Topic Proposal Statement

Overprescription of Opioids Related to the Increase of Opioid Addiction as a Public Health Issue

Would Approaching the Overprescription of Opioids as a Public Health Issue Decrease Rates of Opioid Addictions for Low-Income Americans?

A Future Nurse’s Perspective

Stephanie Bini-Ochoa

West Coast University

Origin of Environmental Injustice: Overprescription of Opioid Medications

Opioids have been used as medications for centuries across the globe. A recent study showed that the first known prescription of opium was discovered on an 8000-year-old hardened Sumerian clay-tablets (Bandyopadhyay, 2019). The modern history of opioid drug overprescription and epidemic is closely connected to the desire to treat pain with effective medications that would be safe for patients. The main root of the overprescription of opioid drugs was an aggressive marketing campaign claiming that these medications did not lead to addiction (Meyer, 2020). In addition to a marketing campaign, several healthcare-related organizations labeled pain as a fifth vital sign and conducted surveys (usually based on the ability to treat pain) on the efficacy of the healthcare services (Meyer, 2020). As a result of these efforts, the sales of oxycodone (opioid prescription drug) exceeded $2 billion a year between 1996 and 2014 (Meyer, 2020). The CDC (2020) distinguishes three major waves of the opioid epidemic, including the first one in the 1990s during the rise of prescription opioid overdose deaths, the second one in 2010 during the increase of heroin overdose deaths, and the third wave in 2013 that marked the rise of overdose deaths due to synthetic opioids. As a result, 450K people died during these three waves due to opioid overdose (CDC, 2020). The use of opioids as pain relief medication for chronic and non-chronic pain has become a major problem in the U.S.

Increased Addiction and Overdose Prevalence on Opioids

While the three waves of the opioid epidemic mentioned earlier could suggest three different types of events caused by distinctive factors, in reality, the epidemic was the outcome of the same forces. For instance, the analysis presented by the American Society of Addiction Medicine (ASAM) (2016) showed that from 1999 to 2008, overdose death rates, sales, and substance use disorder treatment admissions related to prescription pain relievers have boosted simultaneously. In 2008, the rate of opioid-related deaths was four times higher than in 1999 rate; in 2010, sales of prescription opioids were four times higher than in 1999; and substance abuse treatment admissions that involved opioids were six-time higher in 2009 compared to 1999 (ASAM, 2016). In addition, a survey showed that 94% of respondents in 2014 chose to use heroin for chronic pain because it was easier to access and cheaper compared to the prescribed opioids (ASAM, 2016). It was also admitted that women and adolescents were more affected by the opioid pandemic, as females were more likely to experience chronic pain and adolescents had easier access to their parents’ prescribed opioids leading to the development of the addiction (ASAM, 2016). These statistics showed how the overprescription of opioids, lack of accountability among the health care providers, and inability to notice a major issue in the U.S. led to an increase of people developing an addiction to prescribed opioids.

Loss of Productivity of Workforce and Financial Burden

Pain relief medications are quite common in the United States due to the culture to combat the problem as soon as possible. When seeking immediate treatment options for chronic and non-chronic pain that could affect a person’s productivity in professional and personal ways, many Americans received an opposite outcome by losing their productivity to opioid addiction. Davenport et al. (2019) calculated the financial burden of the opioid epidemic in 2019 in the U.S. and revealed that mortality costs reached $74.1B, healthcare costs were $64.1B, loss of workforce productivity costs were $28B, criminal justice costs were $12.2, child assistance reached $7.8B, and educational costs were $1.3B. Altogether, the opioid epidemic cost the U.S. $631B from 2015 to 2019 (Davenport et al., 2020). CDC estimated that prescription opioids caused the U.S. $78.5B a year of financial losses, including the cost of health care loss of productivity, and addiction treatment (CDC, 2018). Employer costs related to OUD (Opioid Use Disorder) increased from $702M in 2015 to $955M in 2018 due to loss of workforce, long-term disability of workers, and short-term disability (Davenport et al., 2019). As a result of massive financial losses shared by the government, taxpayers, and employers, the U.S. lost the ability to reach its full potential as a country and as a society only due to a failure to inspect the forces interested in the opioid epidemic.

