Opioids are a class of drugs that bind to the brain's opioid receptors (Falloon, 2018). When opioid receptors are filled, people experience pain relief as well as feelings of calmness and euphoria (Falloon, 2018). Prescription opioids like oxycodone affect your brain in the same ways that heroin - an illicit opioid - does and have comparable levels of addiction potential. Cigarettes are a popular way of smoking tobacco, which contains the drug nicotine. Nicotine works by binding to neuron receptors for the neurotransmitter acetylcholine (West, 2017). Cigarettes have high addiction potential because they “provide highly controllable doses of the drug, nicotine, rapidly to the brain in a form that is accessible, affordable, and palatable” (West, 2017). It is also possible that certain chemicals in cigarette smoke increase nicotine's addictive properties (West, 2017). Although they fill different neural receptors, opioids and nicotine both cause a release of the neurotransmitter dopamine in a part of the brain called the nucleus accumbens, a process which is thought to be the key factor to addiction (West, 2017). When dopamine is released in the nucleus accumbens, it causes a neural association to be made between the action that immediately preceded the dopamine release and the current situation being perceived (West, 2017). This is why certain objects, places, or even people are ‘triggers' for drug addicts; in the case of cigarette addiction, for example, if someone frequently smoked at a certain spot, they may crave nicotine when near that spot because their brain made a connection between being there and the dopamine release that came from smoking. Addiction comes in two phases: an impulsive and compulsive phase. In the impulsive phase, drug use stems from seeking the feeling of pleasure the drug can cause. However, the receptors eventually become desensitized, and more of the drug is needed to achieve the same high (Falloon, 2018). Once the receptors are more desensitized, the addict begins to enter the compulsive stage of addiction, where instead of gaining pleasure from the drug as in the beginning, they have to use the drug just to avoid withdrawal (Falloon, 2018). Only about half of people who smoke cigarettes report enjoying it, suggesting the other half of smokers only do it compulsively (West, 2017). Even for those who do not enjoy smoking, it is difficult to quit. Only around 5% of unaided attempts to quit smoking succeed for longer than 6 months, after which point there is a 50% rate of relapse (West, 2017). Opioid users also continue use of the drug not out of enjoyment, but for fear of withdrawal, which can cause intense body pains, agitation, and cravings for more opioids (Falloon, 2018). Withdrawal is a physical phenomenon that can in some cases be lethal without medical treatment, and because the intense suffering can be immediately relieved by taking more opioids, 90% of treated users return to addiction (Falloon, 2018).
Did They Know if Their Products Were Addictive?
There is substantial evidence that major tobacco and pharmaceutical companies in the U.S. have been aware that their products were addictive for a long time, even if they did not publicly admit to it at the time. In one case, files from Philip Morris, a major American tobacco company, from 1977 documented the company deliberately covering up their own research. A memo regarding the company's research into the properties of nicotine said that results showing no withdrawal effects of nicotine would be “pursued with vigor”, while results showing addictive properties to nicotine should be “buried” (“Tobacco memo,” 1996). There was even a note from a researcher for the company which said that “important documents should be sent to his home so he could destroy them” (“Tobacco memo,” 1996). Eventually, some did openly admit their knowledge - the Liggett Group Inc., one of America's five leading tobacco companies, finally acknowledged publicly in 1997 that cigarettes are addictive (Portner, 1997). However, this was already public knowledge, as it was nearly a decade after the US Surgeon General declared nicotine an addictive substance in 1988 (Landman et al., 2008). The opioid industry could not hide that opioids were addictive – everyone knew of the addictive properties of morphine and heroin – so their goal was to convince the medical community and the general public that their products were different from those other opioids, that their pills could not be abused, and that almost no one gets addicted to opioids if they're prescribed by a doctor. Industry giant Purdue Pharmaceuticals did the same thing as the tobacco companies by covering up evidence suggesting their product was addictive. Purdue received multiple reports from 1997-1999 of rampant abuse of their painkiller Oxycontin, and internal documents confirm they were aware of their drug's significant abuse at the time (Meier, 2018). Despite this, company officials maintain their claim that they did not learn of Oxycontin's abuse until early 2000 (Meier, 2018).
How Did They Market Their Products?
