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The Root Causes of the Current Opioid Crisis

      To the Editor:
      I read with a great deal of interest the article by Rummans et al
      • Rummans T.A.
      • Burton M.C.
      • Dawson N.L.
      How good intentions contributed to bad outcomes: the opioid crisis.
      and the accompanying editorial by Srivastava and Gold
      • Srivastava A.B.
      • Gold M.S.
      Beyond supply: how we must tackle the opioid epidemic.
      in the March 2018 issue of the Mayo Clinic Proceedings.
      Both sets of authors should be commended for attempting to address the root causes of the opioid epidemic. In particular, Srivastava and Gold deserve recognition for looking beyond the “supply-side” approach to the crisis: too often, potential solutions to the epidemic focus solely on the role of pharmaceutical manufacturers or physician prescription patterns.
      In their description of the “demand side” of the equation, Srivastava and Gold rightly point to the importance of assessing for the presence of concurrent psychiatric illness in patients with substance use disorders. They also state the necessity of treating addiction as a chronic, relapsing disease, one that requires long-term follow-up.
      But in other, critical ways, their editorial paints an incomplete picture. There are additional root causes of the opioid epidemic, which the authors neglect to mention at all—namely, those related to widespread social upheaval.
      The past few decades have been characterized by rising unemployment, poverty, and wealth inequality due to neoliberal austerity measures and a fraying social safety net. In disadvantaged communities, social capital becomes supplanted by feelings of isolation and hopelessness. Meanwhile, the US government continues to engage in drug interdiction efforts, which, in turn, lead to the emergence of synthetic and deadly heroin alternatives in the domestic black market.
      • Dasgupta N.
      • Beletsky L.
      • Ciccarone D.
      Opioid crisis: no easy fix to its social and economic determinants.
      The end result of these seemingly disparate processes, of course, is what we see before us today: increasing overdoses and other “diseases of despair.”
      • Case A.
      • Deaton A.
      Mortality and morbidity in the 21st century.
      No discussion of the “underpinnings and evolution of the current opioid crisis” is thus complete without an account of these structural factors.
      I agree with the authors' recommendation that “more resources need to be devoted to addressing the opioid epidemic,” including implementing comprehensive care programs. I worry, however, that other recommendations, such as developing personalized neurotherapeutics, would draw attention away from what many in the public health community are beginning to realize: structural disadvantage contributes to addiction, and overcoming it will require more than a biomedical approach.
      Physicians are in a privileged position to guide the conversation around this important topic. In addition to spreading the important message of “addiction as a disease,” we should be advocating for social change.

      References

        • Rummans T.A.
        • Burton M.C.
        • Dawson N.L.
        How good intentions contributed to bad outcomes: the opioid crisis.
        Mayo Clin Proc. 2018; 93: 344-350
        • Srivastava A.B.
        • Gold M.S.
        Beyond supply: how we must tackle the opioid epidemic.
        Mayo Clin Proc. 2018; 93: 269-272
        • Dasgupta N.
        • Beletsky L.
        • Ciccarone D.
        Opioid crisis: no easy fix to its social and economic determinants.
        Am J Public Health. 2018; 108: 182-186
        • Case A.
        • Deaton A.
        Mortality and morbidity in the 21st century.

      Linked Article

      • Beyond Supply: How We Must Tackle the Opioid Epidemic
        Mayo Clinic ProceedingsVol. 93Issue 3
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          The opioid epidemic is the most important and most serious public health crisis today. The effects are reported in overdose deaths but are also starkly evident in declines in sense of well-being and general health coupled with increasing all-cause mortality, particularly among the middle-aged white population.1 As exceptionally well described by Rummans et al2 in this issue of Mayo Clinic Proceedings, the cause of the epidemic is multifactorial, including an overinterpretation of a now infamous New England Journal of Medicine letter describing addiction as a rare occurrence in hospitalized patients treated with opioids, initiatives from the Joint Commission directed toward patient satisfaction and the labeling of pain as the “5th vital sign,” the advent of extended-release oxycodone (OxyContin), an aggressive marketing campaign from Purdue Pharma L.P., and the influx of heroin and fentanyl derivatives.
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      • How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis
        Mayo Clinic ProceedingsVol. 93Issue 3
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          The opioid crisis that exists today developed over the past 30 years. The reasons for this are many. Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Following the publication of a short letter to the editor in a major medical journal declaring that those with chronic pain who received opioids rarely became addicted, prescriber attitude toward opioid use changed. Opioids were no longer reserved for treatment of acute pain or terminal pain conditions but now were used to treat any pain condition.
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      • In Reply I—Root Causes of the Opioid Crisis
        Mayo Clinic ProceedingsVol. 93Issue 9
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          We thank Dr. Pendyal for the thoughtful and articulate response to our article.1 We agree that a thorough examination of opioid use disorders and overdoses includes evaluation of structural- and societal-level factors. Indeed, income inequality, social disparities, and other structural inequities are important considerations in chronic illnesses, disease management, premature deaths, infant mortality, maternal illness, and all epidemics past and present, not just the current opioid epidemic. Similarly, depression, despair, hopelessness, and suicide are not exclusively linked to the current opioid crisis but are reflective of the state of health and wellness in our society.
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      • In Reply II—Root Causes of Opioid Crisis
        Mayo Clinic ProceedingsVol. 93Issue 9
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          Dr Pendyal highlights an important point that the opioid crisis is much bigger than just the “supply side” of the problem. It is truly a biological-psychological-social-spiritual problem that impacts both the “supply side” and the “demand side.”1 However, in his description of the social factors, of which there are many, he too fails to acknowledge many of the drivers of the opioid crisis. Many of the drivers go beyond “unemployment, poverty, and wealth inequality,” with an increasing number of those dying from opioids being employed, middle- and upper-class individuals.
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