Opioid crisis? ‘Not my fault,’ say surgeons and drug maker’s heir

As the nation’s opioid and drug overdose crisis deepens, it can be hard to watch as the “Not My Fault” crowd clucks about its blamelessness in pushing potent painkillers that have played a part in killing more Americans in 2016 and 2017 alone than lost their lives in the Vietnam War.

The latest NMF protagonists include:

• David Sackler, the outrage-fueling scion of the family that owns Purdue Pharmaceutical, the maker of OxyContin. That drug — and the relentless and inaccurate sales and marketing push that the Sackler family put behind it — helped to foster a calamitous wave of prescription painkiller abuse and addiction, deep media investigations and court cases have shown. OxyContin, in turn, assisted in opening the door to lethal abuses and overdoses of even stronger legal and illicit drugs, including the painkiller fentanyl and street heroin.
• Surgeons nationwide, who, years after warnings about opioids’ harms, persist in prescribing them in dubious dosages for patients who have undergone operations and may not need major pain relief. Specialists’ reflexive prescribing of opioids concerns addiction experts because research shows that patients who have gotten surgical or emergency room treatment are at heightened risk from getting even one opioid prescription.

The excuse-making abounds by both the Big Pharma surrogate and practitioners who purvey drugs with well-known problems.

Sackler, in brief, seeks to shift any culpability for opioids and the documented nightmares of OxyContin onto federal regulators and the “best available” science at the time. In response to prescribing data dug up by the Kaiser Health News Service and Johns Hopkins researchers, surgeons argued about the evidence — or they, among other reasons, blamed electronic health records systems and their “check the box” approaches to post-op care, including opioid overprescribing.

While it may be frustrating reading, understanding the pathologies that led to the opioid crisis — long in its making and with plenty of fault to be spread among doctors, nurses, hospitals, Big Pharma, insurers and others — may be crucial to stopping what has become a leading killer of Americans younger than 55. Yet more reports also underscore that drug abuse and overdose are associated with a rising toll of younger people who are succumbing to diseases of despair, including addiction and suicide.

Surgeons pushing opioids, still

Kaiser Health News, the Johns Hopkins School of Public Health, and the funding Arnold Foundation deserve public praise for drilling down into “almost 350,000 prescriptions written for patients operated on by nearly 20,000 surgeons from 2011 to 2016 — the latest year for which data are available.”

This research led to the finding that:

Some surgeons wrote prescriptions for more than 100 opioid pills in the week following the surgery. The total amounts often exceeded current guidelines from several academic medical centers, which call for zero to 10 pills for many of the procedures in the analysis, and up to 30 for coronary bypass surgery. While hundreds of state and local lawsuits have been filed against opioid manufacturers, claiming they engaged in aggressive and misleading marketing of these addictive drugs, the role of physicians in contributing to a national tragedy has received less scrutiny. Research shows that a significant portion of people who become addicted to opioids started with a prescription after surgery.

The organizations also discovered that:

[L]ong-ingrained and freewheeling prescribing patterns changed little over the six years analyzed. KHN and Johns Hopkins examined the prescribing habits of all U.S. surgeons who frequently perform seven common surgical procedures and found that in the first week after surgery: Coronary artery bypass patients operated on by the highest-prescribing 1% of surgeons filled prescriptions in 2016 exceeding an average of 105 opioid pills. Patients undergoing a far less painful procedure — a lumpectomy to remove a breast tumor — were given an average of 26 pills in 2016 the week after surgery. The highest-prescribing 5% of surgeons prescribed 40 to 70 pills on average. Some knee surgery patients took home more than 100 pills in the week following their surgery. Those amounts — each ‘pill’ in the analysis was the equivalent of 5 milligrams of oxycodone — are many times what is currently recommended by some physician groups to relieve acute pain, which occurs as a result of surgery, accident or injury. The analysis included only patients not prescribed opioids in the year before their operation.

Although a leading addiction expert told KHN reporters Julie Appleby and Elizabeth Lucas that “prescribers should know better” and should have been more restrained in their opioid orders, they went further and sought to interview surgeons who topped the lists for high painkiller prescriptions.

Some doctors disputed their findings, saying their patients were different and needed more pain help, or that they had suffered no harm from getting extra pills because they didn’t take them (meaning, though, that they may have sat on medicine cabinet shelves where others might get and then abuse them). To their credit, some expressed surprise and said they would re-examine their practices, especially by delving into electronic record systems that might have default prescribing settings for too many opioids.

A Sackler speaks up

As an heir to a family fortune estimated to run in the billions of dollars, 30-something Sackler almost seemed to go out of his way to antagonize audiences in attempting a defense of his philanthropic clan. His chosen media outlet, Vanity Fair, is a publication for swells. He distances himself from the family’s Big Pharma trade — by noting he’s in an even more popular line of work as a hedge funder handling Sackler money.

He gave little quarter when a reporter confronted him with a long list of ways that investigations — by the media, regulators and as part of court proceedings the family has lost — show Purdue fueled the opioid crisis. Instead, he sought public sympathy, saying that Sackler kids have been teased and bullied by classmates.

It may be helpful as a truth antidote to the long magazine article to consider the voluminous negative material that has focused on Purdue and the Sacklers, say, by clicking here or here or here or here or here. Keep multiple tabs open on that internet browser and don’t skip over the VF reporter’s credible effort to provide the deep background on the OxyContin mess.

This all may help put in context the Sackler distress at the considerable shaming the clan is experiencing in its high society life, the sort of existence that VF chronicles and dotes on.

It also may shrink that key Sackler argument that, hey, his father and others in the family did nothing wrong because they relied on the best medical science available at the time and the approval of federal regulators. He, of course, puts a lot of weight on one, terse letter to the editor about painkillers, published in a medical journal — a missive whose author since has expressed regret about and said it has been distorted and misinterpreted.

Unlike the Sacklers, the federal Food and Drug Administration has conceded that the agency made big errors and shares blame in overseeing opioids, with David Kessler, a former commissioner, saying of explosive use of prescription painkillers: “This has been one of the great mistakes of modern medicine … FDA has responsibility, the pharmaceutical companies have responsibility, physicians have responsibility. We didn’t see these drugs for what they truly are.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by dangerous drugs. The opioid crisis traces to the 1990s, erupting into a tragic and nationwide epidemic in the 2000s. Blaming and shaming aren’t optimal ways to deal with awful situations, especially this far into this crisis. But, hey, if the Sacklers and their advisors want to pop up and subject themselves to withering criticism for the NMF-y views, well, at least their keeping a public spotlight on one of the public health torments of our time.

As for the surgeons, here’s hoping that KHN, Johns Hopkins, and the Arnold Foundation have given them a professional jolt that’s positive — and they respond to improve their patients’ care. It would be a good move, for example, for the American College of Surgeons and other significant specialty groups to look hard at the opioid prescribing information, to work with its researchers, and to not be defensive but to reach out to members for appropriate next steps.

The investigating organizations, to their further credit, have created an interactive and accessible data base so patients can learn more about their own surgeon’s opioid prescribing (access it by clicking here). Caveat emptor.