The Pandemic and the Epidemic
“If you’re alone, there’s nobody to give you the Narcan”
“One prevailing theme is the fact that the epidemic now is driven by illicit fentanyl, fentanyl analogs, methamphetamine, and cocaine, often in combination or in adulterated forms. Overdoses related to prescription opioids and heroin remain high and also are increasingly contaminated with illicit fentanyl.” (Issue brief: “Nation’s drug-related overdose and death epidemic continues to worsen,” AMA, Nov. 12, 2021)
We conclude our review of COVID-19 revelations about health/healthcare with a look at the “epidemic within the pandemic”: overdose deaths, which rose more than 30% (year-over-year increase between March 2020 and March 2021: 38%) during the first year of the pandemic. This was the largest increase in overdose deaths in U.S. history. Of these deaths, around 75% involved opiates, and 60% involved fentanyl.
The extraordinary measures required by COVID-19 led to stay-at-home orders, isolation, and despair for both those with resources and those without. Millions turned to alcohol, opioids, and other drugs as coping mechanisms. Those with existing substance-abuse problems feared in-person treatment centers and residential detox facilities as possible sites of contagion; many stayed away and became more vulnerable to relapsing. One of the responses by treatment centers/ clinics was to shift to telehealth provision of services, but participation in online appointments with counselors/caregivers requires an internet connection which is stable and fast – something millions of rural residents don’t have and something millions of urban residents can’t afford to access.
Because so many people who under normal circumstances would have been using in social contexts began to use in isolation, overdoses that might otherwise have been witnessed and reversed with naloxone became fatalities. Naloxone prescriptions decreased 26% during the same period, although this statistic may be connected with a not-fully-explained supply “disruption” in the early months of the pandemic – a disruption related not so much to actual supply (though this may have been the case early on), but to pricing, as the cost for Narcan, which as an opioid receptor antagonist blocks the effects of an overdose, skyrocketed.
The opioid supply chain was also interrupted / contaminated because many people had to seek out dealers they didn’t know and therefore, couldn’t trust to provide a clean product. Producers / distributors / dealers took advantage of this and contributed to the untrustworthiness of supplies; it became commoner for heroin to be laced with fentanyl, a synthetic opioid 80-100 times more potent than morphine.
The “opioid epidemic” has of course been around much longer than the pandemic. Since the mid-nineties when large-scale prescription “programs” began to take off in some of the U.S.’s poorest rural regions (Kentucky, Tennessee, Virginia, West Virginia (Appalachia) and Maine), Americans have since the early 2000s associated use of prescription opioids with a stereotypical demographic: poor, white, rural. From the late forties into the seventies, heroin use was similarly associated with a poor, black/Hispanic, urban population.
Stereotypes are hard to overcome, but this pandemic has shown itself to be an equal-opportunity destroyer in the substance abuse sector. Opioid addiction has now spread everywhere, and the demographics have therefore changed as well, with some of the steepest recent rises in opioid use/abuse now found in states west of the Mississippi. And it no longer matter what socioeconomic class users are from: opioid addiction now strikes the rich as it once struck the poor.
Let’s take a short detour to trace the history of opioid addiction in the U.S. The first and for nearly a century most widely-used opiate was morphine, which comes from the poppy (in common with opium, laudanum and heroin). It was first extracted by the German pharmacist Friedrich Sertürner in the early 1800s. Initially used for medical purposes only, it rose to popularity in the U.S. during and after the Civil War (“every war has its drug”), when soldiers and veterans received it for acute and chronic pain from war wounds; addiction became so prevalent that it was referred to as “the soldiers’ disease.” But morphine (named after the Greek god of sleep, Morpheus) wasn’t just a soldier’s drug; by the final quarter of the 19th century it was also a “mother’s drug” (the 19th century’s equivalent of “mother’s little helper”). Thousands of middle-class women became addicted, having been prescribed the drug for migraines, gynecological complaints, and general states of “unwellness.” Until aspirin came on the market in 1899, it was essentially the only painkiller widely on offer.
