaceutical manufacturers, prescribers, and society as a whole.
According to research, “opioids are a class of psychoactive substances derived from the poppy plant (opium, morphine, and codeine), and can also occur in semi-synthetic (heroin) and synthetic compounds (methadone, buprenorphine)” (Van Hout, 2014, p. 219). ). Holding a significant role in the treatment of certain acute and chronic pain, opioids like Vicodin and OxyContin are commonly prescribed by doctors. According to Solnik's (2016) research, opioids are either derived from or posses properties similar to opium and heroin (p. 2). When ingested, this class of drugs manages the severity of pain signals that are sent to the brain and produce beneficial pharmacological effects. Analgesia, sedation, euphoria, and respiratory depression are all meant to be favorable for patients suffering from pain or anxiety (Van Hout, 2014, p. 219). However, people of all ages are recreationally seeking this sense of wellbeing and pleasure and therefore misusing, abusing, and diverting opioid painkillers.
The dangers of exploiting prescription drugs include addiction, hyperalgesia, bone fracture, pneumonia, erectile dysfunction, motor vehicle crashes, cardiovascular events, irrationality, and death (Psaty & Merrill, 2017, p. 1502). According to Tunajek (2009), opioids are the most dangerous when taken to get high via methods that increase their addictive potential. Crushing the pills, then snorting or injecting their contents is one dangerous way people misuse painkillers to obtain a high, along with combing them with alcohol or other illicit drugs. Although these drugs have helped the lives of millions of Americans, the addictive and dangerous nature of opioids pose a colossal risk to society.
Demographics of Opioid Abuse/Addiction
Since the birth of medicine, the dangers of extensive use, experimentation, and abuse have existed. According to Tunajek's (2009) research, the opioid epidemic may have begun as an alternative to the recreational use of heroin, which became increasingly prevalent among the urban poor during the 1950's (p. 26). Heroin use during this time was so common, that it was described as “contagious”, spreading from peer to peer, according to Green (2017). However, the drastic increase in the number of prescriptions written for opioid painkillers created an outlet for heroin users to begin experimenting with opioids. After realizing that opioids provide a remarkably similar high to heroin, heroin users turned to prescription drugs. Due to this movement away from heroin and toward its cheaper, more pure alternative, the origination of recreational use of prescription medicine began. Unfortunately, prescription painkillers now cause more drug overdose deaths than heroin ever has (Tunajek, 2009, p. 26).
Spanning across all regions of the U.S., victims of opioid abuse can be from any region and be of any race, religion, gender, or age. Van Hout's (2014) research suggests that a range of cohorts including middle aged females, students, elderly, criminal offenders, pain patients, individuals with pre-existing alcohol or drug dependence, and healthcare professionals can all suffer from the effects of opioid abuse. (p.220). Whether it be a general misuse of opioid drugs, or a built up dependency on such, the aftermath of prescription drug abuse is evident among many American populations and places.
However, rates of misuse and abuse of painkillers are higher in certain regions of the country than others. For instance, Kerlikowske referred to the Appalachian states of Kentucky, Tennessee, and West Virginia as “ground zero” for prescription drug abuse (Kerlikowske??as cited in Devi, 2011, p. 474). A lack of federal and state drug monitoring has led this region to have a steady flow of prescription drug trafficking and abuse. These opioid-dependent Appalachian residents are often referred to as “pillbillies”. Excessive rates of opioid abuse are seen in many other regions of the country due to a higher proportion of opioids being prescribed in that area. For example, 98 out of the 100 doctors responsible for nationally dispensing the painkiller Oxycodone are in Florida, creating a well-known and heavily visited opioid attraction sites for pillbillies and other illegal drug users (Devi, 2011, p. 474). Similar geographic “hot spots” of opioid misuse are often found among the country's underserved communities where access to healthcare and police presence is minimal (Vashishtha et al., 2017).
