In the first two decades of the 21st century, about 649.000 Americans died from of an overdose related to an opioid, either illegal or prescribed by a doctor, according to the United States Centers for Disease Control and Prevention (CDC).
In the book “The empire of pain”, published in 2021, the American journalist Patrick Radden Keefe points out that today opioids “are the main cause of accidental deaths in the country”.
“More lives are claimed than traffic accidents, and even than the most prototypically American of the factors accounted for: gunshot wounds”, he highlights.
Radden Keefe, who participates in the Hay Festival of Medellín and Cartagena, analyzes in his ob The origins of this epidemic, which was declared a national public health emergency.
The investigative journalist of The New Yorker magazine traces the beginning of the crisis to the appearance of the first opioid analgesic in general use: OxyContin, in 1994.
His work focuses on the dark plot behind the creation and marketing of this popular painkiller by the Sackler family, one of the richest dynasties in the US
And it reveals how the aggressive marketing strategies they used to promote OxyContin -a drug more powerful than morphine and highly addictive- led to what the CDC calls the “first wave” of crisis: that of prescription opioids.
- The Sacklers, the reserved family of billionaires who are said to benefit from the opioid crisis in the US
Addiction Adding to OxyContin and other opiate pain relievers such as Vicodin and Percocet, led hundreds of thousands of Americans to turn to another opioid, this time illegal: heroin (the “second wave” of the crisis).
Eventually, many addicts switched to synthetic opioids, particularly fentanyl or fentanyl (the “third wave” which is still going on, and kills about 50 people per day, according to the CDC).
But Radden Keefe’s research reveals that OxyContin’s massive success wasn’t just due to the Sacklers’ unscrupulous tactics, but context was also key.
The painkiller’s makers – points out – took advantage of a phenomenon that had been brewing in the American medical establishment in those years: a growing obsession with finding ways to alleviate suffering caused by chronic or minor conditions.
“It’s over I find it very useful that, at the time when the Sacklers began to develop OxyContin, the way in which pain treatment was approached was being thoroughly reconsidered among doctors, ”he says in the book.
“Between 1990 Y 1994, morphine use in the US had increased by 75% ”, he relates, about the years prior to the launch of OxyContin.
“According to company estimates, 50 millions of Americans suffered from some form of chronic pain, and right there lay the market they wanted to reach“.
Avoid pain
According to the American Society of Interventional Pain Physicians, in the USA 50% of opioid analgesics produced in the world.
A commission created in 2017 by The Lancet scientific journal to monitor global access to palliative care and pain relief, concluded, meanwhile, that Americans receive 30 times more opioid analgesics than what they need.
The flip side of this excess – the commission pointed out – is that, while the United States monopolizes these medications, which are the most effective for treating acute pain, such as that caused by cancer or postoperative, in the rest of the world there are serious shortages.
Mexico only receives the 36% of what you need. China on %. And India barely 4%.
Some call it “the other opioid crisis”.
Ironically, this quest to avoid pain has brought enormous suffering to the US, with opioid overdose deaths quintupling in the past two decades, according to the CDC. .
But despite the fact that the risks of consuming these highly addictive painkillers are well known, the agencies pointed out in a report that they are still very prescribed: in 2017 there was three times more medical orders to use opioids than at the beginning of the century.
- “The worst years of the opioid crisis in the US has not passed”: Anna Lembke, American psychiatrist expert in addictions
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Why do doctors in the US prescribe a drug that has done so much or harm?
And why do Americans continue to use these dangerous painkillers to relieve chronic pain?
A problem “ American”
In an article entitled “Why opioids are such an American problem”, the BBC’s Washington correspondent Owen Amos explained the series of factors that came together to make the US become a nation addicted to painkillers.
-Doctors “courted”
Amos pointed out that one of the great problems is how pharmaceutical companies in the US “court” doctors to prescribe their products, something that Radden Keefe describes in detail in his book.
There he tells, for example, how the company of the Sacklers, Purdue Pharma, manufacturer of OxyContin, spent US$9 million alone “inviting the professionals they were trying to persuade to lunch.”
A US study in 2016 looked at the link between doctors, the free meals they received from pharmaceutical companies, and the drugs they prescribed.
Found that receiving free meals was “associated with a higher prescription rate than the promoted brand”.
-The “fifth vital sign”
Amos He also referred to the movement within the medical establishment that, at the time OxyContin appeared, was lobbying for more attention to be given to pain management.
“At the end of the decade of 1990, the Veterans Health Administration, which administers health care for veterans military, pushed for the pain to be recognized c as the ‘fifth vital sign’”, he said.
“This gave the pain the same status as blood pressure, heart rate, respiratory rate and temperature”.
In an interview with BBC Mundo last June, the American psychiatrist specializing in addictions Anna Lembke said that this concept of rethinking pain treatment – which she considered “the core of the pharmaceutical marketing agenda” – put a lot of pressure on doctors.
