Drug overdose is now the leading cause of death for the under-50s in the United States. More than 60,000 people succumbed last year, and millions more are addicted. When compared with other nations, the statistics are shocking. According to a report this year from the United Nations Office on Drugs and Crime, America has 4% of the world’s population but some 27% of its overdose deaths. The bulk of these people have taken opioid drugs — both legally and illegally sourced. Americans consume some 50,000 prescribed doses of opioid painkillers per million people each day — almost double those handed out in the next-highest-prescribing nation, the neighbouring Canada, with just over 30,000.
US President Donald Trump has rightly drawn attention to what he has called a national public-health emergency. (Although he notably failed to declare the situation a national emergency, which would have released extra funds and other resources to tackle it.) Just this month, a report from the White House Council of Economic Advisers said that the opioid epidemic cost the nation half a trillion dollars in 2015. And last week, the Food and Drug Administration (FDA) released guidelines to steer drug companies towards opioid painkillers that are harder to abuse.
The opioid crisis is a slow-motion emergency unfolding in real time. The issue has pushed its way onto the political agenda but has yet to provoke a satisfactory response, partly because there is no easy solution to its convergence of social, cultural and medical factors. (While Americans are dying from overuse of legal opioid painkillers, millions of people with cancer in nations, such as India, with strict narcotics controls have died in agony because they can’t get them.)
The misuse of a valuable resource is partly to blame for opioid addiction and deaths. (The semantics are important here: whereas abuse of a drug seeks a high, its misuse aims to redirect clinical benefit at an inappropriate target. Crudely, abuse is more severe.) Opioid prescriptions in the United States ballooned in the 1990s, when lobbyists and companies succeeded in broadening the range of conditions the drugs could be used for — they were once restricted to pain following surgery or due to late-stage terminal cancer. A study in Nature Reviews Gastroenterology and Hepatology reports this month, for example, that opioid misuse to treat the pain of gastrointestinal conditions (for which there is no good evidence of benefit) has become endemic (E. Szigethy et al. Nature Rev. Gastroenterol. Hepatol. http://doi.org/cgp8; 2017). More than half of people with chronic pancreatitis and almost one-fifth with irritable bowel syndrome are reckoned to be opioid users.
It’s difficult not to have sympathy for desperate people seeking relief from enduring pain. And it’s easy to see why so many front-line doctors are willing to write an off-label prescription when asked. (The above article also said that many medics feel pressured to agree when patients ask for opioids because they fear negative feedback and consequent criticism from managers.) It is too simple to blame overprescribing, not least because there are few other options. Efforts to tackle opioid misuse in medicine can work only if combined with broader re-education and a concerted effort to find alternatives.
Reducing the damage of opioid abuse is a different issue — and probably an even more difficult one. The FDA’s new guidelines urge drug manufacturers to make generic opioid painkillers that are more difficult to grind up and snort, among other measures. But, as the agency admits, it’s not clear that such ‘abuse-deterrent’ formulations will prove effective. Science and medicine can play their part in tackling this crisis, but the rest of society needs to wise up — and fast.
Nature 551, 541-542 (2017)