Recently, the age range of Americans affected by the ongoing opioid epidemic has expanded drastically. According to Tunajek (2009), the biggest increase in prescription medicine abuse is among adolescents, followed by seniors. Amidst college students specifically, opioid abuse is on the rise. Students are abusing opioids not only to get high, but also to self-medicate for anxiety or depression (Tunajek, 2009, 27). Representing an area of high concern for opioid abuse is the older adults and senior citizens of America. “Although this group currently comprises just thirteen percent of the population, they receive approximately one-third of all medications prescribed in the United States” (Tunajek, 2009, p. 26). It is common for the elderly to take the wrong dosage or mix up medications, unfortunately resulting in accidental overdose. Lastly, increasing rates of middle-aged adults have been found to be taking prescription drugs to solve day-to-day stressors and issues. As more and more adults are being prescribed, the finding, stealing, and trading of opioids by family members or roommates becomes relatively easy and common (Tunajek, 2009, p. 27).
Behavior and Characteristics of Opioid Abusers
Throughout the history of opioid use, many people have recognized the medicinal benefit for the relief of pain, just as others have experienced dangerous addictions resulting in escalating abuse and, in some cases, death (Green, 2017). Despite the fact that there is no stereotypical image of an opioid-dependent person, there are certain behaviors and characteristics that surround all people suffering from the drug's adverse consequences. Most opioid addicts and abusers conduct themselves in a very similar manner. Van Hout (2014) describes indicators of opioid abuse to be:
Requesting certain prescribed and/or over the counter opioids, multiple unsanctioned dose escalations, repeated lost or stolen prescriptions, use of multiple doctors and pharmacies, hoarding of medications, forging prescriptions, stealing prescription opioids from other patients, selling prescription opioids, abuse of other licit and illitcit drugs, and injecting opioid formulations. (Van Hout, 2014, 220)
Many abusers and addicts will try to hide their drug usage and may seem irritable or paranoid towards friends and family members. Individuals dependent on opioids may also experience laziness and irregular personality changes. In addition, Cooper (2001), described three distinct types of opioid users based on quantity of consumption, namely, “type I who never exceeded the maximum dose; type II who sometimes consumed slightly higher than recommended doses; and type III who consumed significantly higher doses than recommended” (as cited in Van Hout, 2014, p. 222).
A specific form of dependence can occur following opioid-treatment for pain, anxiety, or insomnia where an individual frequently experiences a “blurring” between remedial and problematic use over time. According to Van Hout (2014), this is referred to as “iatrogenic dependence” (p. 221).
Stakeholders of the American Opioid Crisis
According to Green (2017), the medical understanding of substance abuse has changed substantially since the origination of the opioid epidemic, from a personal weakness to a biochemical and medical problem. A problem so severe, that the rate of overdose deaths involving opioids has more than tripled in the past 15 years (Rochester Business Journal, 2017). Although many Americans are working to end the current prescription drug catastrophe, a few major stakeholders of the epidemic remain successful in aiding the opioid crisis. To name a few, prescribers, pharmaceutical manufacturers, and changing societal norms are synchronously working together as stakeholders to continue the monstrosity caused in America by opioid drugs.
Strong roots of the opioid epidemic lye in the hands of those prescribing such drugs. Research completed by Demi suggests that there has been a steady rise in the circulation of prescription drugs in the USA, with opioid painkillers causing the most concern (2011). Although it may begin as a result of experimentation, self-medication, or succumbing to peer pressure, opioid abuse most commonly begins with a prescription. The number of prescriptions written for potentially addictive pain drugs rose to more than 200 million last year, according to National Institute on Drug Abuse. In addition, the medical community has held on to a recently booming mindset that “a pill for every ill” is available. As a consequence of this new trend in prescribing, an entire generation of physicians was trained to promptly turn to opioids in the case of patient complaints of pain (Psaty & Merrill, 2017).
Physician ignorance is a main reason for prescribers to be labeled as stakeholders in the opioid crisis. Specifically, the common lack of knowledge regarding identification of abuser behaviors and characteristics has led to a plethora of problems for America. Pearlman (2016) suggests that doctors are lacking the requisite knowledge to identify either addicts or those prone to addiction. As a result of being unaware of the telltale signs of drug dependence, physicians end up unintentionally prescribing drugs to the wrong people, and/or prescribing too much of a drug to the right people. For example, as more and more physicians continue to issue unnecessary prescriptions of different opioids, the practices they work in inadvertently become “pill mills” (Psaty & Merrill, 2017). Drug addicts and abusers often target such “pill mills”, by taking advantage of the facility's lax prescribing techniques in order to get their fix for opioid painkillers. According to Green (2017), prescribers are not identifying the early signs of drug abuse, which consequently has led to a continuation of opioid prescriptions being made available for problem individuals despite a history of serious adverse effects or overdose (p. 108).
