more_vert
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.
It seems to be a “Trial and Error” judgement or miscalculation by the medical science researchers and a bad image for the global medical industry- ‘can be a good pain control but missed the addictive effect of it on the long run’.
Would say a similar story of the bad effect of Thalidomide to pregnant women in the 1950’s worldwide.
Medicine is not perfect but it needs more people with good insight and imagination, not only academic excellence with greed.
It is misinformation such as this that keeps the opioid hysteria narrative going. Jane, since prescriptions for opioids have dropped by over 50 percent over the past few years, why do overdoses keep increasing. Using your logic, we could end the meth problem if only doctors would stop prescribing it.
I truly hope you never encounter severe, prolonged chronic pain and lose everything you had worked your entire life for as many of us have. But to try to defend such an absurd premise that addiction to opioids has worse outcomes than constant, unrelenting chronic is ridiculous, naive, and makes me question your motives.
I think we all know the Purdue Pharma story by now w.r.t. opioids and chronic non-malignant pain. However I agree with the comment that overemphasising the down-sides of responsible opioid prescribing is possibly sensationalising and will inevitably lead to a resurgence of ‘opiophobia’ in some doctors faced with a patient in severe pain – then followed by inevitable therapeutic paralysis.. Unfortunately, taking a complete pain history, examining the patient (God forbid – do we do that in this world of telehealth – has Covid-19 given a ‘licence to bypass’?) correlating with imaging, making an overall patient plan with appropriate physical treatments and adequate follow up does not always occur. As a now retired palliative care physician, I have treated many patients with pain, granted mainly malignant, but some not. I have also personally experienced severe pain and have required short term opioid therapy. If I am ever in acute severe pain again, I would expect my medical attendants to treat this adequately.- however I am not sure all have the confidence to do this. Being able to anticipate and manage opioid-related side-effects, instilling confidence in the patient and re-assessing are part of the deal. It is important we don’t ‘throw the baby out with the bathwater’ in our desire to demonise opioids and then be left shaking our heads with little left in the bag…
It’s not very long ago that we were urged to get better at treating pain and not be dismissive of suffering. Pain scores entered common use, and, with them, the expectation to respond to that pain. Many good clinicians would like to take the time to educate and encourage the use of non-narcotic modalities – physical things like splinting, heat or cold, exercise or rest (as appropriate to the condition). For many people in pain, however, medication (especially STRONG medication) validates the suffering. Some patients feel dismissed if they are not given a specific prescription. Others lack the agency to keep going through the pain, to lose weight or exercise – they may be depressed, disadvantaged in many different ways.
In the past, much of this suffering was masked by cigarette smoking, alcohol and sedative use. We now have much lower smoking rates, are much more cautious about prescribing benzos and try to manage risk factors like alcohol consumption. What, then, to do for those who still have trouble coping with chronic pain – especially the elderly? There are long wait-times for pain clinics, and poor remuneration for the amount of time that should ideally be spent with suffering people.
Medicine is not the only answer – chronic pain is a socio-economic issue – but the expectation to fix it rests with health care providers.
There IS a middle way, however. We can reserve the strongest narcotics for acute pain, the disabled elderly and end-of-life care, and do our best to assist others in different ways. This won’t work perfectly, though. We will always be treading the line between “too much” and “not enough”.
I’m not suggesting for one minute that opioids are without their problems – we have all seen them, and they can destroy lives.
However, the focus seems to have entirely shifted to demonising opioids and completely ignoring the fact that they do have a place and can be very useful.
It’s very easy to focus on the negative aspects of something once problems are identified, but to do so by ignoring the benefits seems ludicrous.
As someone who regularly administers and prescribes very short periods of opioids (large doses of strong opioids) as part of an anaesthetic and for post-op analgesia I am concerned at the overly negative emphasis on opioid prescribing.
Yes – there is a problem, but perhaps the focus on the problem needs to be on inappropriate prescribing, and ongoing prescribing when they should be weaned…..a lack of ‘tough love’ perhaps? That would be much more productive in my opinion rather than what is easy and sensationalist headline grabbing!
If I am having a painful operation I want access to opioids (without the associated shame and guilt that seems to be being peddled relentlessly). Opioids can very effective and useful, and contribute immensely to intra-operative and post-operative analgesia, and are entirely appropriate and reasonable for short periods.
I’m not defending allegedly questionable marketing practices and unethical corporate behaviour – those things should be exposed for what they are, but nobody is talking about the reason we use opioids in the first place – because they work! Ultimately, due to appropriately strict regulation, in most places the population don’t get access to opioids unless a doctor prescribes them, so where does the buck stop? We (the medical profession) must be careful to avoid passing the buck for our own failings regardless of ‘clever marketing’ or ‘deceptive marketing’ or whatever you want to call it. If your name is listed as the prescribing doctor then you need to own that. I’m not saying we will get it right every time, and sometimes it is very difficult to say no to a patient, but that is part of the responsibility we took on ourselves when we got our qualifications – we can’t shirk that.
Labelling this the “crime of the century” is sensationalist marketing in its own right. Is it any worse than the poor prescribing of antibiotics over decades that has led to major issues with antibiotic resistance??
Food for thought perhaps?
Jane you quote absolute numbers for opioids dispensed then quote opioid deaths and hospitalisations as percentages. If I didn’t know you better I might think you were trying to mislead. Was the percentage rise over a decade from two deaths or two thousand?
Hi Jane,
Good article. Have you looked at the Australian branch of the IASP activities re the promotion of opioids to general Practitioners via “educational” seminars here in Australia in the early 2000s?
Cheers
Simon
MBBS 1972 Monash Uni.