Blame the opioid maker? Right church, wrong pew

A new article appearing in VOX notes that one member of the Sackler family, longtime overseers of Purdue Pharma, is helping the treatment industry clean up what the opioid crisis cat dragged in. Richard Sackler, former president of Purdue Pharma, is listed on the patent application for a new form of buprenorphine. Buprenorphine (trade names Buprenex, Butrans, Probuphine, and Belbuca) is an opiod agonist used in the medication-assisted treatment (MAT) for opioid addiction.  The new product is a fast-dissolving wafer, designed to keep those administered the dose from cheeking the medication and sharing/selling it.

On one hand, 'Shouldn't we be applauding ANY help going to those who need it?' is the easy question. That question is buried under the emotion of a very traumatic crisis, however. One editorial on the article went so far as to call Sackler the 'devil incarnate,' And the spin on the article is that Purdue helped spawn the opioid crisis with its drug, OxyContin, and Stackler made bank on that drug and now seeks to profit from cleaning up the mess.

Not so fast. OxyContin and Purdue are not the drugmakers that created this crisis. The drugmakers that created this crisis, every crisis before it, and the crises emerging now, are not in the pharmaceutical industry. The drugmakers who have groomed us for drug use, drug abuse, and drug addiction make the gateway drug, alcohol.

Two thirds of drug abusers identify alcohol as the first drug they used, according to an American Addiction Centers 2018 survey. The rest of us learned to take drugs from our cultural acceptance and endorsement of drug use aka drinking. What we ignore, we permit, what we permit, we condone.

The blame-game, legislation, lawsuits, etc. target Big Pharma, sketchy doctors, China, and dope dealers. Right church, wrong pew. Look What Dragged the Cat In details how the opioid crisis (spoiler: it's a crisis, not an epidemic) really emerged (spoiler: it wasn't the Sacklers) and how we can use the tragedy of this crisis to prevent the next one.


Stevens is author of five alcohol, health, and recovery books and is principal of alcohologist.com. He is a founding influencer of the world’s largest medical portal, healthtap.com. He Chaired the 2018 International Conference on Addiction Therapy and Clinical Reports in Paris, France, where Look What Dragged the Cat In was officially launched. He's also the Chair for Addiction Science 2018, in London, UK.

Image by Santalucia Art Inc., used with permission.

Look What Dragged the Cat In: The rise of an opioid crisis

Excerpted from the 2018 USA Best Book Winner, Look What Dragged the Cat In.

The decade of the 2010’s shelled hospitals and first responders with an explosion of opioid-related illness, injury, and death. Preventable drug overdoses tallied 54,793 lives lost in 2016 – an increase of 391 percent since 1999. Accidental drug overdose deaths increased 327 percent over the same period. The majority of OD deaths (38,000) involve opioids, The drug category most frequently involved in opioid overdoses and growing at the fastest pace includes fentanyl, fentanyl analogs, and tramadol. The fentanyl category of opioids accounted for nearly half of opioid-related deaths. The dirty cat in the litter, heroin, accounted for the second highest number of deaths, claiming 14,606 lives.

America struggles with what the opioid cat dragged in: Hard-to-treat opioid addictions, fatal relapses, and needless loss of mainly young lives. Now legislators, first responders, treatment pros, and those in the medical field are forced to focus not on the death toll the cat dragged in, but instead what dragged the cat in.

Every opioid related death is alcohol related

The abuse of drugs, regardless of classification, begins with the permissiveness granted the world’s most lethal drug and third-leading cause of all preventable deaths: Alcohol. It’s a straight line.

Nearly every non-Muslim civilization on this rock has embraced alcohol. As a result, ours is largely a numbing planet, especially in the sedation-happy Americas. This is the root. This is the seed of the opium trade that has gone unstemmed since prehistory. There is legit medical use for opium derivatives: What has driven growth is demand – not by the sick but by people who cannot get the mind alteration they desire through alcohol use alone.

Alcoholics and non-alcoholics alike drink the first drink for the same reason: To relieve a stress. In the U.S., which has a laissez faire agenda toward alcohol since its prohibition failure, the culture embraces a drinking lifestyle. Americans normalize alcohol use. In other words, Americans (like many cultures) normalize drug use. The 1960’s have nothin’ on the 2010’s.

What you ignore, you permit. What you permit, you condone.

