Art of Janet Kozachek: The Opioid Crisis: Pain, Politics and the Media. Part One: Who's Crime is it?

The Opioid Crisis: Pain, Politics and the Media

Part One: Who’s Crime is it?

It was 3:00 AM. The constant pain in my throat and neck, the crawling sensations in my limbs, made for yet another night without sleep. This night I decided to try to distract myself by reading. I had been advised to try late night reading as a treatment for insomnia by well meaning but misinformed health care professionals who have a predilection for missing pain as a causative factor in keeping people awake at night.

For my late night reading, I began to peruse W. Travis Hanes III’s book The Opium Wars, The Addiction of One Empire and the Corruption of Another. I flipped to the pages which described events leading up to Lord Elgin’s decision to burn the Chinese Emperor’s Summer Palace. It was the treatment of French and British soldiers arrested under a flag of truce at the suburb of Tongxian outside Beijing that had elicited such a draconian response from Elgin, the text claimed. The descriptions of prison conditions were not exactly drowsy inducing comfort reading but I proceeded anyway on account of the riveting tale. I gasped when I read about the leather straps tied to the prisoner’s hands and feet being bound tightly and watered periodically so that the straps would eat into the flesh, which then filled with maggots. Since the prisoners so bound could not wipe flies away from their faces, the flies settled on noses, ears, and mouths to lay eggs and soon all their orifices became filled with maggots - driving some of them stark raving mad.

I went back to bed, my eyes wide open and staring at the ceiling , with pain in my body and now maggots on my mind. Sleep would most likely not come this night, I concluded. Despite that, I was distracted by a new revelation that the history text brought to light in my mind, which oddly enough did pause the pain. This small epiphany was the realization that back then, as now, the subject of opioids could elicit such a screaming pitch of human emotion and such a burning desire for vengeance, that all vestige of humanity and rationality can effectively be erased. Then, as now, when emotional reactions become ascendant, evidence-based, realistic solutions fall away. Civil discourse subsides. The search for scapegoats rises.

The greater the pain involved in any crisis, the less the likelihood there generally is for an easy resolution. This is especially true when opposing sides of a crisis experience substantial emotional loss. There is the loss of loved ones to drug overdose, the pain and disruption of addiction. On the other hand, there are patients in need of analgesic relief. There is the very real tragedy of patients taking their own lives when treatment for pain is withheld. And there are countless others for whom daily functioning can only be obtained through the use of opioid based medications.

So how does a society go about the task of treating one population without risking the destruction of another? There are no immediate, unilateral, and easy solutions. To compound that problem, what makes finding solutions especially difficult is that in much of the mainstream media, emotionally charged propaganda tends to drown out facts. And to a large extent, the pain of loss due to drug abuse has secured a far greater rallying cry than the needs of pain patients to effective and dignified care, leading as a consequence to their own losses.

In 2016, The Centers for Disease Control published a list of Opiate prescribing guidelines in an effort to address the addiction problem in the United States. In this document they acknowledge that chronic pain as well as drug addiction coexist as dual epidemics and therefore provide recommendations for the amelioration of both. Yet any student of history as well as any chronic pain patient or care giver will know that these recommendations as well as many others employed at present, will probably serve to ameliorate neither. Adhering to these guidelines may very well not only increase the number of chronic pain patients, but could also actually swell the ranks of drug addicts. Perhaps most problematic is the recognition that there is a confluence between the epidemics of chronic pain, and opiate addiction. But confluence does not equal causation, and it is my hope that my writing will in some small way elucidate that.

The history is fairly straightforward. The United States has a peculiar way of repeating its past mistakes. Most notably are the failed policies that came in to play during previous spikes in illicit opioid use. Two examples would be the Harrison Act of 1914, and the subsequent more stringent Heroin Act of 1924. Then as now the United States faced an opioid addiction problem. And then as now, law enforcement tended to lump together addicts, patients in pain, and health professionals prescribing analgesic relief in to one great toxic mix of moral failures. These acts, although initially providing better regulation of common products with habit forming contents, also penalized physicians who prescribed pain medications and attempted to curb the availability of such drugs for pain. The acts were failures. There will always be a product available to fill a need - the illicit drug trade only grew. The same can be said for Prohibition. The same faulted logic of applying restrictions to legal manufacture of a product in the hopes of stemming the tide of illegal knock offs is at work today, as is the notion that addiction is a moral failing rather than a disease.

One possible solution to the problem of widespread illicit drug use and addiction in the United States might be to follow the models of other countries rather than to repeat the failed policies of its own past. Portugal might be a good example. Drugs were decriminalized in 2001, with fines for possession but not prison. Addiction was treated as a medical condition rather than a criminal act. Most recent numbers indicate that drug overdose rates in Portugal are now the second lowest in the European Union. On the contrary, the probable results of the United States policy of restricting legal prescriptions in tandem with increased criminal prosecution may be foreshadowed in states like New Jersey, a state that saw a three fold increase in illegal opioid addiction following the application of stringent prescribing. The Guarini Institute for Government and Leadership published a study in 2015 which claims that although New Jersey ranks 45^th in nation in terms of opioid prescriptions, the state’s heroin abuse rate is triple the national average.

Using a less emotionally charged product as an example, the above dilemma might be better explained. Let’s say, for example, that our market was being flooded by illegal knock offs of designer purses with fake Versace labels. Using the logic of the drug wars, the answer would be to close down Versace. And where would that lead? Would not eliminating the legitimate source open up the markets even more to the cheap and poorly made substitutes? We do know from such sources as the National Institutes for Drug Abuse that what is fueling the opioid epidemic now is in fact, not prescribed drugs, but the unregulated illegal production and distribution of dangerous substitutes.

