The opioid epidemic is a crisis more than 30 years in the making, and one that continues to worsen. According to The Lancet, without urgent intervention, more than 1.2 million additional opioid overdose deaths are expected in North America by 2029, and the epidemic is set to expand globally.
However, as experts expressed at the recent launch of the Stanford–Lancet Commission on the opioid crisis, a commitment to reform and progress — powered by innovation, regulation and compassion — could curtail the global spread.
Dr Keith Humphreys, the Esther Ting Memorial Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, explained that the opioid crisis is the consequence of three interlinked problems. Starting in the 1990s, he said, the pharmaceutical industry’s unregulated push to increase the number people who were prescribed opioids resulted in many millions of people becoming addicted. Addiction to Rx opioids can lead people to turn to illicit drugs such as heroin and synthetic drugs such as fentanyl, creating an opportunity for people who sell these drugs. In 2014, fentanyl started infiltrating the supply of street drugs.
That shift — from something that started in the healthcare system and expanded into the illegal market — makes the problem much harder to deal with, Keith said:
As tough as it was getting decent regulations around the pharmaceutical industry, it is — at least theoretically — regulatable. You can’t regulate a lab in somebody’s sink in China who’s mailing fentanyl precursor chemicals to Ohio.
What’s more, the crisis — which is often seen as a US issue — is rapidly becoming global. “It’s a very common view that it’s a US problem,” Keith said. “But part of the reason that the Commission focuses on North America is that it’s almost as serious in Canada as in the US, despite Canada having less inequality, universal healthcare and more generously provided treatment.”
The report also highlights the 15-fold increase in opioid dispensing in Australia between 1992 and 2012, and trends around the aggressive marketing of opioids in European healthcare. Keith explained:
That’s coming about because suppliers are often the same companies, or mirrors of the companies, that drove this in the US. And they can do things abroad that they’re no longer allowed to do in the United States, including not tell the truth about the relative risk and benefit of these kinds of medications.
Alongside the report issued by the Commission, Keith’s commentary paints a dire picture: an escalating crisis expanding globally, driven by international pharma and unregulatable illegal operators, claiming the lives of millions.
Charting a course of action
Because of the gravity of this problem, the Commission also focuses on action — making it clear that a sustained, multi-pronged program of action will save many lives.
For example, one of the recommendations from the Commission is to support the development of new non-addictive pain management options alongside more effective prescription drug monitoring programs and safer prescribing protocols. The COVID-19 pandemic showed that policymakers, healthcare providers and drug companies can move quickly, effectively and in concert when the stakes are high, so how can society generate the same urgency around the opioid crisis?
Dr Rebecca Cooney, North American Executive Editor at The Lancet, believes the answer lies in global collaboration:
COVID showed us what remarkable things we can do with a time-limited, resource-intensive but giant-payoff situation. If you have international investment and a pan-organizational interest in solving a problem, you can do it. It’s going to take bringing people together who don’t necessarily always agree, to look at new ways of treating something like this.
Keith agreed, noting that the benefits of creating new pain management therapies go beyond the people who are already suffering from opioid addiction:
Sometimes private institutions are averse to this issue. They’re afraid to create medications that help a deeply stigmatized population. But there are populations other than the addicted who benefit. If you can make a pain reliever that’s not addictive, it benefits everybody — like a kid with a broken ankle who’s never had an opioid in his life. The incentive is there.
Part of the purpose of the Commission is to generate the sense of urgency necessary to make that kind of progress. Keith notes that the current data around opioid overdoses “rolls into Washington about six months late” and is often lacking in detail and accuracy. By clarifying the scale of the problem, the Commission is looking to trigger urgent action.
Among the recommendations from the Commission is to invest in young people to reduce the risk of addiction in the first instance , or break the cycle of addiction. That can mean programs that aim to strengthen health, well-being and school readiness starting in young people, as well as helping build the tools to help young people navigate risks around addiction. Those initiatives can start earlier than you might think.
“You can literally start when they're in the womb,” Keith said, noting that the report highlights the Nurse Family Partnership setup to help first-time mothers on low incomes deliver healthy babies and get the information and support they need to assure a healthy start for their children.
“There's no discussion of drugs in that program at all,” Keith said, “yet kids who were in the program are less likely to smoke, drink or have problems with drugs if that basic investment is made.”
Promoting compassion for a universal problem
Another way the report recommends tackling the problem is by promoting compassion when dealing with people suffering from opioid addiction. Keith’s comment on “stigmatized populations” alludes to a long history of negative portrayals of addiction in politics and in the media. The Commission itself recommends that addiction should not be treated as a moral failing that needs punishment but as a chronic health condition that requires ongoing treatment and long-term support. Is there a way to promote that more compassionate approach in an environment where demonization of people suffering from addiction continues? Rebecca believes so:
I think there’s a really fascinating groundswell of bipartisan legislation, partially driven by the mental health awareness that is itself driven by the pandemic. It’s a really timely place for us to be considering addiction and the prevention of addiction in the same sentence as mental health and consider that what has previously been seen as a moral failing is actually a mental health issue.
Keith noted that the willingness for people across the political divide to cooperate stems in part from the particular profile of the opioid epidemic. Whereas previous addiction epidemics — crack-cocaine, heroin, methamphetamine — were focused on under-resourced or minority communities, the opioid epidemic is universal, which prompts a universal response:
This problem is everywhere. You cannot sit in the United States or Canada and say, ‘Oh, addiction is something that happens over in the bad neighborhood in the other side of town.’ Everyone knows someone, which maybe prompts them to be more compassionate.
By way of example, Keith pointed out that even with all the polarization in American politics, Congress has passed increasingly strong laws to require insurers to cover addiction treatment:
They’re fighting on everything else, but this goes through. I think a big part of that is that they’re hearing from their constituents — left wing, right wing, rich, poor, middle class — that this is destroying them.
Taking a cue from anti-smoking progress
As widespread as the problem is, there are examples of other embedded healthcare problems that demonstrate how progress can be made. Keith compares the opioid epidemic to the challenges around smoking. It makes for a good comparison, being a very widespread addiction backed by politically and economically powerful industry actors, yet, as Keith points out, “massive” progress has been made over the past decades. In some ways, he said, the battle was harder with tobacco than it is for opioids.
For the tobacco industry, tobacco was existential. They had one product. Pharma has a whole load of other products they make, so they should fight less hard to start doing the right thing, whereas with tobacco, it was a fight to the death on every single point. That makes me optimistic.
He also highlighted the magnitude of addiction survivors, who number in the many millions. He acknowledges that it’s not always easy for people to come out and talk about their stories, but these individuals show what a difference treatment and support can make:
The deaths are heartbreaking and crushing to our spirit, but the millions and millions of survivors are part of the story, too. It’s not all doom and gloom — these people in recovery are healthy, they’re in school, or they’ve got a job — they’re parenting kids and doing all the things you hope to do in life.
For Rebecca and Keith and the dozens of other people involved in the Commission, the journey continues. They will be meeting with government officials across the US and Europe to share their findings and recommendations and continue to build the urgency and intensity that will spur action.
Rebecca reflected on these next steps, saying:
I think this is a tremendous opportunity, especially alongside the President’s reboot of drug policy. We can bring the number of deaths down. We can frame the opportunities and challenges that come next. And I hope we can be inspirational for the people who are just starting their journey, whether it’s in a course of education or becoming a medical specialist, to shape what they do next.
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