Opioid abuse happens when a person can’t get where they want to get with alcohol. The opioid crisis wasn’t created by doctors overprescribing, manufacturers wooing doctors, China shipping heroin and cheaper fentanyl via cartels and the U.S. mail. Drinking, especially binge drinking, is the pandemic that dragged in the opioid ‘epidemic.’ Americans condone the buzz, the sedation. We created this monster on our own.

What’s the way out?

Legislative attempts to curb use of potentially lethal drugs resemble shooting an arrow and then drawing a target around where it hit. Locking up dealers and traffickers, creating prescription databases and prescribing limits, and promoting Narcan availability all deal with control of the supply and its aftermath. The demand is unchanged. Within a cultural adoration of the buzz, our current crisis can only be curbed by control of the demand. If a drug user wants a drug, theywill get that drug. It’s the American freedom thing.

In 1967, 72 percent of adult men smoked. Today, 72 percent don’t. Prevention works. If there is genuine interest in healthy outcomes and preventing premature death from opioids, Americans’ permissiveness of the starter or feeder or gateway or predecessor drug has to be addressed on five levels to reduce demand for all antecessor drugs.

• Advertising agencies court alcohol manufacturers with a promise of creating demand for the drug. You can ban advertising without banning the product. When cigarette marketing/advertising was banned, demand dropped without banning the product. The National Bureau of Economic Research (NBER) studied bans in 20 countries over 26 years. The results indicate that an increase of one ban could reduce alcohol consumption by five to eight percent.

• Public drinking encourages drug use. Smoke-free regs cut down on the demand by curtailing where cigarettes can be smoked. Applying the same model for drinking – instead of popping up a brew pub on every corner – can reduce demand. The idea of having a cocaine bar on every corner is absurd, but a pub peddling a drug that kills more people (89,000 Americans per year) is somehow acceptable. The availability of alcohol can be regulated either through restricting the hours or days it can be sold or by reducing the number of alcohol retail outlets, according the a World Health Organization (WHO) study. Logicaly, reduced sales hours have been found to be effective in lowering consumption. In the former Soviet union in the mid-1980s, strict alcohol regulation, which included among other measures restricted hours and fewer outlets, led to a dramatic reduction.

• The ‘Smoking Stinks’ campaign brought an anti-smoking message down to the earliest grades. A modest effort to create similar anti-drinking messages demonstrating health risks of even moderate use (see viewbook.at/prehab) will stunt demand by discouraging the very first drink of the gateway drug.The American Journal of Public Health analysis of the anti-smoking campaign suggests that per capita consumption would have been one-fifth to one-third larger than it actually is, had the years of anti-smoking publicity never materialized.

• Increase the tax on the gateway drug. The bottom line is that many states and municipalities balance their bottom lines with so-called ‘sin taxes.’ The sin taxes on alcohol haven’t kept pace with inflation. These taxes are usually based on the amount of beverage purchased (not on the sales price), so their effects can erode over time due to inflation if they are not adjusted regularly. The Community Preventive Services Task Force (CPSTF) recommends increasing taxes on the sale of alcoholic beverages, on the basis of strong evidence of the effectiveness of this policy in reducing excessive alcohol consumption and related harms. Opioid use is a related harm. The CPSTF is an independent, non-federal panel of public health and prevention experts that provides evidence-based findings and recommendations about community preventive services, programs, and other interventions aimed at improving population health.

• Many will argue that legalizing recreational use of marijuana will reduce opioid abuse and erroneously point to Colorado as an example. (By the Center for Disease Control and Prevention’s (CDC) numbers, you can call BS: Colorado’s death rate from opioid overdose is barely in the top half of the state-by-state death-rate comparison … if you wanted to complete the morbid, pointless comparison. One death is too many.) What’s entirely missing from the debate is that no evidence exists that encouraging recreational use of another drug furthers public health in general. Marijuana is revenue-neutral when you subtract societal, medical, and legal costs.

When we rethink the drink we can douse the pandemic that begat the current opioid crisis. Legislators and treatment experts must lead the transition from managing aftermaths of the current crisis to prevention of the next one. And phase out the ancient alcohol crisis – the elephant in the room – America ignores.

Stevens is author of four alcohol, health, and recovery books and is principal of alcohologist.com. He is a founding influencer of the world’s largest medical portal, healthtap.com. He will Chair the 2018 International Conference on Addiction Therapy and Clinical Reports in Paris, France.