Yet the emphasis in both the CDC recommendations as well as in popular media is on opioid prescribing. One could argue here that the present opioid epidemic may have had part of its roots in legal prescribing, and that pharmaceutical companies may have been complicit in their marketing campaigns by underestimating the addictive nature of such drugs as oxycontin. Things do have a beginning somewhere. A family member might have stolen another member’s pain medication. A criminal might have stolen a pain medication, the formula determined, and illegal production begun. This is usually referred to somewhat euphemistically as "diversion." But trying now to curb the illegal use of street drugs that have been formulated upon prescription opioids, would seem to be about as effective as closing a barn door after all the horses have run out. So why does the United States do this?

Perhaps the answer lies in an affinity to eschew difficult solutions and complex problems in favor of simple and easy ones. Going after drug cartels is complex and dangerous. Going after doctors is easy. Treating people addicted to street drugs is difficult and expensive. Addressing the social fragmentation and strains that cause people to turn to illegal drug use is time consuming and expensive. Criminalizing them is easier and more efficient. Eradicating the supply of illegal drugs is overwhelming. Taking pain medications away from patients who may need them in order to function or have any semblance of a quality of life is easier by far.

One set of answers is fraught with expense, time, diligence and humanity. The other set is more efficient and may be more cost effective, yet is ultimately inhumane. In the United States we have been tending towards the latter.

What would cause us to embrace the draconian over the humanitarian? Enter a media backed by industries motivated by self interest. These self interests can range from support from for profit drug treatment industries to pharmaceutical companies that manufacture so called "safe alternatives" for pain management or those that manufacture opioid drug treatments It might also be worth exploring the self interest of our media, in the knowledge that inciting a public to anger sells news, and there is nothing so certain in that than finding common enemies.

There are enemies to be sure in the opioid crisis. Then there are those who are criminalized for behavior that has its basis in a health crisis. And finally, there are those who are criminalized in the court of public opinion. The media is at its most effective in this last category. The tools used in this last case are semantics, propaganda, misrepresentation of facts, obfuscation of the facts, fragments of truths, cherry picked reporting, and outright falsehoods.

In the case of semantics, the most obvious misleading term is "prescription opioid abuse." This phrase confuses the public by lumping together legally produced prescribed drugs with drugs that are illegally produced knock offs of the pharmaceutical industry to make it sound as if they all come from doctors furiously scribbling away on their prescription pads.

The best, or worst depending upon how one looks at it, example of propaganda might well be the South Carolina government’s anti-opioid ad campaigns. One such television ad features a woman rifling through her purse to find an empty prescription bottle. This is on a split screen with her on the left and on the right a picture of a man shooting heroin up his arm. A voice over tells us that filling this prescription will result in the right hand scenario. "Pain killers are killers," they like to tell us, as well as "Pain killers are people killers." To add to the confusion, South Carolinians are also told in these ads that four out of five people taking a prescription pain killer will end up becoming drug addicts. The National Institute For Drug Abuse puts that statistic closer to about four in a hundred - and that only for opioids. Interestingly, the South Carolina ads don’t even bother to make any distinctions between classes of analgesics. I have written to my state representative to voice my concern about my tax dollars being used to fund misinformation, but have yet to hear a response.

The most commonly misrepresented statistic in our modern day opioid war is the one about 80% of the world’s opioid supply being consumed in the U.S. The actual amount, while not being great perhaps, is 30%, according to the NIDS. But this does not prevent the media from persistently repeating what could indeed be an inflated statistic. Sometimes the facts are simply obfuscated by switching the placement of percentages and numbers; for example stating that 75% of people addicted to prescription opioids switch to heroin, when it was actually 75% of heroin users started out abusing prescription opioids (legal or illegal source not identified). Another way that numbers might not accurately reflect the overdose epidemic is how opioids present at death data is tabulated. Coroners’ practices are still in need of standardization, otherwise it would be possible to include end stage cancer patients who died on morphine.

Fragments of truth in reporting are often difficult to spot, especially when they come from a self professed "expert." On one NPR podcast, for instance, an ER doctor in an interview stated that opioids actually cause "an increase in pain." I checked that in a pharmaceutical journal and found that in some cases, an opioid can actually cause an increased sensitivity to pain, referred to as "hyperalgesia." The phenomenon still is not universal, nor even common in some findings, and does require more study.

Cherry picking in reporting can also serve to skew public opinion in one direction, without consideration for the other. This might best be addressed by balance. One example might be to balance reports of drug overdose deaths to deaths of people resulting from under treated pain. Perhaps news articles that tout the virtues of countries like Germany and Japan getting by without the use of post operative analgesics should be balanced against journal reports citing these countries for under-treating pain.

The intricacies of law and public policy on drug use, what actually needs to be done with regard to addressing drug addiction, may be ultimately too complex for this essay. I am not a legal historian with expertise in this area. Perhaps we may want to give some final consideration in re-framing how we perceive each other in these United States and to refrain from casting blame without accurate evidence based knowledge on human conditions. It would behoove us to know where data comes from, how it was generated, when it was generated, and who sponsored it. We should cultivate trust in non-partisan sources without commercial ties or strings attached to political power.

In re-framing, we might come to the realization that we are not, in fact, engaged in a twenty-first century opium war with each other, but in the midst of a common health crisis.

My mosaic art used to illustrate this essay, "Sub-clinical Harpies," is in a private collection. The small pills of unused hydrocodone tablets that I was given post surgically were painted and incorporated in to the background, not diverted to the black market trade.