This piece is a companion to the Dean-O-Files podcast #40, published 5/24. It can be found on Alternative Internet Radio.
Nothing in the following article should be considered medical advice. I am not a medical professional, nor do I pretend to be. The following consists entirely of opinion.
In the news, between appearances of Stormy Daniels’ lawyer and analysis of Donald Trump’s breakfast, horror stories from the “Opioid Crisis” have been in heavy circulation for the past couple of years. Tales of widespread addiction, over medication, overdose, and fraudulent practices of pharmaceutical companies seem to have garnered mainstream support for more regulation, tighter restrictions, and greater awareness of the dangers of opioids.
This was not the effect years ago, when concern over ADHD medication in children and widespread antidepressant use was lumped in with conservative anti-vaccination fervor and modern Ludditism, but that is beside the point. Whenever something is broken, it is always important to dig in and think hard about why that thing is broken because, chances are, it is simply the effect of another broken cause. Treat the problem, not the symptoms.
That is the goal here. Overprescription is a massive problem in today’s healthcare establishment, but this problem is the expected result of a number of other broken systems upon which the healthcare system is built. And as we all know...
The focus here will be overprescription specifically. I’m not going to focus on how inherently terrible the FDA is, how many millions of dollars pharmaceutical companies spend on lobbying, or how the economic realities of the healthcare system have pushed drug production into unwatched facilities in India and China. I’m going to overlook the fact that the availability of insurance has been a direct cause of the rising costs of healthcare and prescription medications. I’m going to ignore the fact that some (nowhere near all) doctors and therapists are just scheisters with a degree running a pill mill out of a strip mall. I’m doing this for brevity's sake, and because I just don't have the energy to read hundreds of studies and CDC data briefs numbering thousands of pages on these subjects. I have a day job.
First, some stats:
Opioids and Pain Relievers:
A total of 214,881,622 opioid prescriptions were dispensed by retail pharmacies in 2016. The total opioid prescribing rate was 66.5 per 100 persons.
Annual prescribing rates of ≥30 days’ supply was 27.3 per 100 persons in 2016; annual prescribing rates of <30 days’ supply was 39.2 in 2016.
During 2015, an estimated 12,462,000 persons aged 12 years or older in the U.S. misused prescription pain relievers in the past year, with an estimated rate of 4.7 per 100 persons.
During 2015, an estimated 591,000 persons in the U.S. aged 12 years or older had a substance use disorder involving heroin, with an estimated rate of 0.2 per 100 persons.
During 2015, an estimated 5,251,000 persons in the U.S. aged 12 years or older misused prescription stimulants in the past year, with an estimated rate of 2.0 per 100 persons.
The above statistics come from the 2017 CDC Annual Surveillance Report Of Drug-Related Risks And Outcomes. Further statistics can be found in the NIH Misuse of Prescription Drugs report from the National Institute on Drug Abuse (revised Jan 2018)
During 2011–2014, 12.7% of persons aged 12 and over, 8.6% of males and 16.5% of females, took antidepressant medication in the past month.
Antidepressant statistics are sourced from the CDC NCHS Data Brief No. 283 (Aug 2017).
In the time that I had to prepare this piece, I could not find statistics for legitimate prescription rates of stimulants or more in depth statistics regarding antidepressants without resorting to unscrupulous sources such as the Citizens Commission on Human Rights (a Church of Scientology front organization). While such stats may have been accurate, I did not want to risk the credibility of the piece by using them.
Phew. That’s... a lot of numbers that mean nothing to most people. Which is fine because I’m going to reframe all of this and (hopefully) affect some people's thinking about the way pharmaceutical companies push these drugs into the populace.
First on the chopping block: Opiates. This section will also serve as a primer on the methods that pharmaceutical companies use to increase the public’s perceived need for their products. These methods apply to all drugs.
Opiates are a class of drugs used primarily for pain relief. I’m conflating other pain relievers with opiates here because that’s what the media does, but be aware that certain drugs (like OxyContin) are actually synthetic versions of drugs like morphine. Many opiates are sourced from the same places as heroin (poppies), and that may sound scary. It really shouldn't. Smart and responsible use of opiates can be a great boon to chronic pain sufferers and people who just had a tooth ripped out of their head. I’m. Not. Anti. Drug.
