Punish Pharma, Not Patients

The decision on Monday by an Oklahoma judge to fine Johnson & Johnson $572 million for its role in the state’s opioid crisis is only the first step in what promises to be years of complex litigation. In ruling that pharmaceutical marketing caused a “public nuisance” by increasing addiction and overdose deaths, Judge Thad Balkman created a strong precedent.

What this decision should not do, however, is further distort our understanding of the causes of the crisis and add to the misery of people in pain.

Drug companies like Johnson & Johnson twisted the truth about the potential risks of these medications. That caused great harm. Nonetheless, for many — including people with chronic pain or at the end of life — opioids are the only drugs that seem to work. Understanding the facts about these drugs is critical to resolving the crisis and making pharma pay for solutions that work.

The reality is this: 80 percent of those who begin misusing prescription opioids are taking drugs obtained illegally — from theft, dealers, friends, relatives, the internet or other people’s medicine cabinets, not from doctors. And nearly three out of four young people who misuse opioids have previously taken cocaine or crack repeatedly. Indeed, researchers say that prior recreational drug use is a much larger risk factor for opioid addiction than medical exposure. That is not to say that there aren’t some whose addictions begin with a prescription — but this group is a decided minority.

This shouldn’t deflect blame from the pharmaceutical industry — as Judge Balkman’s decision suggests, misleading marketing might have helped quadruple medical opioid sales from 1994 to 2006 in Oklahoma. Where those drugs ultimately went and who got harmed, however, is a more complex story than we’ve been led to believe.

Part of the confusion comes from this: Addiction rates vary tremendously depending on factors like age, mental illness and history of use of alcohol and other drugs. Consequently, studies that exclude people with these risk factors show very low rates of addiction.

Take, for instance, the 2010 Cochrane review of clinical trials of opioids for the use of chronic non-cancer pain. Cochrane reviews are among the most rigorous and respected in medicine, intended to help physicians and countries with national health care determine the best treatments. Among the 2,613 participants who were evaluated for possible addiction, the authors found a risk that was little more than one-fourth of one percent.

When drug companies cite such studies to doctors, they aren’t exactly lying: The risk of addiction in carefully screened patients is indeed low. But the result can be to elide the differences between people who go through extensive screening to participate in a clinical trial and those who just stroll in to their general practitioner’s office.

Doctors don’t seem to be adequately screening their patients for addiction; indeed, many have received scant education on such screening in medical school and consequently often rely on stereotypes. This can mean that many doctors simply assume that the nice patients that they have been seeing for years aren’t at risk of addiction. So they might not ask unpleasant questions about possible past misuse of alcohol or other drugs.

The result, however, is that they wind up treating a population that has a risk for addiction estimated at 8 percent to 12 percent. It is worse for doctors who deal with teenagers and young adults: The risk of addiction for them is at least double that of older people.

Further, since people who misuse drugs often deliberately seek them from doctors, addiction rates in pain practices can be many times higher than in the general population — not because the doctor has caused addictions, but because addicted people go where the drugs are.

So, yes, the pharma industry was the source for these opioids and its marketing convinced many doctors to write large prescriptions, helping to create an addiction epidemic. But it wasn’t primarily pain patients who got hooked.

The policy response, then, needs to focus on getting appropriate treatment to people with addiction — not on taking medication from the pain patients who most need it.

Today, illicitly manufactured fentanyl is causing an increasing percentage of overdose deaths. This is probably because when the medical supply of opioids began contracting, as doctors sought to reduce prescriptions, large numbers of addicted people switched to illegal heroin and fentanyl — often because they were already familiar with illegal drug markets.

Pharma must pay for its role in creating these markets. But simply cutting people off from opioids treats neither pain nor addiction. What they most need is access to effective anti-addiction medications.

To solve this problem, funds from the Johnson & Johnson settlement — as well as from any settlement with Purdue Pharma or other major manufacturer of opioids — must go toward supporting effective treatments, including providing proven addiction medications. (Johnson & Johnson is appealing the decision.)

The United States Preventive Services Task Force has just recommended that physicians screen all adults for substance use disorders — and settlement funds could also be used to support this effort, which will require improved training for doctors in dealing with pain and addiction.

The pharmaceutical industry, doctors and regulators all deserve blame for overselling and overprescribing pain medications. But now, as they reverse course, they are abandoning people in pain as well as people with addiction. If the Johnson & Johnson settlement and any future ones are to provide some measure of justice, they must help both groups.

Maia Szalavitz is the author of “Unbroken Brain: A Revolutionary New Way of Understanding Addiction.”

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