In the early 20th century, the pharmaceutical company Bayer began producing and distributing heroin (rel. to “heroic,” because of its power), and by the 1920s-1930s America was in the throes of its second great addiction wave. Heroin (derived from morphine, but more potent) was marketed as a safe alternative to morphine, even though it was soon realized (by 1906) that it could become addictive after only a few days’ use. Early advertisements were directed at both adults and children (yes, children).
Once heroin was acknowledged to be addictive, an attempt was made to create a closed system, and with doctors no longer prescribing it, production / distribution shifted to the underworld – there was, after all, continued demand, but no legal supply for users. With the arrival of Prohibition in 1920, the “syndicate” began employing the same routes used for alcohol to smuggle in street drugs – heroin, in this case. It was outlawed for all purposes, including medicinal ones, in 1924.
The Boggs Act (1951) imposed mandatory minimum sentences for drug possession, which primarily meant in urban populations of poor minorities. But illicit heroin continued to circulate widely from the fifties through the early seventies. It was deemed a pestilence of the inner cities. America is still grappling with the effects of the Boggs Act 70 years later, as the debate between those who would criminalize use and those who prefer to see addiction as a disease, and thus a public health crisis, continues. It would appear that the pendulum is now swinging towards decriminalization and treatment rather than punishment; many local jurisdictions across the country have introduced innovative programs which aim to keep users out of jails/prisons and shepherd them towards treatment (methadone clinics being the best-known) or at least, harm-reduction programs (needle exchanges).
In the forties, three brothers from Brooklyn, all doctors, all keen on research (together they published more than 150 scholarly articles), took a particular interest in biological psychiatry – i.e., in the use of pharmaceuticals as opposed to psychoanalysis. One of the three, Arthur, also had a distinct talent for marketing and business, and he had purchased a small medical advertising agency. Arthur Sackler must be considered the father of modern pharmaceutical marketing, which was based on direct marketing to physicians (to persuade them to write prescriptions) and secondly, to the public through appeals such as “Ask your doctor about XX drug.” (Cf. “Most of the questionable practices that propelled the pharmaceutical industry into the scourge it is today can be attributed to Arthur Sackler.”) The brothers, who purchased a small, nondescript pharmaceutical company in 1952, turned among other ventures to marketing two benzodiazepines, Valium (= diazepam) and Librium, used primarily as tranquilizers for anxiety. By 1973, physicians were writing 100 million prescriptions a year for tranquilizers. The Sacklers (Arthur as CEO of the medical ad agency, Mortimer and Raymond as co-CEOs of the pharma company, rechristened “Purdue Pharma”) made millions in the sixties and seventies.
During the seventies and eighties, Purdue Pharma had tremendous success with a slow-release formulation of morphine (“MS Contin”). But in 1987 MS Contin’s patent was about to run out, so they needed another narcotic – a drug that would also contain the “twist” of delayed release. This drug, which consisted of the opioid oxycodone, was approved by the FDA in 1995 and christened OxyContin. While oxycodone (synthesized in 1916 by German scientists) was already available in other formulations (Percocet = oxycodone + Tylenol; Percodan = oxycodone + aspirin), in addition to the delayed absorption feature, OxyContin was pure oxycodone. And it was produced in a range of concentrations (titrations), from 10mg all the way up to 160 mg. It was promoted for use for “moderate to severe” pain.
In the mid-1990s, pain was re-classified as the “5th vital sign,” and the opportunities for production and marketing of effective pain medications, including opioids, changed again. The Sacklers found the opening they’d been waiting for. OxyContin was marketed not just for the types of pain opioids had legally been limited to – basically, end-of-life pain – but for just about any type of pain – injury-related, dental-related, surgery-related; back pain, neuralgia, arthritis, athletic injuries – you name it, OxyContin could treat it. Not surprisingly given the technique employed to sell it – by doctors (paid by the Sacklers) to doctors (including general practitioners and other non-specialists) – by 2000 OxyContin was generating a billion dollars a year in revenue.
Throughout the late nineties and into the early years of the 21st century, OxyContin was marketed aggressively to doctors in poor, rural, white communities (with a population described as “opioid-naive”) as a “delayed absorption” opioid, the implication being that it was therefore less addictive (in absence of any objective evidence). It took only a few years for the realization to sink in that OxyContin was just as addictive as other opioids which had come before it.
