I recently watched the 2017 documentary, Heroin(e), directed by Elaine McMillion Sheldon which focuses upon three women—a fire chief, a judge, and a missionary—battling West Virginia’s opioid epidemic. Set in Appalachia’s Cabell County, this film examines the financial and real-life costs of reviving addicts in what very much seems to be an endless cycle of IV drug use related to pain medication prescription in the town of Huntington.
What is shocking in the recent rise of the opioid epidemic in the US is how the various narratives within the opioid and heroin crises have taken form such that today the trajectory of this tragedy was not only sparked by bad medical practices but also given steady institutional support despite evidence to demonstrate the mounting addiction crisis in the country. First, epidemiological data have shown that drug abusers have transitioned their addictions from prescription opioids to heroin. Moreover, several studies have shown that 80 percent too 86 percent of those who use heroin arrived at this drug through misused prescription opioids (eg. OxyContin) where the prescription opioid was discontinued and people went elsewhere to seek out pain relief. Heroin proved to be more readily available and affordable. Then there is another tier of pharmaceutical medication that factors into this crisis: that of the illicit pharmaceutical drugs, namely fentanyl, that have proven even more accessible and cheaper than heroin to procure.
For instance, a December 2018 report from the University of California San Francisco shows how fentanyl, a powerful synthetic opioid, was not only implicated in approximately 29,000 overdose deaths in the United States in 2017, but that fentanyl spread in use because of heroin and prescription pill shortages. More devastating, this report shows that it was cheaper to get fentanyl from drug wholesalers than heroin while most users have no idea that they are even taking this drug. Sarah Mars, PhD, a researcher in the Department of Family and Community Medicine at UCSF and the lead author of the paper stated, “Fentanyl is rarely sold as fentanyl. The dealers selling fentanyl directly to the users often don’t know what’s in it….Whether or not they prefer fentanyl, users don’t have any influence over what drugs are being sold.” Where countries like Estonia are experiencing an illicit drug market dominated by fentanyl, there is a real fear that this drug will take over the worldwide drug market.
Around the country, there are different chemical versions of fentanyl (also known as analogues) being distributed. However, these analogues have vastly different potency levels which makes them extremely dangerous since the strength of these drugs is uncontrolled. Some analogues like carfentanil, designed to tranquilize animals as large as elephants, are estimated to be 10,000 the strength of morphine. Mars contends, “Without accurate information about these drugs, [users] can’t make an informed choice about what they are buying. Also, very little drug slang has developed to describe fentanyl, which lends support to the notion that this is not a demand-driven epidemic.”
Another important factor to these analogues is that the DEA currently has no power to crack down on those who are illegally producing these drugs which are constantly turning out tweaked fentanyl analogues specifically to evade strict Schedule I regulations. In fact, the Trump administration is having great difficulty deciding how to address the fentanyl and copycat fentanyl crisis in terms of the law. By classifying fentanyl in all its forms as Schedule I, this would allow the authorities to crack down on illicit sales. However, one expert from the HHS’s (U.S. Department of Health and Human Services) National Institute on Drug Abuse (NIDA) told the Senate staff at June 20 briefing that permanently placing all fentanyl analogues into Schedule I poses problems, according to one participant who spoke to Reuters. This person said that by making all analogues Schedule I drugs, the fear is that it would make it more difficult for researchers to be able to study potential new approaches for dealing with the drug overdose epidemic and addictions—addictions which range from coffee to opioid.
But the toll has become one of interest to everyone within West Virginia and Ohio because this crisis has become a drain on the local economies there. Southwest Ohio’s Montgomery County has one of the highest overdose death rates in the country and this crisis is costing the state between $4 billion and $5 billion a year. The opioid crisis has affected every community in the state to include the prison populations since Montgomery County has the largest female prison population for whom thirty-five percent of all charges against women in the last decade have been drug-related. Although there has been a slight decline in the past year’s overdose mortality deaths in the US, regions like West Virginia and Ohio will likely be dealing with the repercussions from this epidemic for several generations.
What we do know is that there are direct contributing factors to this epidemic. Research shows that the “supply-led addition of fentanyl to the drug market in response to heroin supply shocks and shortages” means that the changing of prescriptions by medical professionals is a first step to reversing this crisis. This means offering fentanyl-free alternatives must be imposed upon doctors and insurers alike.
Other factors like health insurance, housing, and income directly determine how long a patient remains on medication and what alternatives there are for when the doctor-prescribed pain-management regime has expired. The central factor here is that once opioid receptors are stimulated, the areas of the brain responsible for pleasure and mood are triggered and this is where prescription drug addiction kicks in. As insurers are more invested in covering products over services, we are not seeing very many insurance companies that cover behavioral pain therapy. Clearly, this is another area which needs to be pressed between the federal and local governments in getting insurers to cover more alternative pain management regimes. Let’s not forget that the fentanyl crisis began where biopharmaceutical manufacturers sensed an opportunity to insert themselves and the more logical response from the states is to oblige all insurance companies to cover non-allopathic pain management over pharmaceutical responses. Similarly, evidence-based treatment for opioid addiction such as methadone and buprenorphine, must be rapidly in the very states (West Virginia and Kentucky) which currently prohibit Medicaid coverage of methadone maintenance and where insurance pre-authorization obstructs low threshold access among privately insured patients.
What is clear is that the opioid and heroin crisis is not going away any time soon and the national government needs a strategy in addition to listening to experts on the ground in these key states. Beginning with experts in the areas of the greatest distress will likely bring solutions as well as awareness to the public so that we can all be aware that, for instance, we all have a higher risk of opioid addiction the minute a family member is prescribed an opioid. And this crisis is not limited to Canada and the United States, as Mexico is dealing with the very same levels of addiction and mortality. While the reasons for the need for pain relief likewise need to be better understood (eg. increased obesity, surgical interventions and survivorship after injury and disease), we must be able to insist that Big Pharma and insurance companies are held accountable for invoking drastic reforms in how they market and cover pain relief.