Opinions
8 November 2021
Opioid “pseudo-addiction” lives up to crime of the century tag
NOT that long ago, Tasmania’s opium poppy industry was widely lauded for the economic boost it offered the island state.
The poppies not only offered farmers a far more lucrative crop than potatoes, they were also being used in the production of medicines that could provide much needed relief to suffering patients – or at least so the story went.
As recently as 2015, the New York Times published an article about Australia’s “Opium Island”, where pretty much the biggest challenges the industry faced were a state ban on genetic engineering and the predation of wallabies, “close relatives of kangaroos”.
Stoned wallabies “can become disoriented and lose their ability to find water”, a pharmaceutical company supply manager told the Times.
Six years on, it’s hard to imagine a major news organisation writing about the poppy fields without mentioning the wallaby in the room: opioid addiction.
Last week, I watched HBO’s The Crime of the Century , in which the poppy fields of Tasmania make a guest appearance. Tasmania is the world’s largest producer of legal alkaloids – the raw materials that make opioid painkillers.
HBO’s two-part documentary delves into the origins of the opioid crisis that has ravaged America, revealing the web of corruption and lies woven by those who stood to earn unthinkable sums from sales of the drugs.
Purdue Pharma kicked off the addictive bonanza in 1996 with the launch of its slow release opioid, OxyContin.
Determined to maximise sales of the drug, Purdue used aggressive sales tactics, including payments to top prescribers under the guise of “speaker fees”.
The marketing onslaught was portrayed as a crusade to save millions of Americans from inadequately treated pain.
In a promotional video titled I Got My Life Back, a smiling woman exclaimed: “I can be more of a partner to my husband again.”
Some doctors thought the representatives pushy, a Purdue sales director acknowledged. But they were insistent, he said, “because they are on a mission to bring this medication to people who need it”.
One rueful former sales representative told HBO he’d thought it was an honourable undertaking at the time, although he had since come to understand the devastation the drugs had caused.
It wasn’t always easy for doctors to see through the hype either.
“We were constantly being told there was a growing epidemic of pain and doctors had to do something about it,” one unconvinced doctor told HBO. “No dose is too high. And, if you don’t use them, you are a bad doctor: you want people to suffer.”
One of the keys to the commercial success of the drugs was allaying doctors’ fears about their addictive potential.
To do that, Purdue relied on the concept of pseudo-addiction, a counterintuitive theory that argued higher doses of opioids could actually prevent addiction.
If the patient’s motivation for seeking opioids was pain, that meant they were not addicted but “pseudo-addicted”, the argument went. Patients with inadequately treated pain might exhibit symptoms of addiction, but the best way to treat those symptoms and prevent addiction was to increase their opioid dose.
The implicit assumption was that pain and addiction could not coexist, as the authors of a 2015 review of the medical literature on pseudo-addiction pointed out.
In the US, the concept of pseudo-addiction had been widely accepted among clinicians and influential in medical education despite it never having been empirically verified, they wrote.
In the context of the prescription opioid epidemic, it was hard to conclude pseudo-addiction was “an objective, evidence-based diagnosis that [had] been clinically beneficial to patients’ lives”, they found.
The prescription opioid saga did not end with Purdue, which in September reached a financial settlement in relation to multiple lawsuits.
The next cornucopia for the pharmaceutical industry was a range of synthetic opioids such as fentanyl, which are now the most common cause of opioid overdose mortality in the US.
A major player in the escalating opioid epidemic was Johnson & Johnson, which had acquired poppy processing company Tasmanian Alkaloids back in the 1980s to ensure “a reliable source of raw narcotic materials”. In a recent judgement against Johnson and Johnson in Oklahoma, where 362 million opioid pills were dispensed in 2015 alone, District Court Judge Thad Balkman said scientists at Tasmanian Alkaloids were a “key part of Johnson and Johnson’s ‘pain management franchise’”.
In all, more than 500 000 Americans have died from overdoses of prescription or illegal opioids over the past two decades. The toll has been highest in disadvantaged rural communities, where oxycodone and the newer synthetic opioids have found a ready market.
Australia may not have been hit as hard as the US, but we still rank 8th in the world for the number of "defined daily doses of prescription opioids per million population".
Around 3.1 million Australians were dispensed opioid prescriptions in 2016–17, according to the Australian Institute of Health and Welfare. The rate of opioid-related deaths in this country rose by 62% over the decade to 2016, with a 25% rise in the rate of hospitalisations due to opioid poisoning in the same period.
