The Opioid Crisis: From Opium Wars to OxyContin

3. Nomenclature • Opiate – derived from opium, as in codeine, morphine, or heroin • Opioid – drugs that work by binding to the same receptors as opiates, but do not occur naturally • Semi-synthetic opioids – chemical modification to natural opiates, as in oxycodone and hydrocodone • Synthetic opioids – synthesized entirely, as in fentanyl • ‘Opioid’ has become the umbrella term for all of these terms.

4. Opium • Derived from the poppy plant, Papaver somniferum • Illegal crops grown in: • The Golden Crescent of Afghanistan, Iran, Pakistan • The Golden Triangle of Myammar, Laos, Thailand • Columbia and Mexico

6. Opium Wars • To fund their desire for Chinese tea and other products, Britain, through the East India Company, began smuggling Indian opium to China. • This resulted in a soaring addiction rate among the Chinese and led to the Opium Wars of the mid-1800s. • Subsequent Chinese immigration to work on the railroads and the gold rush brought opium smoking to America.

8. Morphine • Early 1800’s: isolation of the active ingredient in opium • Much more powerful than opium itself. • Marketed as a cure for many ailments

9. Doctors and druggists provided Civil War veterans with hypodermic and supply of morphine – the addiction to it was called ‘soldier’s disease’ • By 1870, injecting morphine was widely available ad was popular among upper classes in US and Europe. • No regulatory oversight, no prescription necessary.

12. Heroin • 1888 German company Bayer derives heroin, 10X more potent than morphine. • Pitched as a less addictive substitute for morphine. • Respiratory suppressing qualities were promoted to treat cough, asthma, bronchitis • Injected with a hypodermic syringe for pain, headaches, alcoholics’ delirium tremens, gastrointestinal diseases and menstrual cramps • Bayer was soon selling it in 23 countries for a variety of over the counter medicines. • By late 1800s, opiates had led to an addiction epidemic that affected roughly 1 in 200 Americans.

13. Heroin • 1906: American Medical Association recognizes heroin is habit forming • Harrison Narcotics Act of 1914 severely regulated sale and manufacture of heroin • Access to opiates became restricted • Cost of drugs increased • Criminal networks took over illegal trade • Attitudes toward users changed

14. The U.S. War on Drugs • Federal policies directed toward the control of illegal drugs domestically and abroad • Began in 1960s but by mid-2000s its impacts were questioned • Targeted nations that complicit in the cultivation and smuggling of opium or coca into the US • Federal intervention in Central and South America to combat drug shipments • However, in some cases US turned a blind eye toward drug shipments if it was politically advantageous • Enacted harsh laws for the sale and possession of drugs • Laws disproportionately impacted poor and people of color in the US • Addiction was criminalized instead of being treated as a disease

15. 1996: introduction of OxyContin • OxyContin is the brand name for oxycodone hydrochloride, an opioid analgesic (pain reliever) • Coincided with recognition that pain was the fifth vital sign

16. Pain as the fifth vital sign • For much of the twentieth century, doctors were discouraged from treating even terminally ill patients with opioid analgesics • The assumption was that alleviating pain was less important than avoiding addiction. • But pioneers in the hospice and palliative care movement denounced such views, insisting that allowing a patient to suffer needlessly was unethical medical practice. • Before we had an addiction and overdose crisis, there was first the crisis of undertreated pain.

17. The role of marketing and advertising • OxyContin heralded as non-addictive, aggressively marketed by sales reps • Doctors who were increasingly being rated and ranked were often quick to prescribe • Patients sent home for routine procedures were given OxyContin

21. Hardest hit were areas of the USA that had been most impacted by the economic changes of globalization – the small towns that had once been manufacturing centers. • Automation, exporting of jobs abroad, switch from coal to natural gas – reduced employment. • Diminished economic opportunities increases vulnerability to drug use

25. Closing of pill mills • As soon as supplies of OxyContin started to dry up – doctors and pill mills came under scrutiny – price of pills went up and it became harder to get a prescription. • Pain patients left with few alternatives • Higher prices and stringent regulation of prescription pills pushed people to other drugs, including heroin • Heroin was cheaper and easier to obtain than prescription drugs

28. Opiod shortages during an opiod overdose epidemic • To slow supply of opiods, the US federal government (Drug Enforcement Agency) set restrictions on the amount of opioids drug companies can produce each year • Unintended consequence of limiting availability of intravenous opioids for patients who need them.

31. Fentanyl • Fentanyl easier to make then heroin • 25-50X stronger than heroin • Legally used to treat pain in advanced cancer patients • Fentanyl is added to heroin and other drugs to increase potency

32. Fentanyl is completely synthetic, made in labs • Illegal fentanyl enters US direct from China or through Mexico via China • Ordered over the dark web and shipped through US Postal Service • US is putting diplomatic pressure on China to curtail production • Carfentanil, a fentanyl analog

33. Fentanyl analogs • Analogs are designed to mimic or intensify the effects of the parent drug while avoiding the legal classifications and restrictions that those markings impose on the original. • In other words, a small molecular tweak can change the status of a chemical as an illegal substance • Enforcement structure and legal standings cannot adjust as rapidly to changes in molecular formulas.

34. Palliative care • Morphine and fentanyl are often used in palliative care • In palliative care, the goal is to improve the quality of life for anyone living with serious illness • Includes hospice care • WHO essential pain medicines • Aspirin, ibuprofen, Tylenol • Codeine, fentanyl, morphine

37. The access abyss in pain relief

43. Tramadol is the opiod problem drug for the rest of the world • Used heavily for non-medical purposes in west, central and north Africa and Middle East • Illicitly manufactured in India and south Asia and trafficked to these regions. • Some consume tramadol for its calming, analgesic and anti-fatigue effects • Taken for pain, sedative effects, although in large quantities has a heroin effect.

45. Tramadol consumption has increased globally • March 2019 the UN Commission on Narcotic Drugs declined to add tramadol to its list of scheduled substances. • Its concern was that international controls might make access harder for those in low-income countries who genuinely need the painkiller.

46. Summary • Opiod addiction is and long has been a global public health issue and not just a moral defect of character • Unfortunately, only until movement of opiods into mainstream white America has change occurred • Synthetic opiod manufacturers responsible for opiod pill epidemic in US have been successfully sued • Globally, opiods represent a challenge to find productive balance between production, availability and access to pain-relieving drugs, while avoiding the conditions for scenarios that lead to societal addiction crises