The Opioid Tragedy

The Opioid Tragedy, Part 1: “We’ve Addicted an Entire Generation” (Ep. 402) - Freakonomics Freakonomics

"Barack OBAMA: We are seeing more people killed because of opioid overdose than traffic accidents...

Aside from the loss of life, the broken families, consider the economic cost of prescription-opioid abuse. The Centers for Disease Control and Prevention recently put that number at nearly $80 billion a year, once you add up the healthcare costs, addiction treatment, lost productivity, and policing and imprisonment. When it comes to unintended consequences, this one is hard to beat: $80 billion a year to treat the pain and suffering of a product intended to treat pain and suffering... In one recent year, for instance, twice as many people died in Philadelphia from drug overdose — most involving opioids — as from homicide. The city’s health department estimates that some 75,000 Philadelphians are addicted to heroin or other opioids: that’s nearly five percent of the population...

PERRONE: A lot of lobbying to medical boards and the Joint Commission led to this idea that we’re going to use a pain scale and that we’re going to count a pain scale as a vital sign. You know, vital signs are blood pressure, heart rate, respiratory rate, and temperature. And pain scores, are subjective. Whereas vital signs are objective. But they really somehow fooled us into thinking that pain was a vital sign as well, and that we needed to treat it more liberally... Medical advisory boards were involved. There were fines. There was at least this threat of fines to physicians who weren’t treating pain appropriately. And then there were patients who could complain to hospitals that they thought they weren’t getting their pain well treated. And that led to sanctions against clinicians...

The Joint Commission, the medical-accreditation agency, pushed doctors to adopt pain as a new vital sign even though, in retrospect at least, this is an obviously problematic idea. For one thing, it’s hard to reliably measure pain, and especially hard to measure it consistently across patients, the way you can measure blood pressure or heart rate. There’s also the fact that painkillers are, by their nature, a desirable medication — they literally make your pain stop — so you can imagine patients demanding them a bit more adamantly than they’d demand a statin or an ACE inhibitor...

When you hear about people using, and dying from, heroin — an illegal drug — you might think of them as a different category of drug user than the people who take legal prescription painkillers. But it’s intellectually dishonest to divorce those two populations. The fact is that roughly 80 percent of Americans who use heroin started down the path with prescription opioids. And that path was laid by the promiscuous dispensation of prescription opioids in hospitals and doctors’ offices...

MODESTINO: What’s been kind of interesting is there’s been a reverse trend in terms of racial differences. So it’s something that’s affecting the white community more than the African-American or Hispanic community... You know, oddly enough, it seems that discrimination perhaps, in terms of prescribing for pain, or the ease of giving these kinds of medications to people of different races, had a perverse outcome that actually protected African-Americans.

DUBNER: Meaning, white privilege would make one more likely to get hold of an opioid prescription in the first place, yes?...

Opioid addiction is not unique to the United States. Overdose rates have also risen in Canada and Australia and Europe. But we are, unfortunately, the world leader, and by quite a margin. With just 4.4 percent of the global population, we consume more than 80 percent of the world’s opioids...

[On pill buybacks] At least half the patients who did return their pills brought back the entire number of pills they’d been prescribed. Meaning: they did not feel the need to take a single pill. And yet: those pills still got prescribed. So despite all the new prescribing guidelines; despite all the lawsuits against opioid makers and promoters and distributors; and despite all the deaths — you sense this crisis is a long, long way from over.


Is it really 'white privilege' if you get inappropriate medical treatment?


The Opioid Tragedy, Part 2: “It’s Not a Death Sentence” (Ep. 403) - Freakonomics Freakonomics

"LOYD: I’m a big believer in medication-assisted treatment. And we know that the most effective thing that we can do for opioid addiction is actually medication-assisted treatment with the use of drugs like buprenorphine, methadone, and naltrexone. And I’ve taken heat from this in the local treatment community as well as the treatment community statewide, and even nationally.

DUBNER: Can you just describe where that pushback and that reluctance is coming from?

LOYD: Well, unfortunately Stephen, the pushback comes from people in the recovery community. And one of the problems with addiction medicine is that most of the people that work in the field, or a lot of the people that work in the field, had the issue themselves. That’s how they got in the field. Like myself. But they believe that the only way to get healthy is how they got healthy. So it’s totally anecdotal...

Alcoholics Anonymous claims that 75 percent of its participants stay sober. But academic studies put the success rate closer to 10 percent or even less...

LOYD: Everybody who looks at this says the role of medication is paramount, it should be the cornerstone. Yet it’s so hard to get people into those programs because of the stigma associated with it. A lot of times, it’ll be from parents. I’ve had numerous parents talk their kids out of medication because they said they were trading one drug for another, and then a few months down the road, I get the call that they’ve overdosed and died. And I can’t tell you how heartbreaking those calls are.

DUBNER: If I say to you, I don’t like the idea of the pharmaceutical industry being able to be the chief beneficiary of medication-assisted treatment because they helped drive this problem in the first place. It’s a little bit like I set a house on fire, then I’m the hero who calls in the fire to the fire department. I don’t like the optics of that. I don’t like the economics of that. What do you say to that argument?

LOYD: I have to say I agree with you a million percent. It makes me choke every time I think about it. But I don’t have a better option. I don’t have anything else that’s going to stop my patients dying at the rate that M.A.T. does. I can’t stand it. I read somewhere recently that, several years back, Purdue Pharma tried to acquire the marketing rights to buprenorphine, which just absolutely is unconscionable to me, and so I would agree with you one thousand percent. I wish there was a better option. But right now, there’s not. And so I can’t let my feelings get in the way of trying to help my patients and help them stay alive...

DUBNER: You and many others call addiction, generally, a disease, and it sounds like the factors that may determine your likelihood for the disease are pretty much everywhere. So do you see this as a different sort of disease than we typically think about with epidemiology?

LOYD: Let’s take a disease that everybody agrees on. Type 2 Diabetes mellitus. You know, nobody has a problem with Type 2 Diabetes being a disease. Right? I never hear any discussion about that. Yet for the most part it’s behavioral, right? Why do people get Type 2 Diabetes? Well, they don’t eat right, and they don’t exercise correctly. And so we treat that widely with medication to try to decrease the bad outcomes with diabetes. So I look at addiction as being much the same."


This is like weight loss - people assuming that what worked for them will work for everybody else, and is the best way for everybody else