Crime of the century, indeed.
Jane McCredie is a Sydney-based health and science writer.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
The poppies not only offered farmers a far more lucrative crop than potatoes, they were also being used in the production of medicines that could provide much needed relief to suffering patients – or at least so the story went.
As recently as 2015, the New York Times published an article about Australia’s “Opium Island”, where pretty much the biggest challenges the industry faced were a state ban on genetic engineering and the predation of wallabies, “close relatives of kangaroos”.
Stoned wallabies “can become disoriented and lose their ability to find water”, a pharmaceutical company supply manager told the Times.
Six years on, it’s hard to imagine a major news organisation writing about the poppy fields without mentioning the wallaby in the room: opioid addiction.
Last week, I watched HBO’s The Crime of the Century , in which the poppy fields of Tasmania make a guest appearance. Tasmania is the world’s largest producer of legal alkaloids – the raw materials that make opioid painkillers.
HBO’s two-part documentary delves into the origins of the opioid crisis that has ravaged America, revealing the web of corruption and lies woven by those who stood to earn unthinkable sums from sales of the drugs.
Purdue Pharma kicked off the addictive bonanza in 1996 with the launch of its slow release opioid, OxyContin.
Determined to maximise sales of the drug, Purdue used aggressive sales tactics, including payments to top prescribers under the guise of “speaker fees”.
The marketing onslaught was portrayed as a crusade to save millions of Americans from inadequately treated pain.
In a promotional video titled I Got My Life Back, a smiling woman exclaimed: “I can be more of a partner to my husband again.”
Some doctors thought the representatives pushy, a Purdue sales director acknowledged. But they were insistent, he said, “because they are on a mission to bring this medication to people who need it”.
One rueful former sales representative told HBO he’d thought it was an honourable undertaking at the time, although he had since come to understand the devastation the drugs had caused.
It wasn’t always easy for doctors to see through the hype either.
“We were constantly being told there was a growing epidemic of pain and doctors had to do something about it,” one unconvinced doctor told HBO. “No dose is too high. And, if you don’t use them, you are a bad doctor: you want people to suffer.”
One of the keys to the commercial success of the drugs was allaying doctors’ fears about their addictive potential.
To do that, Purdue relied on the concept of pseudo-addiction, a counterintuitive theory that argued higher doses of opioids could actually prevent addiction.
If the patient’s motivation for seeking opioids was pain, that meant they were not addicted but “pseudo-addicted”, the argument went. Patients with inadequately treated pain might exhibit symptoms of addiction, but the best way to treat those symptoms and prevent addiction was to increase their opioid dose.
The implicit assumption was that pain and addiction could not coexist, as the authors of a 2015 review of the medical literature on pseudo-addiction pointed out.
In the US, the concept of pseudo-addiction had been widely accepted among clinicians and influential in medical education despite it never having been empirically verified, they wrote.
In the context of the prescription opioid epidemic, it was hard to conclude pseudo-addiction was “an objective, evidence-based diagnosis that [had] been clinically beneficial to patients’ lives”, they found.
The prescription opioid saga did not end with Purdue, which in September reached a financial settlement in relation to multiple lawsuits.
The next cornucopia for the pharmaceutical industry was a range of synthetic opioids such as fentanyl, which are now the most common cause of opioid overdose mortality in the US.
A major player in the escalating opioid epidemic was Johnson & Johnson, which had acquired poppy processing company Tasmanian Alkaloids back in the 1980s to ensure “a reliable source of raw narcotic materials”. In a recent judgement against Johnson and Johnson in Oklahoma, where 362 million opioid pills were dispensed in 2015 alone, District Court Judge Thad Balkman said scientists at Tasmanian Alkaloids were a “key part of Johnson and Johnson’s ‘pain management franchise’”.
In all, more than 500 000 Americans have died from overdoses of prescription or illegal opioids over the past two decades. The toll has been highest in disadvantaged rural communities, where oxycodone and the newer synthetic opioids have found a ready market.
Australia may not have been hit as hard as the US, but we still rank 8th in the world for the number of "defined daily doses of prescription opioids per million population".
Around 3.1 million Australians were dispensed opioid prescriptions in 2016–17, according to the Australian Institute of Health and Welfare. The rate of opioid-related deaths in this country rose by 62% over the decade to 2016, with a 25% rise in the rate of hospitalisations due to opioid poisoning in the same period.
Crime of the century, indeed.
Jane McCredie is a Sydney-based health and science writer.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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