Opiate prescription practices, though, are inherently broken. There are three main causes for this: pharmaceutical advertising, pharmaceutical promotion, and medical ignorance.
The American Psychological Association ran an incredible article in 2012, in which they stated,
“Several studies have found that prescription drug ads don't adequately explain side effects and can adversely affect decisions by patients and doctors. In one study, American patients were more than twice as likely to request advertised drugs than patients in Canada, where most direct-to-consumer advertising is prohibited (Canadian Medical Association Journal, 2003). Patients who requested advertised drugs were nearly 17 times more likely to receive one or more new prescriptions than patients who did not request any drugs.”
All that “ask your doctor about [drug name here]” nonsense at the end of pharma ads? It works.
This is further supported by drug manufacturers promoting their products to doctors in unscrupulous ways. In 1995, Purdue Pharma began promoting OxyContin as a safer alternative to other opiates, due to the time released nature of the drug. Safer meaning less risk of overdose, less likely to be abused, and less addictive overall. According to the New York Times, “the company aggressively pressed doctors to prescribe the drug, wooing them with free trips to pain-management seminars and paid speaking engagements.” Fast forward to 2007, and Purdue Pharma is paying $600 million to resolve federal charges that it had misled consumers when it claimed that OxyContin was less likely to be abused. Because, you know, it was bullshit.
But the part of the story that is most troubling: “the company aggressively pressed doctors to prescribe the drug, wooing them with free trips to pain-management seminars and paid speaking engagements.” They. Weren’t. Charged. For. That. If you think that doesn’t still happen, I’ve got a spaceship made of gumdrops in my backyard that’ll take you all the way down the rainbow bridge to Happy-Time-Unicorn-Land. Of course it still happens; it works.
But why does it work? Well, imagine you’re a doctor, you get an invitation to go to a pain-management conference in Florida. You listen to a lecture from a snappy-looking MD (who is, in all probability, playing the role of a salesman), tee time at 5:00, beers at 8:00. Of course I’m embellishing, but that is how a lot of professional conferences go. Ask anyone who's been to one.
Now imagine you’re that same doctor, but you went to med school, did your residency, and still know next to nothing about pain management.
This is, apparently, the case for most doctors, especially General Practitioners and ER Docs. Harvard Health Publishing, in 2016, ran an article titled “Why are doctors writing opioid prescriptions — even after an overdose?” In it, I found this little nugget:
“...the reality is that doctors have relatively little training in safely managing chronic pain and treating addiction. Whether in medical school or in residency training, very little curricular time is devoted to helping doctors safely prescribe pain medications, recognize patients at high risk for overdose, intervene when patients need to be taken off of opioids, and adequately treat opioid addiction. As such, a critical component in reducing the overprescribing of opioid medications is for medical schools and residency programs to improve how doctors are educated.”
So, you’re that doctor. You go to this pain management conference and sit through the lecture. You. Think. You’re. Learning. The whole thing is a sales pitch, but you don’t know that because you were never educated on what real pain management looks like. Everyone knows you never buy the timeshare, but how many doctors really know what this cool little conference is actually about? My guess, given the statistics: not many.
Let’s move on because this is getting long. Next up: Stimulants!
Stimulants are a class of drugs that are, most often, amphetamines. These are usually prescribed to treat ADHD, but can be used for other things. That same APA article from earlier has a whole section devoted to this issue, but let’s bring the knowledge we’ve gained from the opioid discussion with us. We know how drugs are marketed and promoted to doctors, so we have part of the picture filled in for stimulant overprescription already, but there are other factors at play here as well. From the article:
“About 4 million children — or 8 percent of all youths in the United States — have been diagnosed with ADHD, and more than half of them take prescription drugs. The subjective nature of ADHD symptoms, along with varying reports about children's behavior from parents and teachers, has made it difficult for researchers to untangle the reasons for the increase in diagnosis of ADHD.”
Psychology Today published an article in 2017 outlining the probable reasons for the overdiagnosis of ADHD including, but not limited to, pediatricians not applying criteria correctly, a lack of proper diagnostic training, and pharmaceutical intervention in diagnosis such that one psychiatrist went so far as to describe ADHD as “a ‘bespoke’ disorder, modeled to fit pre-existing chemical substances such as methylphenidate (Ritalin).” And another “calls ADHD ‘a pharmaco-induced pseudo-disease now completely out of control.’” Finally, the article also mentions the following:
“...the problem of ‘intentional overdiagnosis due to health policy constraints.’ This is especially acute in the U.S., where ‘in many health care systems a diagnosis is required in order to access and reimburse treatment.’ In such scenarios, which the studies in question suggest may be widespread, ‘intentional wrong coding in diagnosing mental disorders does occur in child and adolescent mental health services and can partly account for the overdiagnosis found in studies reevaluating earlier diagnoses.’”
