Sources and Contributors to the Opioid Crisis: Who is to blame?

The World Health Organization cites that 70% of the 500,000 drug-attributed deaths globally are due to opioids.1 The devastating impacts of the opioid crisis begs the question, "who is to blame and why?" Although it is easy to blame this crisis on one group, such as pharmaceutical companies or physicians, the sources and contributors to the opioid crisis are multifactorial.

Pharmaceutical companies have been under the spotlight for the countless ways in which they introduced and incentivized the use of opiates. Large pharmaceutical companies push their product by financially influencing health and medical professionals, patient advocacy groups, teaching practices, public agencies, and policymakers.2 Between 2014-2015, approximately 1 in 7 physicians and 1 in 5 family physicians in the United States received gifts and incentives from pharmaceutical companies, influencing their opioid prescription practices.2 Pharmaceutical companies also donate to patient and health professional advocacy groups to promote their product and fund political campaigns to get their medications on the market.2 The Associated Press and Center for Public Integrity reported that between 2006-2015, opioid pharmaceutical companies spent an estimated 880 million dollars on lobbying and campaign donations.2 A United States Senate report further exposed pharmaceutical contributions to advocacy organizations, fracturing the integrity of groups like the American Pain Foundation that eventually lost its funding.2 Pharmaceutical companies have neglected their ethical responsibility to prevent opioid abuse and presence on the black market, an issue that Purdue Pharma please guilty to in a November 2020 hearing.2,3

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Outside of pharmaceutical influence, variations in physician prescribing practices are another contributor to the opioid crisis. Prescription opioids emerged as a way to treat non-cancer chronic pain.4 Between 2013-2016, there was a shift from prescribing low-dose opioids like codeine to more potent opioids like oxycodone and fentanyl, potentially due to pharmaceutical pressure and availability.4 Prescribing high-dose opioids is a cause for concern as their potency increases the risk for addiction and overdose.4 According to a 2019 BMC Family practice study on Ontario family physicians, divergent beliefs on the consequences of prescribing opioids and expected misuse influence prescribing practices, producing a significant variance in opioid prescribing spanning two decades.4 In fact, the study found that “high-prescribing” physicians prescribed opioids 55 times more often than their low-prescribing colleagues.4 Physicians who believed in prescribing opioids believed in their ability to manage the therapy.4 More specifically, 86% of opioid prescribing family physicians interviewed reported high confidence in opioid prescribing.4 Additionally, pharmacists can facilitate exposure to opioids by failing to effectively counsel patients on the risks of addiction and side effects.5 Varied prescribing practices and ineffective patient counselling give patients access to these potent and addictive substances without information or effective therapy management to mitigate addiction and overdose potential.5 As such, guidelines and strong patient-provider relationships can be paramount to overcoming this hurdle.4,5

Patient reliance and distribution, as well as ineffective policies and systems, can also contribute to the opioid crisis. A 2018 study from the American Public Health Association suggested that a contributor to the crisis could be opioid usage as a refuge from physical and psychological trauma.6 The study observed that substance use and abuse usually coincided with the somatization of stressful situations and experiences into pain.6 One example is the incidence of new-onset back pain due to economic hardships following earthquakes in Japan.6 Traumatic events manifesting as physical pain coupled with overprescribing opioids lead to unnecessary opioid exposure and reliance, thereby contributing to the crisis.6 Additionally, policies and insurance coverage contribute to this crisis by not covering opioids or opioids management, leading to street use and substance abuse.6 Systems like auto-refills are not always reviewed, leading to accidental overprescribing and exposure to opioids.7 Finally, a Canadian epidemiological review of the crisis found that patient distribution of medication through sharing with family members, double doctoring, fraud and forgery, and illegal selling could contribute to the opioid crisis by providing access to opioids for non-medicinal uses.8,9 As such, prescribing practices, avenues for increased toxicity, and emergence on the illegal market propelled contributed to the current state of the crisis.

Evaluating the sources and contributors to the opioid crisis illuminates the complex relationships that have influenced its progression. The interactions of pharmaceutical companies, physicians, other healthcare providers and patients contribute to a cycle of overprescribing, exposure and distribution. Addressing these factors involves re-evaluating policies and systems, enforcing guidelines and improving patient-provider relationships. Though it is clear that the contributing factors to the opioid crisis are multifactorial, perhaps the real question we must ask ourselves is not just how to address this crisis, but rather how to make meaningful changes within the system to prevent these interactions from contributing to additional crises in the future.

References

  1. Opioid overdose [Internet]. [cited 2021 Jan 14]. Available from: https://www.who.int/news-room/fact-sheets/detail/opioid-overdose
  2. Marks JH. Lessons from Corporate Influence in the Opioid Epidemic: Toward a Norm of Separation. J Bioeth Inq. 2020 Jul 13;1–17.
  3. OxyContin maker Purdue pleads guilty to charges related to opioid crisis | CBC News [Internet]. [cited 2021 Jan 14]. Available from: https://www.cbc.ca/news/health/purdue-opioid-epidemic-guilty-1.5814318
  4. Desveaux L, Saragosa M, Kithulegoda N, Ivers NM. Understanding the behavioural determinants of opioid prescribing among family physicians: a qualitative study. BMC Family Practice. 2019 May 10;20(1):59.
  5. CPhA - Opioid Crisis - English [Internet]. [cited 2021 Jan 14]. Available from: https://www.pharmacists.ca/advocacy/opioid-crisis/
  6. Dasgupta N, Beletsky L, Ciccarone D. Opioid Crisis: No Easy Fix to Its Social and Economic Determinants. Am J Public Health. 2018 Feb;108(2):182–6.
  7. Overprescribing is major contributor to opioid crisis | The BMJ [Internet]. [cited 2021 Jan 14]. Available from: https://www.bmj.com/content/359/bmj.j4792
  8. Clarke H, Bao J, Weinrib A, Dubin RE, Kahan M. Canada’s hidden opioid crisis: the health care system’s inability to manage high-dose opioid patients. Can Fam Physician. 2019 Sep;65(9):612–4..
  9. Lisa B, Jessica H. Evidence synthesis - The opioid crisis in Canada: a national perspective. Health Promot Chronic Dis Prev Can. 2018 Jun;38(6):224–33.
Aditi Venkatraman