CHHS News

Fueling an Epidemic

- Keith Fagerquist

MS student in Health and Medical Policy

The “live free or die” state now has the second highest rate of drug overdoses in the US, trailing only West Virginia, the well-known epicenter of the opioid epidemic. Media coverage of the opioid crisis has labeled it the “worst drug epidemic in American history”. In many respects that is true. Overdose deaths have reached unprecedented levels and the at-risk population is troublingly broad, uncontained by historic demographic boundaries. 

As a New Hampshireite myself and a graduate student of health policy, the opioid epidemic has forcibly gripped my attention, much as it has the nation’s. It was hard for me to imagine at first that the beautiful state where I had so enjoyed growing up was now coping with a severe drug problem. When had my home town of Nashua, “the Gate City” transitioned to the “Gateway city”? Why was the President of the United States referring to my state as a “drug infested den”?

Despite all this doom and gloom, the epidemic has traceable roots and historic parallels which can and should be drawn in the search for a solution. Let’s begin by traveling way back to the late 1800s America. Pain management is still in a primitive stage as highly potent drugs are entering the pharmaceutical market. Opioids are widely recognized for their “soothing” effects, heroin is an over the counter brand name cough suppressant, and cocaine is the new wonder drug designed to help returning Civil War soldiers relieve their war time addictions to morphine. Naturally, this practice backfires, addiction levels spike and America enters one of its first major drug epidemics.

Gradual understanding of the dangers associated with these drugs leads the country to its first major regulations on pharmaceuticals beginning with the Pure Food and Drug Act of 1906 which mandates proper labeling. In 1919, the US Supreme Court ratifies the Harrison Anti-Narcotic Act. This regulates narcotics under federal control and establishes that it is not professional practice for doctors to prescribe patients drugs which maintain an addiction. Because addiction at this time is not seen as a true disease, addicts are not seen as true patients and should therefore no longer be prescribed any of these now-controlled drugs. Despite the misguided reasoning behind this ruling, it works. Opioids suddenly become more tightly regulated than ever before, a drop in addiction follows, and the country climbs its way out from a drug problem.

Now let’s flash forward to the mid-1990s as a new opioid based painkiller, OxyContin, is about to enter the drug market. OxyContin’s effectiveness in treating acute pain is without question and the pharmaceutical companies aggressively push this drug as a safe, non-addictive, chronic pain option, willfully ignoring nearly 100 years evidence of opium’s highly addictive properties. The FDA bites on the sell, wrongly believing that the drug’s “slow-release” formula yields only a low risk for addiction. OxyContin enters the drug market in 1996.

Now jump to 2010, OxyContin has been on the market for 14 years. In that time, the sale of opioid based painkillers has quadrupled in the US while during the same timeframe, overdose deaths from painkillers have also quadrupled. The correlation is apparent but yet only beginning to gain national recognition. Nevertheless, opioids for pain remain the primary if not the only pain management option covered through most insurers.

Finally, we arrive back in the present where the number of prescriptions written for painkillers in the US has continued to climb, cresting over 300 million in 2016. For scale, keep in mind that the entire US population is 323 million. This issue has now fully captured the nation’s attention and a variety of policy options are being thrown at the problem from both state and federal levels. The CDC recently released recommended safety guidelines for prescribing opioids for chronic pain. Many states, including New Hampshire have accepted those as their new standards of practice, which is a step in the proper direction, but will not be enough to drag ourselves out of this.

New Hampshire has also invested in its prescription drug monitoring program, a highly touted tool which queries prescription requests and prevents “doctor shopping”. However this tool will have a limited effect in combatting the epidemic given that most people who overdose on prescription painkillers had valid prescriptions filled by one doctor.

Too many policy options skirt around the true issue, slapping on band aids but not addressing the root of the problem. Yes we absolutely need robust treatment options, and yes we should mitigate the ability to doctor shop. But if we have taken anything away from America’s drug history, and if we truly want to beat this epidemic we need to aggressively regulate the way we prescribe for pain. America is not experiencing over 4 times as much chronic pain as they did before the mid-1990s. The ugly fact is that America is addicted to pain killers and our current loosely regulated prescribing practices are fueling an epidemic.