That last one is particularly frightening.
This is a touchy subject, so I’m going to be totally transparent here. I have standing in this realm because I take a relatively low-dose SSRI for depression/anxiety. I’ve done extensive research on SSRIs and know what I’m talking about with regard to them. Now, not all antidepressants are SSRIs, but antidepressants generally are designed to mess with the brain’s chemistry to allow a better balance of certain hormones and/or neurotransmitters. Some people like being on them, some people hate being on them, and some people are totally unaffected by them. This is neurochemistry, and no one really knows how these drugs work. They know what they usually (sometimes, maybe) do, but doctors and neuroscientists don't always know why, how, under what circumstances they do those things. Antidepressants and mood enhancers are a big, hulking gray spot in our collective medical knowledge. But sometimes, in the right people for the right reasons, they work. I am an example of that.
I suffered from debilitating anxiety-induced depression that basically made me a hermit for months. Therapy, which had helped me in the past, wasn’t really cutting it that time, so I started a low dose SSRI. I still felt like me, I didn’t feel like my personality had been drained away (as some people do), and I was able to actually interact with the world again. I still hate maintenance medication, and I plan to work my way off of the drug in the next couple of years, but you’ll never hear me saying antidepressants are always bad or dangerous.
I’m. Not. Anti. Drug.
All of that said, the relatively unknown nature of these drugs make their over-prescription incredibly dangerous. According to that same APA article from before, “Since the launch of Prozac, antidepressant use has quadrupled in the United States, and more than one in 10 Americans now takes antidepressants, according to the CDC. Antidepressants are the second most commonly prescribed drug in the United States, just after cholesterol-lowering drugs.”
Antidepressants are being used in lieu of therapy more and more for a few important reasons. Bearing in mind what we’ve already learned about pharmaceutical companies’ methods, some of those reasons include low reimbursement rates to clinicians, the high cost of therapy, and bias in academic publishing. The article sites a meta-study that covered “74 FDA-registered studies for a dozen antidepressants and found that most studies with negative results were not published in scientific literature or were published in a way that conveyed a positive outcome.”
I would submit another possible cause to add to the pile: Stigma. I know it sounds Social Justicey to say, but it is true that therapy is avoided by a number of people who could benefit from it, and it is possible that therapy is not suggested by general practitioners (who prescribe most antidepressants) because of this stigma. According to a Psychology Today article published in 2013, the stigma against the admittance of any mental problem is alive and well. With this in mind, imagine being a GP with a patient who is suffering from depression or anxiety. Which path would you take if your options are, 1) prescribe a pill that, even if it doesn’t work, may have a placebo effect and (you assume) won’t be dangerous to the patient or, 2) suggest therapy to a patient and run the very real risk of having them get offended that you would even suggest that they are crazy enough to need therapy. The choice is clear.
So, here we are. With over prescribed drugs due, in large part, to unscrupulous pharmaceutical companies and general ignorance in the medical establishment.
I typically like to end my pieces by offering some type of constructive dialogue. I like to try to offer solutions. Here, though, I really am at a loss. I don’t know what can be done to fix these issues other than to demand that they be fixed by someone. This is a behavior I hate, but I’m so far out of my depth when considering the finer points of medical science, that I feel all I can do is bring the issue further into public awareness and encourage people to be aware of their options. All of them. I’m not suggesting you try to cure your cancer with herbs, but I am saying that, if you’re feeling depressed or anxious and it is impacting your life, maybe consider therapy. If your kid is a little hyper, maybe consult a behavioral specialist and try some non-pharmacological methods. If you’re in pain, but you know you have a tendency toward addiction, maybe don’t hop on the opioid train just yet. Try some extra-strength OTC solution or, better yet, smoke a bowl and see if that helps you.
Just make sure you consult your local laws, because pharmaceutical companies have spent a lot of money making sure that bowl stays illegal. But that’s a topic for another day.