By R Carter
The opioid crisis has been in full swing now since around 2010, this is when the bureaucratic machinery of government sounded “Red Alert” about a rapidly increased death rate do to opiates and the rapid growth in the number of prescribed opiates for pain conditions. I was introduced to this at the first symposium held by the State of Oklahoma in 2011, a collection of groups represented by drug manufactures, addictionologist, public health, healthcare professionals, physician groups and nursing.
Morgues were filling up and the media jumped on the story reporting the news. I remember one of the first articles I read was about county morgues having to rent refrigeration trailers in order to have enough space to store the bodies. The more outrageous the story or the higher the body count, the wider the circulation on an article and isn’t this what news agencies are all about? Selling advertising so you can pay the bills and building a following, so it only follows, the more shocking the headline, the more attention your story gets.
I’m not a journalist, I am in fact a healthcare and IT professional by trade, retired now, but because of my thirty years in healthcare, practicing anesthesia, I was intrigued by this story and decided to start following it closely as it evolved.
As time went by the story morphed into something altogether different, rather than opioid overdose deaths from street drugs as the cause, the narrative became opioid overdose deaths from prescription opiates. One can understand this assumption, after all, the number of prescription written for opiates was climbing along a similar path to that of opiate related deaths, but it was still an assumption which was not built on facts. There was literally no way to connect the dots between overdose deaths and drug sources and that wasn’t the only obstacle, we had no way of collecting details on this phenomena which would give us a comprehensive view nationwide.
And to some extent, that problem still exists today. Changing what data gets collected, how it is collected, complied, cross referenced, verified, from hospitals, morgues, pharmacies, pharmaceutical manufactures, distributors, law enforcement, crime labs, state agencies and non-profit sources, to form a profile of specific sources, legal or illegal, takes 10 to 15 years at a minimum on a national level, and costs billions.We didn’t start this effort in full force until around 2012-2014.
Prior to 2010 our nation’s means of documenting a drug overdose from opiates was essentially limited to identifying heroin during an autopsy. But since heroin is quickly converted to morphine in the body, even this remains an unreliable data point for identifying legal vs illegal sources. With the sophistication of today’s black market, identifying trace elements related to illegal sources is more difficult at autopsy with adulterants used in cutting heroin ranging from rat poisoning, laxatives or powdered milk to Fentanyl. But with Fentanyl costing significantly less than Heroin, it’s now rare to find Heroin which does not include Fentanyl as an adulterant.
In 2010 prescription opiate deaths occurred so infrequently, there was no need for the expense of documenting them and doing so was left to the discretion of the coroner or primary care provider filling out the death certificate. Most death certificates today are still prepared by a primary care provider and with a lack of standards and guidelines on how to complete them, we are still incapable of collecting large reliable datasets on specific causes of death. Likewise, toxicology testing for confirmation was rarely performed except in cases where foul play was suspected or other causes could not be confirmed. New laws in some states now require toxicology testing on suspected overdose deaths but without a compulsory law requiring it on all deaths, the true facts will remain unknown. Reviewing how this data is collected confirms how unprepared we were for what was occurring. See “How Prescription Opiate Overdose Data is Collected”, Part 1, Part 2, Part 3.1, Part 3.2
In 2012, despite the growing number of written prescriptions, something about laying the blame on prescription opiates just didn’t set well with me. Genetically speaking, the actual addiction rate for the whole population runs around 5%, so assuming prescription opiates as the cause would require 7x as many written prescription as what was being reported, so there had to be another source for these drugs.
Not trusting the references cited in the publications I read, I began fact checking every source available. I discovered what appeared to be a deliberate effort to twist and distort facts when the data was inconclusive. In other cases, authors reported unsubstantiated opinions despite what the data was telling them. If the numbers didn’t add up, then conclusions were published which cleverly misdirected the reader into drawing conclusions which made the point of the author. I had to wonder, what could be behind the bias that would cause men and women of science to so consistently deviate from scientific principles?
My question was solidified after reading a paper from a non-profit whose mandate was to review research performed by others in specific industries. Their conclusions about medical research were alarming, more than 25% of all medical research failed to meet quality and accuracy standards, not following scientific principles required for reliability. Given the way medical research is cited by other researchers, the compounding rate for these errors appearing in other research meant that as much of 65% of medical research fails to meet quality standards.
The combination of poor research standards, profit motive, compromised ethics, ideological bias, political pressure and a rush to judgement by the press, is a bad combination when making policy which affects the health and lives of millions, but in my opinion, these are the contributing factors which lead to an illegal drug problem becoming a prescription opiate crisis.
As the opiate problem grew to national attention I decided to publish my own findings, not that it would make a difference, but at least someone would be reporting truths which could not be bought with money, political influence or affected by poor ethics. That’s when I decided to test the theory, if it bleeds, it leads, meaning, the more outrageous the claims, the more attention garnered by it, leading to the article being published without fact checking simply because it sells the drama and controversy surrounding a topic.
My test articles was based on a half-truth, one which capitalized on the extreme measures being taken by the media, government and public health to demonize the use of prescription opiates and their use in treating chronic pain. I titled the article “Frontal lobotomy for the relief of intractable pain” and in it I quoted research references to an old out dated practice of performing a frontal lobotomy for a number of different and untreatable ailments, including chronic pain. Being unknown in the world of blogging, up until then I was getting less than 50 views per post and had at best, 200 subscribers on my blog. But with one post that all changed. Within two weeks of posting, I had over 1,000 shares and 5,500 views with traffics rates that exceeded 500% of average.
While not a conclusive effort to prove a point, few would argue the results lacks a basis. About the same time the media had towed the line of government and public health rhetoric, one which had morphed into laying the blame for the opiate crisis and opiate related deaths at the feat of prescription opiates and had further demonized the treatment of chronic pain by primary care providers as the leading cause. All of which could only be supported with inconclusive evidence which was contradicted by a body of evidence going back more than a hundred years. Yet after years of searching blog and news articles on these facts only a very small number report them and none of the major news outlets report it.
It wasn’t until reports of Vets committing suicide following forced tapering or termination of pain medication started appearing, that the media found another dramatic counter point which added to the drama of the opiate crisis. With this reporting, a new perspective emerged and those who had warned of this outcome for more than five years began getting the attention needed to provide an alternative perspective to the nation’s kneejerk response on opiates. With this trend the media is now reporting another perspective, but just as before, only the headlines which attract the drama, depth of research is still lacking, leaving it to a brave few to do the hard work of fact checking the details to get the story right.
My point of view remains this. Both Federal and State governments were caught off guard and unprepared for what became a loosening of morals within society, one which was fueled by the good times to be had on the back of substance abuse and a black market more than willing to sell a product equal in quality to any pharmaceutical manufacture. Prior to 2010 the only sources of Fentanyl in the black market came from those clever enough to steal it from pharmaceutical companies, divert it from distributors and a handful of manufactures which supplied those sources. Today, the black market is far more sophisticated, able to produce large quantities of illegal Fentanyl, Carfentanyl, Hydrocodone, Oxycodone and others, which appear on Coroner Toxicology reports as the genuine stuff sold by legal sources, leading to the false assumption that the opiate crisis is really one of large scale diversion of legal sources or over prescribing by physicians.
Now that government is responding through better data collection, improved toxicology testing and prescription drug monitoring programs, a new picture is beginning to emerge, one which is line with what I and many others have believed for ten years. The opiate crisis is a crisis fed by the illegal drug trade, a government asleep behind the wheel and law enforcement which has not had the tools and resources needed to fight the battle against illegal importers and a growing number of domestic entrepreneurs.