In the ’90s, chronic pain was rampant in America. Opioids, which had previously been taboo, were suddenly being prescribed by doctors. A supposedly safer opioid had been developed which, as a physician wrote in the New England Journal of Medicine, was “not a hypnotic” and carried no “danger of acquiring the habit.”

This movement created a monster, addicting millions of Americans to opioids. Global overproduction fueled even more demand and, as authorities clamped down, many of those addicted to these medicines turned to more potent ones, making an overdose only a minor miscalculation away.

I’m referring, of course, to the eighteen nineties, which eerily echo how the modern opioid epidemic emerged a century later.

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The 1890s and 1990s were both characterized by unopposed amplification of the benefits of opioids, the transformation of physicians into unabashed cheerleaders, and the central role of China — first as a global consumer of opium and later as a manufacturer of fentanyl. In the 1890s, the compound marketed by Bayer to supposedly treat morphine addiction was heroin, while in the 1990s, the drug made by Purdue Pharmaceuticals and marketed as a painkiller with low potential for abuse and addiction was OxyContin.

In his 1932 book, “Brave New World,” Aldous Huxley foresaw the modern opioid crisis by depicting a society addicted to a drug called soma, which mirrored the effects of opium, instantly overcoming pain while providing a sense of well-being. Soma was provided free to citizens, and its characterization predated our modern inclination to look to pills to overcome our ills.

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The current opioid epidemic is a huge tragedy, albeit one that could have been mitigated, had we learned from the epidemic of yore. While the pharmaceutical industry has been singled out for retribution — and it does carry the greatest burden of responsibility — other groups have largely escaped accountability. This includes physicians as well as the regulators who spectacularly failed to protect the public. If we focus only on punishing pharmaceutical companies, this won’t be the last time opioids infest our society.

Americans constitute 5% of the world’s population but use an estimated 30% of the world’s prescription opioids. This disproportionate use of prescription drugs in the United States is not an accident but arises from a culture deliberately crafted by the pharmaceutical industry. The United States and New Zealand are the only countries that let drug makers directly advertise their claims to consumers. Their sales pitches have been so potent that, over time, Americans’ responsiveness to placebos has increased while that in other countries remains the same. This sustained marketing blitz means that when the average American takes a pill — any pill — for pain or depression, his or her expectation of relief is greater than it is for someone living in another country.

The pharmaceutical industry had help pushing opioids. The other recurring aspect of these cyclical opioid crises has been the role played by physicians in propagating them. At the end of the 19th century when heroin was first marketed, it could be acquired only with a prescription from a physician. Many of them fell over themselves to praise opioids like heroin.

One doctor wrote in the Journal of the American Medical Association in 1915, “I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.” Decades later, in 1980, a five-sentence, 101-word letter in the New England Journal of Medicine concluded — incorrectly — that “the development of [opioid] addiction is rare in medical patients with no history of addiction.” That letter would be cited hundreds of times to make more false claims about opioids. While the senior physician who wrote the letter now regrets doing so, the damage has been done.

Every prescription opioid that killed an American had a physician sign off on it. That’s why it is essential for the medical community to examine itself to see how it contributed to this tragedy.

When I was a young resident in the early 2010s, I struggled with balancing the need to alleviate my patients’ pain but also make sure they avoided becoming dependent on opioids. Yet “Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education, and Research,” a Congress-mandated report published by the Institute of Medicine (now known as the National Academy of Medicine) read more like a marketing brochure for narcotics. Subsequent investigations revealed that almost half of those who wrote this guideline had undisclosed financial conflicts of interest and they used grossly exaggerated estimates of how many Americans suffered from chronic pain. I felt betrayed when I learned they weren’t the only offenders: Other physician-led organizations that advocated for opioids were being heavily supported with funding from pharmaceutical companies.

The biomedical industry holds broad sway over not just what physicians do but what they are taught, shaping them throughout their careers. Most training materials about opioids have been funded and developed by opioid manufacturers themselves.

Unless we make wholesale changes in how the biomedical industry can manipulate patients and physicians, we will surely find ourselves back in this quagmire at some point down the road. Training materials need to be vetted for bias, and physicians with financial conflicts of interest should be restricted from medical journal editorial boards as well as from FDA and medical guideline committees.

The FDA should be strengthened by expanding its budget and the approval process for new drugs, and post-market surveillance of approved drugs must be made more stringent. The desperate need to develop better medications to treat pain should not lead to lowering the regulatory threshold for approving new treatments. Until the FDA revamps its mechanisms to ensure opioid safety, it should heed the moratorium on additional opioid approvals filed by Public Citizen, a consumer protection group.