Major tobacco companies and Purdue Pharmaceuticals both have a history of using deceptive and morally dubious advertising to market their products. One of the strategies used was distributing promotional merchandise for their products. One tobacco company admitted the industry targets minors by giving away merchandise with cartoon mascots, and a lawsuit banned former industry practices of using appealing advertising in publications with a large youth readership, giving away or selling promotional merchandise, and having cigarette vending machines in places that cater to children (Portner, 1997). Though aimed at healthcare professionals instead of children, Purdue Pharma practiced similar strategies by distributing “OxyContin fishing hats, stuffed plush toys, and music compact discs (“Get in the Swing With OxyContin”)”, which the Drug Enforcement Administration described as “unprecedented for a schedule II opioid” (Van Zee, 2009). Purdue's advertising to doctors was exceptionally aggressive and manipulative, involving strategies such as paying pain specialist Dr. Russell Portenoy to tell doctors that opioids were not addictive (Deprez & Barrett, 2017). Some of their tactics even bordered along the lines of bribery:
From 1996 to 2001, Purdue conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California. More than 5000 physicians, pharmacists, and nurses attended these all-expenses-paid symposia… It is well documented that this type of pharmaceutical company symposium influences physicians' prescribing… (Van Zee, 2009)
Purdue strongly incentivizes its sales representatives to frequently visit physicians with high opioid prescription rates, giving bonuses nearing $240,000 for individual salespeople and spending $40 million in bonuses in the year 2001 alone (Van Zee, 2009). Promotions for OxyContin consistently minimized the risk of addiction, emphasizing an unsubstantiated claim that less than one percent of patients become addicted to opioids (Van Zee, 2009). Tobacco companies also used deceptive marketing to minimize the appearance of risk with their products by forming the “Associates for Research in the Science of Enjoyment”, whose goal was to promote the health benefits of legal substances such as tobacco, citing stress relief and relaxation, while concealing their origins with tobacco companies (Landman et al., 2008). In order to influence public opinion to be more favorable towards tobacco, the association “created favorable surveys and opinions, infusing them into the lay press and media” (Landman et al., 2008).
How Their Products Affected Public Health
Tobacco smoking and opioid abuse are two of the leading causes of preventable death in the country and worldwide. Approximately 6 million people worldwide suffer from premature death from smoking, with an average of 10 years of life lost (West, 2017). By 2002 in the United States, the number of unintentional overdose deaths on prescription opioids surpassed those of both heroin and cocaine (Van Zee, 2009). Overdose is nearly always the cause of deaths related to opioid abuse, but needle-sharing diseases such as hepatitis and HIV are common among addicts (Van Zee, 2009). Tobacco does not have one directly related cause of death like opioids do with overdoses. Instead, tobacco-related deaths come from diseases caused by smoking, such as cancers (most commonly of the lung), respiratory disease, or cardiovascular disease (West, 2017). Although not necessarily a direct cause, smoking greatly increases one's risk of stroke, Alzheimer's disease, blindness, deafness, peripheral vascular disease, pain, and disability (West, 2017). Smoking also causes reduced fertility, and smoking while pregnant “causes underdevelopment of the fetus and increases the risk of miscarriage, neonatal death, respiratory disease in the offspring, and is probably a cause of mental health problems in the offspring” (West, 2017). Exposure to secondhand smoke is a major public health concern, as merely being exposed to a smoky environment increases risk of smoking-related health problems (West, 2017). Smoking is on the decline in the United States, but opioid abuse has skyrocketed in the past two decades. Lifetime nonmedical OxyContin use rose from 1.9 million in 2002 to 3.1 million in 2004, with 615,000 new nonmedical users of OxyContin in 2004 (Van Zee, 2009). By then, OxyContin was the most widely abused prescription opioid in the nation (Van Zee, 2009). It was not just OxyContin that has been on the rise, though. “Nationwide, from 1997 to 2002, there was a 226%, 73%, and 402% increase in fentanyl, morphine, and oxycodone prescribing, respectively”, and during this period “hospital emergency department mentions for fentanyl, morphine, and oxycodone increased 641%, 113%, and 364%, respectively” (Van Zee, 2009).
Should They Be Financially Accountable for Their Behaviors?
As attorney general of Mississippi, in 1994 Mike Moore negotiated the “largest corporate legal settlement in U.S. history” against tobacco companies for “lying about nicotine addiction and hold them accountable for sick smokers' health-care costs” (Deprez & Barret, 2017). The $246 billion settlement continues to fund smoking cessation and prevention programs that have resulted in a significant decline in smoking rates (Deprez & Barret, 2017). He now believes that a similar legal battle should ensue against the pharmaceutical companies responsible for the current opioid epidemic. The U.S. Centers for Disease Control and Prevention estimated the cost of the opioid epidemic to the U.S. economy to be $78.5 billion in 2013, with a quarter of the cost being funded by taxpayers – by 2015, the cost grew to over $500 billion for that year alone (Deprez & Barret, 2017; Schulte, 2018). Lawsuits argue that the companies responsible should bear the financial burden instead of the taxpayers and the victims of reckless prescribing (Deprez & Barret, 2017). Moore's goal is to get a “comprehensive, company-funded national program that would make treatment more widely available… as well as expand prevention education and force a change in doctors' prescribing habits” (Deprez & Barret, 2017). The opioid manufacturers' main defenses include causation – arguing that they are not responsible for getting pills into the wrong hands – and evidence being too old to be credible by some state laws (Deprez & Barret, 2017). Purdue Pharmaceuticals has previously pleaded guilty to felony charges of misbranding, and almost had three top executives sent to prison for, among other things, conspiracy to defraud the United States – they instead paid a fine of $634.5 million and performed community service (Meier, 2018).
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