Purdue Pharma has now been sued thousands of times, but has never admitted complicity to causing the opioid epidemic; cases are settled out of court for dollars on the billions in profit the family made out of others’ suffering. In 2019, Purdue Pharma filed for bankruptcy, a filing that was recently rejected (January 2022) upon appeal. We shall see; a further appeal is pending with the 2nd U.S. Circuit Court of Appeals.
Back to 2022:
The majority of now-adult substance abusers first became dependent as a result of a legal opioid prescription (estimates range as high as 80%). What does one do once doctors become fearful about writing further prescriptions – today, for example, patients are normally given only one week’s supply following routine surgeries and modest injuries – i.e. for “moderate” pain. Initially users turned to street supplies – the “pill mills” which churned out prescriptions in the late nineties and early 21st century put legally-prescribed supplies out there for a price, with pills often being sold as singletons. Once that supply began to dry up, addicts turned again to street providers – but this time, of heroin.
And that heroin is frequently laced with fentanyl (more than 25% of drugs confiscated by the DEA now contain fentanyl), a synthetic opioid 80-100 times more potent than morphine and 25-40 times more potent than heroin, rather than the innocuous baking soda, sugar, or starch which were once used to cut it. In consequence, during the first year of the pandemic, around 190 people died every day of opioid-related deaths, making them the leading cause among all drug-related deaths. It’s a sellers’ market out there, and buyers – at least in part due to the disruption of reliable supply chains during the pandemic – are at their mercy.
We noted above that the most-used antidote for overdoses – especially those caused by unknowing ingestion of fentanyl – also experienced market “turbulence” during the pandemic. Pfizer admitted that it “ran into problems in manufacturing doses of naloxone” early in 2021, but insists that the “issues are now fixed” (without revealing what those issues were). The real turbulence was connected with pricing, with the cost of a single dose of Narcan (produced by Emergent BioSolutions) going from $2.50 to $75.00 for harm-reduction centers, which do not receive a discounted price. The Opioid Safety and Naloxone Network (OSNN) Buyers Club, which Pfizer had been supplying with an injectable formulation, was cut out of purchasing altogether. It’s estimated that the astronomical rise in cost resulted in between 12,000 and 18,000 unnecessary drug-related deaths in the past year.*
That’s a lot of excess deaths, and the explanation for what happened with naloxone – first to the supply (if anything) and then to the price – has not yyet been thoroughly investigated.
*Addendum: Further research after this post was written failed to reveal more about what happened to Pfizer’s manufacturing of naloxone in early 2021:
The drab Pfizer website lists the availability of its injectable naloxone formulation as “depleted.” In a perfect world, Pfizer’s listing would be banal. A shortage of one generic WHO-declared essential medication for one manufacturer (among several in the US) doesn’t sound like a crisis scenario. Yet Pfizer’s supply disruptions are causing the worst naloxone shortage the country has faced since at least 2012, when overdose levels were less than half of what they are now.
In a juster world, Pfizer could have diverted some of its estimated net profit of almost $22 billion (2021, up from $9.1 billion in 2020) to ensure that the supply of injectable naloxone could meet demand.
Readings
“Opioids and the COVID-19 Pandemic”
“An Epidemic within a Pandemic: The Opioid Crisis and COVID-19”
“How the COVID Pandemic Made the Opioid Epidemic Worse Even as Telehealth Helped”
“2022 a critical year to address worsening drug-overdose crisis”
“Drug Overdose Deaths in the U.S. Top 100,000 Annually”
“It’s really, truly everywhere: How the Opioid Crisis Worsened with COVID-19” (podcast)
“America’s Opioid Epidemic” (pre-pandemic podcast))
“Price for drug that reverses opioid overdoses soars amid record deaths”
“The Family That Built an Empire of Pain” (on the Sacklers)
“Opioids, Inc.” (PBS Frontline)
“Chasing Heroin” (PBS Frontline)
“7 Days: The Opioid Crisis in Arkansas” (PBS Arkansas)