Busting the flashy car for 75 mph to let the 250 mph Peterbilt pass

The public relations approach to hiding an alcohol pandemic

In opioid news this week, state attorneys general across the country are stepping up their game against the opioid crisis. Awhile back, the AGs sent letters to insurers, asking them to do more to curb the opioid epidemic. Now, they say they're expanding an ongoing investigation into pharmaceutical companies make or distributing opioids. That's according to MedPage Today. The publication also reports the Substance Abuse and Mental Health Services Administration (SAMHSA) offered up an additional $144 million in grants for preventing and treating opioid addiction … a crisis costing the economy $78.5 billion a year.

That's correct. Opioid use and addiction costs the U.S. $78.5 billion.  

Alcohol use and addiction costs the U.S. $250 billion a year, using the same measurements of health care costs, lost productivity, and legal system expenses.

We focus on an epidemic, so we don't have to focus on a pandemic. The 75 mph 'vette gets the ticket. The 250 mph Peterbilt gets a pass. Classic PR.

The public relations tactician works it something like this: 

Pick a drug – One that is sold only by prescription, generating profit for a few, wealthy souls vs. a drug sold nearly everywhere in the U.S., generating profit (and tax revenue… but not as much as you think) for every restaurant, bar, retailer, grocer, hotel, gas station, henhouse, outhouse, and doghouse where it's sold. Villify alcohol? Not on your life.

Draft in support – According to FollowTheMoney.org, Big Pharma contributed $163 million to local, state, and federal candidates in 2016… alcohol interests (manufacturers, distributors, retailers) donated $219 million. Don't bite the hand.

Choose an opponent you can outspend – BusinessInsider.com put beverage alcohol spending at $421 million in a single calendar quarter. Every one of those ads tells Americans we can drink a toxin and known carcinogen 'responsibly.' You're not going to run with these big dogs. Stay on the porch.

Capitalize on ignorance – Fewer than 1 in 10 Americans know that alcohol kills three times as many people as opioids (89,000/yr. vs. 30,000/yr). Less than 1 in 4 know that alcohol's a carcinogen and a third of the 22,000 annual alcohol-related U.S. cancer deaths occurred in people who had downed one and a half drinks a day or less. Alcohol is legal. Legal equals 'safe' in our society. Except for those nasty drunk drivers, binge-drinking college kids and hard-core, red-nosed alcoholics, this isn't a drug: It's responsible and fun in moderation. Opiates and opioids are controlled substances, illegal without a prescription, and have a high risk of addiction and/or overdose. Nevermind the medicinal relief in chronic pain situations: Opioids are definitely the baddie.

Don't make them think, either – There is a short line between opioid use and overdose death. Drinking alcohol is more like stepping out onto the highway and waiting for the Peterbuilt to hit you: It could take years or decades. Too many dots to connect – and other causes to which to pin the death while you're waiting. Brevity is better in our 'always-on' planet. A recent Pew Internet study in the US suggests that people benefit from instant access to a wealth of information from numerous sources, but their attention span and desire for in-depth analysis is consequently diminished. That's how we got the term bounce rate. “If you start a message and I can't see the end from the beginning, I will find it elsewhere… and bounce.” Opioid tragedies tell what time it is… alcohol deaths tell how to build a watch.

Sell the sizzle, not the steak – There are 91 deaths a day from opioid overdose. Opiates and opioids take lives in a single-dose for some people. And sadly, the lives are often kids and young adults that society wouldn't have picked out as a drug user. The old newsroom saying was, “If it bleeds, it leads.” Crass and cynical? Yes. Accurate? Pretty close. Stories of an honor student dying are tragedies with great images on par with hurricanes, school shootings, and blazes… compared to someone dying a death from alcohol-related illness like heart attack, stroke or cancer.

Wag the dog – We have a genuine health crisis. The opioid problem is real and tragic and a worthwhile fight. Now, if we turn a genuine health crisis and spin it up to an epidemic… maybe we don't have to talk about a pandemic or other health crises like fetal alcohol spectrum disorders (FASDs) which are now more prevalent than autism. It's the sleight of hand performed by politicians, PR wags, confidence men, and magicians for millennia: Watch what I do with this hand, while the other takes your wallet. Or your health. 

And, most importantly of all, don't make enemies – According to the 2015 National Survey on Drug Use and Health (NSDUH), 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1 percent reported that they drank in the past year; 56.0 percent reported that they drank in the past month. Even if you went with the lowest figure, 56 percent of adults used alcohol in the last thirty days. That's 137 million adults. By American Society of Addiction Medicine (ASAM) stats, 2.5 million adults have substance use disorder involving prescription pain relievers or heroin. You've got a good shot at convincing me something is bad if you're not doing it. You're even more effective telling me something is bad if I'm not doing it.