We should also expand how we address chronic pain, not by writing more prescriptions but by focusing on and developing nonpharmacologic approaches. A good place to start reversing our pill-popping culture is banning direct-to-consumer pharmaceutical advertising.

Unless we learn from the past, and focus only on punishing opioid producers and distributors while ignoring the role of physicians and regulators, it is inevitable that the wheels of time will keep churning, and this tragedy will recur.

Haider Warraich, M.D., is a physician and researcher at the VA Boston Healthcare System and Brigham and Women’s Hospital, and an instructor at Harvard Medical School.

  • This so problem started with unregulated pharma marketing, and history does repeat itself. Laws and regulations that we have had on the books for decades to protect the public are no longer enforced. The regulatory agencies were not allowed to track the sales of these drugs on the black market, even the DEA had their hands tied.

    The CDC failed in their response, causing more deaths, because no treatment was available for the addicted when they slowed the availability of prescription drugs. The entire time, misreported facts, hysteria, and deceptive marketing created even more profitable alternatives. Even now the public is severely misinformed.
    The attack on sick people with chronic pain were started by pharma, conveniently demonizing certain people with workplace injuries genetic disorders and post surgical pain, by categorizing them all as addicted. Various peddlers for everything from pain implants, steroid injections, and lazer surgery all took advantage of the situation, preying on vulnerable people in pain. The FDA even hid reports of the deaths from surgical implants, and the alternative medications, which did not effectively treat pain.

    Deliberately conflating people with pain, taking prescribed medications as directed by a physician, with street drug addicts, was a brilliant move, and it was amplified by the media. Physician remained silent, because the big corporations they work for found that dehumanizing patients in pain was good for their bottom line. Physician were allowed to dehumanize the addicted who showed up at ER, and with no treatment available it was fine to bully and threaten them, then have the cops take them away.

    The lies and were spread by physicians who sough out influencer careers, and hoped to get a media career like Dr Drew’s, spreading alternative fats while advertising for expensive celebrity treatment programs. These expensive treatment programs were profitable, especially since there were no standards, or regulations and laws. He created reality stars out of people with compelling stories of addiction, some died after they went to treatment multiple times. Families were forced into selling their homes or using their life savings for fly by night treatment programs, and the children still died.

    This deceptive marketing campaign dovetailed nicely with the Epidemic of Despair in the US. No economic opportunity and communities hollowed out when jobs were shipped overseas, as the media blamed the victims. Sensationalizing addiction fueled crime, when the real crime was the lack of jobs and corporate greed, was a good tactic for the media.

    Physicians remained silent even as the AMA protected them from treating the addicted or speaking up about injustice. They were silent as corporate healthcare drained the life out of them, closed their practices, and forced them to work under extreme conditions. Physicians were silent, when the hospital they worked for were understaffed, to increase profits.

    This would not have happened under Medicare for All. The complicit pharma companies, peddled a repackaged product, Oxycontin that was much more expensive than the drugs that were used previously. They had help from corrupt politicians, and eviscerated regulatory agencies that were captured by industry.

    Plenty of people are still making money from the fear and despair. Compassionate doctors have been thrown in prison for treating pain, while the communities they worked in, cut funding to behavioral health programs, and made healthcare access more difficult. America’s two tiered healthcare system, and lack of healthcare access is leading to even more deaths, while the physicians and media protect the corporations.

    This is the result of an unregulated Free Market healthcare system, there was money to be made selling brand name opiate, and money to be made on the alternatives. People die every day lacking even basic healthcare, so a few suicides, even in Veterans, from untreated chronic pain are acceptable.

    A look at the response to the Corona Virus, shows the same lies, corporate greed and denial, at the expense of American lives.

    Gas-lighting and deceptive marketing, a good way to increase profitability. How many more lives are they going to ruin before they figure it out?

  • I didn’t realize when I became a nurse 7 years ago that my job was to be a glorified pill pusher. The MDs never listened to use and they rarely weaned these patients either. It was asinine to me that i was give Percoset for headaches! Not to mention the addicts we were creating in the process. We could see it. Cell phone alarms would go off and then we’d be getting called to the room for pain meds. And to make it worse, hospitals are in pissing contests to get patients, so they DEMAND we baby patients.

    • Just wait until you get injured on the job, all it takes is one unruly patient or lifting a patient without help, because your employer finds it more profitable with less staff. Plenty of nurses end up with intractable chronic pain from workplace injuries. It sounds like you have no empathy at all for your patients, that require medication after painful surgeries. The industry pits nurses against patients, blaming them for the broken healthcare system.

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