In the United States, more people die of prescription painkiller abuse than they do of motor vehicle crashes. But while news reports often peg the cause of the problem on a minority of overprescribing "bad apple" doctors or Internet sales, a new review of the scientific literature argues that the problem likely originates within the health care system itself.
"The purpose of our article was to take a step back and say, there's a lot of coverage of the opioid epidemic—what does the hard data say?" explains Nicholas King, a professor of biomedical ethics at McGill University and lead author of the review. "The cause that we found the most evidence for was quite simply a massive increase in prescribing of these painkillers."
King says that there had been surprisingly little research done on the causes of prescription deaths in the past, but after analyzing 47 studies done in North America, he and his colleagues were able to pull together several likely culprits. The biggest surprises of the study, published this month in the American Journal of Public Health, found that evidence for the cause of deaths had little to do with single "pill mills," doctor errors, or even people seeking out drugs online. Instead, researchers discovered that skyrocketing prescription rates—in the U.S. alone, prescribing opioids for chronic pain has doubled over the last 17 years—held the biggest connections to increased mortality.
Part of the issue likely has to do with the types of painkillers doctors began prescribing on a widespread basis in the ‘80s and ‘90s, King explains. In a push to expand painkillers to new classes of people, oxycodone and methadone weren’t just for cancer patients and addiction treatment anymore—instead, they were prescribed to people with chronic non-cancer pain. Canada and the U.S. now consume 99.9% of the world’s hydrocodone, 87.3% of the world’s oxycodone, 60.1% of its morphine, and 51.8% of its methadone.
But why did prescribing stronger opioids suddenly become so popular? Aggressive marketing could have been a key factor. Purdue Pharma, for example, earned more than $1 billion from OxyContin sales a year while preaching the benefits of prescriptions to family practitioners. Its salespeople argued that the drug, which releases oxycodone over 12 hours, held a reduced risk of addiction compared to other painkillers. Meanwhile, addiction rates in poor areas spiked. In 2007, three Purdue executives pleaded guilty to criminal misbranding charges, and the company agreed to pay $600 million in fines.
"The manufacturers of these pharmaceuticals certainly do bear some responsibility for marketing them as safer than they actually were, and for marketing them as effective when there wasn't a lot of evidence that it was," King says.
But now that researchers have a clearer picture of some of the social, environmental, and systemic factors that lead to prescription deaths, they say even more research ought to be conducted. How best to tackle specific causes of miniature epidemics all over North America will take more scrutiny, and more time.
"We did find evidence that this is a large scale, systemic problem," King says. "This is widespread, it's been increasing steadily over time."