Ignorance of physicians and/or prescribers is yet again to blame for the ongoing phenomena of “doctor-shopping”. However, the ignorance regarding this issue relates back to a lack of adequate patient information. According to McDonald and Carlson (2013), “doctor-shopping” patients can obtain multiple opioid prescriptions for nonmedical use from different unknowing physicians. Addicts are able to either visit multiple doctors or use different methods to receive painkillers without physicians discovering or even realizing how many prescriptions have been written (Pearlman, 2016, p. 839). A recent NIDA analysis of prescription practices in the USA showed that approximately 60% of individuals who had been given a new prescription for drugs had been given another one within the next three months by a physician who was unaware of the original prescription. Lacking universally available healthcare records, physicians often must rely on whatever past medical information a patient provides, whether it be the whole truth or not.
Of the many stakeholders contributing to the severity of the American opioid epidemic, pharmaceutical companies take a hefty portion of the share of blame. Due to aggressive advertising techniques used to promote the consumption of opioids as well as persuasive/incentivizing interactions with the medical community, large pharmaceutical companies have caused widespread availability of opioid drugs resulting in high rates of abuse and addiction.
It is practically impossible to open a magazine, turn on the television, or search the Internet without coming across a prescription drug advertisement. Expenditures by the pharmaceutical industry for direct-to-consumer advertising increased from $1.8 billion in 1999 to $4.2 billion in 2004 (Tunajek, 2009, p. 27). By exaggerating the benefits of their prescription drugs while undermining the risks that opioids pose, large pharmaceutical companies have created massive and unprecedented marketing campaigns in order to increase revenue.
Commonly known as one of the country's most deceiving and tout pharmaceutical companies, Purdue Pharma set the standards for aggressive marketing strategies after introducing OxyContin to the American drug market. According to Van Zee's research, a consistent feature in the marketing of OxyContin was a systematic effort to promote the so-called “minimal” risk of addiction surrounding the drug by training sales representatives to publicize the message that the risk of addiction was “less than one percent” and far lower than that of similar opioid drugs (2009). In response to this fabrication of truth regarding OxyContin's addictive qualities, individuals as well as state and federal governments have accused the Purdue Pharma of campaigning with inappropriate and incorrect information. In addition, critics of the pharmaceutical industry have linked Purdue Pharma's advertising practices with a host of social harms including manipulation of consumer perception and outright fraud (Griffin and Spillane, 2013, p. 165).
One particular reason Purdue Pharma's advertising and promotion of OxyContin was so successful was due to an extreme increase in expenditures available for marketing purposes. According to Van Zee, OxyContin's commercial success did not depend on the merits of the drug compared with other available opioid preparations. The drug offered no advantage over appropriate doses of other potent opioids (2009). Therefore, Purdue Pharma focused company assets on actively increasing consumer demand. As Van Zee (2009) noted, in 2001 alone, Purdue Pharma spent $200 million on advertising and promoting OxyContin. Purdue's promotion of OxyContin for the treatment of non-cancer-related pain contributed to a nearly tenfold increase in OxyContin prescriptions, from about 670,000 in 1998 to approximately 6.2 million in 2002 (Van Zee, 2009, p. 223). The outrageous increase of expenditures made available for the marketing and propaganda of OxyContin not only lead to a drastic increase in sales, but also in overdose and death rates.
Another cornerstone of Purdue's marketing plan was to influence or incentivize American physicians to prescribe OxyContin to their patients. As a more forward approach, the large pharmaceutical company conducted more than forty national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California. More than five thousand physicians, pharmacists, and nurses attended these all-expenses-paid symposia where they were recruited and trained for Purdue's national speaker bureau (Van Zee, 2009, p. 221). This type of pharmaceutical company convention made thousands of prescribers aware and comfortable prescribing OxyContin, directly influencing them to prescribe more often. According to Van Zee (2009):
One of the critical foundations of Purdue's marketing plan for OxyContin was to target the physicians who were the highest prescribers for opioids across the country. Purdue Pharma would compile prescriber profiles on individual physicians-detailing the prescribing patterns of physicians nationwide-in an effort to influence doctors' prescribing habits.
In addition, Purdue paid $40 million in sales incentive bonuses to its sales representatives in 2001 (Van Zee, 2009, p. 222).
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