It's not the back bumper of the Peterbilt that hits you

What we've got here, is failure to communicate: There's a drug acceptance problem in the U.S. There's not just an opioid overdose crisis. There isn't only an alcohol pandemic. There isn't a weed legalization debate. The problem is cultural in the way we normalize drug use, stigmatize those who've become ill from them, and throw too little money, too late, at treatment instead of prevention. Did any alcoholic become alcoholic without taking the first drink? Is any case of alcohol-related injury or illness possible without a first drink? Giving a 'gateway drug' a free pass negates prevention efforts on other drugs we find less 'responsible.'

No amount of PR is going to paper over it for long before it becomes fiscally unsustainable.

Scott Stevens, is the author of four alcohol books including the December 2016 release, I Can’t See The Forest With All These Damn Trees In The Way: The Health Consequences of Alcohol. Get the new BookLocker title now on Amazon (viewbook.at/prehab), alcohologist.com, and everywhere you buy books.  Click Alcopocalypse for the author’s 2017 Alcohol Awareness Month whitepaper. Image by  Peter Lecko, used with permission.

Barney, participation trophies, and Nintendo: We didn’t see an opioid crisis coming?

(Originally posted on AddictedMinds.com)

Overdose deaths involving opiates and opioids have quadrupled since 1999, according to the Center for Disease Control and Prevention (CDC). Using information from death certificates compiled for the CDC’s Wide-ranging Online Data for Epidemiologic Research (WONDER) database, almost half of the 13,000 heroin overdose deaths in 2015 (5,941) were to people born between 1981 and 2000. Prescription opioid drug overdose deaths match the same age bubble.

Clearly, a single generation or demographic isn’t involved in the crisis. If half of the deaths occur to one age band, half don’t. However one half is a statistically significant batch of dope deaths.

There are those who would direct the anger about this at pharmaceutical companies. They made stronger opioids and aggressively marketed them by the truckload to every doc with a prescription pad. There would be no supply, however, without demand. Economics. So what spiked the demand? A purple dinosaur, a medal for everyone, and constant entertainment with a reset button. They could be as much to blame as overzealous Rx writers and an uninterrupted flow of street smack.

An entire generation programmed for susceptibility

Barney, the purple dinosaur, became a phenom with the Pack-n-Play set in 1992. It was geared toward kids aged 1 to 8 years with sometimes educational value. Barney had kids singing, “I love you, you love me” etc. until the runaway hit was canned in 2009. It lives on today in syndication.

One specific rub on Barney is that the show didn’t help kids learn how to deal with negative feelings and emotions. As one commentatorput it, the real danger from Barney was, “denial: the refusal to recognize the existence of unpleasant realities. For along with his steady diet of giggles and unconditional love, Barney offers our children a one-dimensional world. Everyone must be happy. Everything must be resolved right away.'” Ouch.

On the topic of not dealing with unpleasant realities is that there is, in the real world, a concept of winning and losing. They are not two separate and unrelated concepts: You cannot have all winners and no non-winners. We used to call them ‘losers,’ a la racer Dale Earnhardt once proclaiming ‘second place is the first place loser.’

It’s hard to peg an exact year when the everyone-gets-a-trophy movement began but a 2015 episode of the HBO Real Sports with Bryant Gumbel documentary points to the late 1980’s or early 90’s as well. It was initially a California phenomenon. It was to boost the self-esteem of inner city youth. “We thought, especially for kids in struggling communities, if we just told them they were great they would believe it. Then they’ll achieve more because they were certain they were great,” researcher Ashley Merryman told HBO.

The first gaming system to reach mega-saturation in American households was the 8-bit Nintendo. It launched in October 1985 and Mario Bros. could be spotted babysitting millions of kids by the next fall. In fact, the entire gaming industry was $100 million in 1985: In 1986 it was $430 million, $310 million of it was Nintendo’s share.

Not blaming the opioid victim

Sociologists are big on generational cohorts like GenX or Millennials or Baby Boomers and enjoy painting with a broad brush the ills or successes of each cohort. The ones turning to the relief they find in opiates and opioids are not the ones to find fault with. Who gave them Barney, participation trophies, and gaming systems?

The Recession stymied economic growth, halted job creation, kept older Americans in the workforce longer, and encouraged younger American couples to have two wage earners. That Recession was 1982, NOT the most recent one of 2008. The opioid tragedy of those born 1981-2000 was written before many of them had even learned to read. GenX and Baby Boomer parents and grandparents who authentically loved and cared for kids, hobbled the same kids. How? By setting up an unrealistic world of expectations that all things are resolved in an hour, everyone gets an award and we must all be entertained all the time.