“First, spread the message that pain is being ‘undertreated’. Then, it spreads the message that opioids are an effective treatment for all types of pain”, he pointed out.
“And spreads the message that any doctor who does not prescribe opioids is “undertreating” pain, reserving a remedy that would prevent suffering and therefore, was indirectly harming patients ” .
“These doctors were embarrassed”, he said.
-Insurers
Amos’ research pointed to another structural problem in the US health system that has fostered the use of opiate analgesics: health insurance.
In the US there is no universal health care system and people should take out their own insurance, he pointed out.
“Most insurance, especially e for poor people, they only pay for pills “, explained the medical expert in the opioid crisis Judith Feinberg, professor at the West Virginia University School of Medicine .
“Let’s say you have a patient of 45 years. She has lower back pain, you examine her and she has a muscle spasm. Physiotherapy is really the best, but no one will pay for that. So the doctors prepare to pull out the prescription pad“, he stated.
“Even if insurance covers physical therapy, you probably need prior authorization (from the insurance company), which implies a lot of time and paperwork“, he added.
Phillip Coffin, a physician expert in addictions, a professor at the University of California in San Francisco (UCSF), pointed out that something similar occurs with people who, due to chronic pain that prevents them from continuing to work, want to collect financial assistance for disability.
“For a patient can access the disability benefit, there are two things that the doctor must do: diagnose it and treat that ailment.”
“How HMOs (medical insurance) do not want to pay for complex treatments to treat pain, which are expensive, and the only thing they are willing to cover is go are opioids, the doctor must prescribe these painkillers so that the patient can access financial assistance for disability”, he explained during a conference on the opioid crisis at UCFS at 1996.
-Poorly trained
But why do so many doctors prescribe opioids and not other less harmful pain relievers?
One of the explanations Amos found, speaking with experts, is that many health professionals are simply poorly prepared.
“Physicians have received almost no training in pain management,” said Richard Frank, professor of health economics at Harvard Business School, and former US Department of Health official
“Until recently, there were some pretty big misconceptions about how addictive various products are,” he said.
Radden Keefe gives an account of this in “The empire of the d odor”.
There he explains that many of the doctors who started prescribing OxyContin believed that oxycodone, the active ingredient in that painkiller was “softer than morphine”, when in fact it is “about twice as powerful“.
The book also points out that Purdue Pharma took advantage of ignorance of many professionals, not only reinforcing this misconception, but also convincing them of other falsehoods.
For example, that “’less than l 1%’ of patients who had taken OxyContin had developed addiction” or that it was “almost impossible for people with chronic or severe pain to become addicted”.
-A cultural problem
But the background of the crisis of opioids -concludes Amos- is “the culture of medication” that prevails in the US
It is based on two parallel phenomena.
On the one hand, the high number of Americans who report feeling pain, a figure that could be associated with health problems such as obesity and sedentary lifestyle, but which -for many experts- also reflects a high sensitivity or low tolerance to pain, which is a very subjective experience.
In 2019, a survey by the National Center for Health Statistics revealed that the 58,9% of Americans older than 18 years old claims to suffer some kind of pain.
Another survey of 2011 of the International Social Survey Program showed that the US It is the country with the highest perception of pain in the world, widely surpassing nations such as Russia, China, France, South Africa and Chile.
Added to this is a second cultural peculiarity, something that psychologist Keith Humphreys of Stanford University described like the belief of some Americans that everything in life is “fixable”.
According to Humphreys, if a man like him, of more than 45 years old, he goes to his doctor and tells him that he ran a marathon that he used to run when I had 30 years old, but now he is all sore and wants the doctor to fix it, “my doctor will probably try to fix me”.
“If you do that in France, the doctor would say: ‘It’s life, have a glass of wine, what do you want from me?’”.
This attitude of the Americans of wanting to cure any ailment is enhanced by a third cultural characteristic very typical of that country: the commercials that promote medicines.
EE.UU. is one of the few countries in the world that allows television ads for prescription drugs, Amos says.
This has led to pharmaceutical companies to invest more than US$6.000 millions each year to promote their products, according to the consulting firm Kantar.
Feinberg, who is a clinician, said that the result is that “people are going to see you and say: ‘I saw this on TV, can you give me this drug?’”, which puts additional pressure on physicians.
Although the American Medical Association has requested that prescription drug ads were banned, they are still allowed today. 
“It is obvious that there is an inclination and a habit of relieving pain with opioids that is not shared anywhere else (in the world), “said the expert.
“Other countries deal with pain in much healthier ways“.
This article is published within the framework of the Hay Festival Medellín , a meeting of writers and thinkers that takes place in that Colombian city between the 25 and the 27 of January of 2022.
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