Money, Power, and Control: Big Pharmaceutical Companies

Lack of regulation in health care, free-market structure, and a possibility to lobby interests in the governmental circles allowed large pharmaceutical companies to profit from the opioid epidemic that led to the loss of many lives and resources in the U.S. For example, in October 2020, Purdue Pharma pleaded guilty for its role in the opioid epidemic in the U.S. in a multilayered lawsuit versus the United States Department of Justice (Miller, 2020). As a result, Purdue Pharma is going to pay $3.5B criminal fines, $2B in criminal forfeiture, $2.8B in a civil settlement, and $225M in damages to resolve civil liability by owners of the company (Sackler family) (Miller, 2020). Large opioid manufacturers across the U.S. are sued by the local and state government for their role in the opioid epidemic, which includes the aforementioned Purdue Pharma, Johnson & Johnson, Teva Pharmaceuticals, and Endo International; also, AmerisourceBergen Corp, Cardinal Health Inc., and McKesson are sued as the drug distributors for the same reasons (Kaplan, 2018). Analysis of these lawsuits showed that Haffajee & Mello (2017) the government holds pharmaceutical companies responsible for boosting the popularity of opioids through advertisement, lobbying, and making the physicians prescribe them. These companies are held liable for deceptive ads and suspicious prescriptions as well as its sudden increase (Haffajee & Mello, 2017). These lawsuits showed that only recently, so-called “big pharma” is held accountable for their actions concerning the opioid epidemic.

While the U.S. government wins the lawsuits, it is the Federal Drug Administration (FDA) is blamed by the public for the lack of oversight and regulation of the pharmaceutical organizations, drug distributors, and health care institutions that were directly involved in the opioid epidemic in the U.S. the criticism of the government is understandable, as the pharmaceutical companies generated about $2.5B for lobbying and funding members of Congress during the past decade (McGreal, 2017). In 2016, pharmaceutical lobbyists tried to push the legislation that could have prevented the DEA (Drug Enforcement Agency) from arresting drug distributors or pharmacies recklessly dispensing opioids (Higham & Bernstein, 2016). One of the laws passed in 2003 allows the pharmaceutical companies to charge more for their products and preventing the government from seeking bids for the drugs and medical devices manufacturing (McGreal, 2017). The government allowed large pharmaceutical corporations to impose their policies and safeguard their own interests at the cost of the citizens.

Legislation: SUPPORT for Patients and Communities Act (HR 6)

Due to the large array of errors in the governmental action aiming at addressing the opioid crisis, recent legislation has been developed aiming at the citizens who suffer from the OUD. A Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (2018) is a bill aimed at targeting the problem of the opioid epidemic. SUPPORT represents the landmark legislation that aims at teaching about addictive medications, standardization the delivery of addiction medicine, and establish quality evidence-based care services that would care for the patients with OUD. This Bill has become the latest effort of the government to address the complex problem of the opioid epidemic in a complex way by addressing several avenues of this issue at the same time. SUPPORT was passed in 2018 and it is expected that it would help to provide more accessible treatment for individuals with OUD, prevent opioid addiction, and ensure that the youth are educated concerning the use of prescription or non-prescription opioids. Yet, the main population group affected by this legislation is the people who already developed OUD.

Culture: Pill Popping

Many Americans do not realize that they consume more pills compared to their counterparts across the globe. According to the CDC (), 45.8% of U.S. citizens use prescription drugs and this prevalence is increasing with age, from 18.0% of children under age 12 years to 85.0% of older adults (60+). A comparison among the European countries and the U.S. concerning the spending on prescription drugs shows that Americans spend much more money on pills compared to any other country. Specifically, according to the (Ways and Means Committee, 2019), average spending for prescription drugs in the U.S. is $466.15, while the highest average expenditures in European Union was $182.29 in Denmark and $152.86 in the Netherlands; the lowest result was shown by Portugal with $82.97. The same report showed that the prices of prescription medications in the U.S. are significantly higher compared to other countries, especially considering these countries’ GDP (Gross Domestic Product) rate. For example, the average price of prescription drugs in Switzerland is 24.9% of the average in the U.S., while this country’s GDP is 132.2% higher than the U.S. (Ways and Means Committee, 2019). Overall, the average price of drugs in the EU is 26.8% of the U.S. average prices for the same medications with the Union maintaining 79.6% GDP (average) of the U.S. (Ways and Means Committee, 2019). It was noticed earlier that the prices of prescription drugs in the U.S. are not regulated due to the legislation preventing the government from regulating this area.