The grave consequences of an opioid crisis for this generation were entirely foreseeable – in hindsight. It’s like when the world first heard that Queen’s Freddie Mercury was gay. When we went back and watched the old videos we collectively said, ‘Well, that makes sense.”

Addicted Minds’ Editor-in-Chief, Scott Stevens, is the author of four alcohol books including the December 2016 release, I Can’t See The Forest With All These Damn Trees In The Way: The Health Consequences of Alcohol. Buy the new BookLocker title now on Amazon (viewbook.at/prehab), alcohologist.com, and everywhere books are sold. Stevens also heads up BlogTender LLC, a content marketing firm headquartered in Lake Geneva, Wis.

Dope 101: Opioids, opiates… six of one isn’t a half-dozen of the other

(Originally posted on AddictedMinds.com)

The terms opioids and opiates are frequently – and mistakenly – used as interchangeable words for the same drug when they really mean two related drug classes. The media doesn’t get that. Nor do they have to when they ring the ‘epidemic’ bell to get more viewers. For the record, we have a drug crisis, not just an opioid or opiate crisis.

An opiate is a natural narcotic analgesic (e.g. painkiller) derived from the opium poppy. Think opium, morphine, and heroin.

An opioid is a synthetic narcotic analgesic created in a lab to mimic or intensify or attempt to remove undesired inconsistencies of the natural product. Think Oxies.

Physicians used to prescribe the former. They now prescribe the latter when other pain meds like ibuprofen or acetaminophen aren’t strong enough. Street dope used to be only the former. Now street dope can be purely the former, impurely the former, or even mixed with the latter with usually disastrous outcomes.

From a dependency treatment standpoint, both classes are essentially equal in their abilities alter neurochemical processes in the body and change how the brain and body work over time. With the opioids, the carnage is often quicker. To explain the reason for that, I’m tossing out two words that will slay your opponent is Scrabble: Dolorimetry and pharmacopeia.

Big words, bigger problems

It all starts with pain. Dolorimetry (dolor is Latin for pain) is the measurement of pain in animals and, notably, humans are animals. If humans can measure it, they next want to fix it. There’s a long human history of not tolerating pain and seeking a remedy for it. And from that we get the ancient Greek word pharmacopeia, the science or study of drugs, their preparation, properties, uses, and effects.

For thousands of years, opium was used to treat the pain. In the 1500’s, laudanum (opium dissolved in alcohol) became the next generation. In the early 1800’s, the most active part of opium, morphine, was extracted. A less active part – codeine, about two percent of opium – was also extracted. Merck went commercial with morephine in 1827. Tens of thousands of Civil War soldiers became addicts. In 1874, heroin was first made by boiling down morphine in an attempt to find something twice as strong but less addictive. They got it half right… and by most accounts a century and a half later: ALL wrong.

Opioids speeding the way to ruin

Opium was banned in the U.S. in 1905 and set in the opioid lab race, which really took off later that decade when Bayer (yes, THAT Bayer) stopped mass production of heroin because of its dangers. Oxycodone was born in the lab in 1916. It was hoped that oxycodone would retain the analgesic effects of morphine and heroin with less dependence. Nope. But it still lives on today as OxyContin and Percocet. Hydrocodone was first synthesized in 1920, approved in the U.S. in 1943 and became Vicodin in 1984. Hydromorphone (Dilaudid) was first synthesized in 1924. Methadone was created in a lab in 1937 to find something, again, less addictive than morphine and heroin in surgery. Epic fail. Janssen Pharmaceuticals gave us fentanyl in 1959.

Which leads us to the latest trend is mixing into cheap street heroin even cheaper, illegal modifications of fentanyl (like carfentanyl) thousands of times more powerful than morphine or heroin.

By the way, that old opiate, morphine, is still among the World Health Organization’s List of Essential Medicines because of its relative safety in comparison to the misbegotten offspring. However, we can’t put the pharmacopeia toothpaste back in the tube and we have a drug crisis today.

Addicted Minds’ Editor-in-Chief, Scott Stevens, is the author of four alcohol books including the December 2016 release, I Can’t See The Forest With All These Damn Trees In The Way: The Health Consequences of Alcohol. Buy the new BookLocker title now on Amazon (viewbook.at/prehab), alcohologist.com, and everywhere books are sold. Stevens also heads up BlogTender LLC, a content marketing firm headquartered in Lake Geneva, Wis.