By creating a culture that demands people to spend a lot of their personal funds on prescription drugs, pharmaceutical companies are able to generate large profits. The essence of the “pill-popping” culture is in the intention to solve the problem connected to health as soon and as effectively as possible in an easy and accessible way. On the other hand, overprescription of medications among American healthcare providers is another side of the problem that stimulates this culture. The cost of medications and the amount spent on purchasing them are two major indicators that show that this problem is complex and it has to be solved at the level of healthcare, government, big pharma, and media.

Ethical Obligations: Profession of a Nurse

Nurses are obligated to care for patients, advocate for their rights, and ensure that healthcare providers comply with the ethical code of conduct. The nursing ethical code of conduct was developed by the American Nurses Association (ANA), which requires the nurses to comply with the principles of nonmaleficence, justice, and autonomy among other rules (ANA, n.d.). This means that nurses have to ensure that the treatment provided to patients in the healthcare facility and outpatient settings provides more benefits than harm, which appeals to the principle of nonmaleficence. In this case, overprescription of opioids by physicians has to raise a “red flag” for a nurse and stimulate her for action. Nurses have to take an active part in combating overprescription by reporting reckless prescription of opioids, recommending other medications, and whistleblowing when patients’ health is at stake.

The principles of justice and autonomy have to drive nurses to not only help patients to treat their opioid addiction but also to prevent it. The principle of autonomy fosters patients’ individuality and dignity in decision-making concerning their health and treatment. Nurses have to educate the patients and the community regarding the dangers of opioid prescription drugs in patients with non-chronic pain. Patients suffering from chronic pain could be proposed the alternatives that would minimize the addictiveness of pain relievers. Nurses have to ensure that patients receive the complex treatment of their health issues instead of only addressing the symptoms with prescription medications.

References

ANA. (n.d.). American Nurses Association Code of Ethics for Nurses with Interpretive Statements, 1-14. https://www.dphu.org/uploads/attachements/books/books_5459_0.pdf

ASAM. (2016). Opioid addiction: 2016 facts & figures. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

Bandyopadhyay, S. (2019). An 8,000-year history of use and abuse of opium and opioids: How that matters for successful control of the epidemic? Neurology, 92(15), P4.9-055.

CDC. (2018). Opioid overdose crisis. https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis#:~:text=The%20Centers%20for%20Disease%20Control,treatment%2C%20and%20criminal%20justice%20involvement.

CDC. (2020). Opioid data analysis and resources. https://www.cdc.gov/drugoverdose/data/analysis.html#:~:text=The%20findings%20show%20three%20distinct,from%20IMF%2C%20including%20fentanyl%20analogs.

Davenport, S., Weaver, A., & Caverly, M. (2019). The economic impact of non-medical opioid use in the United States. Society of Actuaries, 1-93. https://www.soa.org/globalassets/assets/files/resources/research-report/2019/econ-impact-non-medical-opioid-use.pdf

Haffajee, R. L., & Mello, M. M. (2017). Drug companies’ liability for the opioid epidemic. The New England Journal of Medicine, 377(24), 2301–2305. https://doi.org/10.1056/NEJMp1710756

Higham, S. & Bernstein, L. (2017). The drug industry triumph over the media. The Washington Post. https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/?utm_term=.53ceae6194b3

Kaplan, G. (2018). How one court case in the opioid crisis could impact millions of patients. Healio Care. https://www.healio.com/news/primary-care/20180523/how-one-court-case-in-the-opioid-crisis-could-impact-millions-of-patients

McGreal, C. (2017). How big pharma’s money – and its politicians – feed the U.S. opioid crisis. The Guardian. https://www.theguardian.com/us-news/2017/oct/19/big-pharma-money-lobbying-us-opioid-crisis

Meyer, A., LeClair, C., & McDonald, J. V. (2020). Prescription opioid prescribing in Western Europe and the United States. Rhode Island Medical Journal, 103(2), 45–48.

Miller, J. (2020). Purdue Pharma pleads guilty, will pay billions for a role in the opioid epidemic. Healio Care. https://www.healio.com/news/primary-care/20201021/purdue-pharma-pleads-guilty-will-pay-billions-for-role-in-opioid-epidemic

Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (2018). H.R. 6. https://www.nasmhpd.org/sites/default/files/HR_6_SUPPORT_Act-9-26-18.pdf

Ways and Means Committee. (2019). A painful pill to swallow: U.S. vs. international prescription drug prices, 1-77. https://heatinformatics.com/sites/default/files/images-