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| Why opioids are such an American problem | Why opioids are such an American problem |
| (35 minutes later) | |
| When it comes to taking opioids, the United States has the dubious honour of leading the world. | |
| For every one million Americans, almost 50,000 doses of opioids are taken every day. That's four times the rate in the UK. | For every one million Americans, almost 50,000 doses of opioids are taken every day. That's four times the rate in the UK. |
| There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example). | There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example). |
| But take too many and you have a problem. And America certainly has a problem. | But take too many and you have a problem. And America certainly has a problem. |
| In two years, the town of Kermit in West Virginia received almost nine million opioid pills, according to a congressional committee. | In two years, the town of Kermit in West Virginia received almost nine million opioid pills, according to a congressional committee. |
| Just 400 people live in Kermit. | Just 400 people live in Kermit. |
| Nationally, opioids killed more than 33,000 people in 2015, according to the Centers for Disease Control and Prevention. | Nationally, opioids killed more than 33,000 people in 2015, according to the Centers for Disease Control and Prevention. |
| That figure includes deaths from heroin, an illegal opioid. But almost half involved a prescription opioid - that is, a painkiller available from a pharmacy with a note from a doctor. | That figure includes deaths from heroin, an illegal opioid. But almost half involved a prescription opioid - that is, a painkiller available from a pharmacy with a note from a doctor. |
| So why does America - more than any country in the world - have an opioid problem? | So why does America - more than any country in the world - have an opioid problem? |
| There is more than one cause. But these are some of the most important. | There is more than one cause. But these are some of the most important. |
| American doctors prescribe - a lot | American doctors prescribe - a lot |
| Unlike most European countries, the US does not have universal healthcare paid for by taxes. | Unlike most European countries, the US does not have universal healthcare paid for by taxes. |
| Instead, Americans must get their own insurance - usually via an employer or the government. | Instead, Americans must get their own insurance - usually via an employer or the government. |
| "Most insurance, especially for poor people, won't pay for anything but a pill," says Professor Judith Feinberg from the West Virginia University School of Medicine. | "Most insurance, especially for poor people, won't pay for anything but a pill," says Professor Judith Feinberg from the West Virginia University School of Medicine. |
| "Say you have a patient that's 45 years old. They have lower back pain, you examine them, they have a muscle spasm. | "Say you have a patient that's 45 years old. They have lower back pain, you examine them, they have a muscle spasm. |
| "Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad. | "Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad. |
| "Even if the insurance covers physical therapy, you probably need prior authorisation (from the insurer) - which is a lot of time and paperwork." | "Even if the insurance covers physical therapy, you probably need prior authorisation (from the insurer) - which is a lot of time and paperwork." |
| The CDC says opioid prescriptions have fallen by 18% from their peak in 2010. But the total is still three times higher than in 1999. | The CDC says opioid prescriptions have fallen by 18% from their peak in 2010. But the total is still three times higher than in 1999. |
| 'I saw this drug on TV' | 'I saw this drug on TV' |
| The US and New Zealand are the only countries that allow prescription drugs to be advertised on television. | The US and New Zealand are the only countries that allow prescription drugs to be advertised on television. |
| According to the research firm Kantar, spending on advertising by pharmaceutical companies in the US reached $6.4 billion in 2016 - a rise of 64% since 2012. | According to the research firm Kantar, spending on advertising by pharmaceutical companies in the US reached $6.4 billion in 2016 - a rise of 64% since 2012. |
| None of the 10 most-advertised brands in 2016 was an opioid. But mass-marketing of drugs has an effect, says Professor Feinberg. | None of the 10 most-advertised brands in 2016 was an opioid. But mass-marketing of drugs has an effect, says Professor Feinberg. |
| "As a clinician, people will come and say 'I saw this on TV - can you give me this drug'. | "As a clinician, people will come and say 'I saw this on TV - can you give me this drug'. |
| "Sometimes they were so confused, they were already on the drug - they were using the brand name, where I used the generic name." | "Sometimes they were so confused, they were already on the drug - they were using the brand name, where I used the generic name." |
| In 2015, the American Medical Association called for a ban on adverts for prescription drugs. It didn't happen. | In 2015, the American Medical Association called for a ban on adverts for prescription drugs. It didn't happen. |
| Three months later, the extent of America's opioid culture was seen at half-time of the Superbowl - the country's most expensive advertising slot. | Three months later, the extent of America's opioid culture was seen at half-time of the Superbowl - the country's most expensive advertising slot. |
| A 60-second ad was devoted to opioid-induced constipation. The advert - paid for by AstraZeneca - advised sufferers to visit their doctor and "ask about prescription treatment options". | A 60-second ad was devoted to opioid-induced constipation. The advert - paid for by AstraZeneca - advised sufferers to visit their doctor and "ask about prescription treatment options". |
| President Obama's chief of staff was not impressed. | President Obama's chief of staff was not impressed. |
| Gifts to doctors | Gifts to doctors |
| In the US, it is common for drug companies to court doctors, in an effort to promote their products. | |
| "When you're a doctor in the US, these detailing people (salespeople) come in from the industry," says Professor Keith Humphreys from Stanford University. | "When you're a doctor in the US, these detailing people (salespeople) come in from the industry," says Professor Keith Humphreys from Stanford University. |
| "They are invariably smooth, friendly, attractive, sharply dressed, adorable, they're giving out gifts to everybody. They host dinners, they sponsor conferences, they sponsor junkets. | "They are invariably smooth, friendly, attractive, sharply dressed, adorable, they're giving out gifts to everybody. They host dinners, they sponsor conferences, they sponsor junkets. |
| "That is going to affect prescribing." | "That is going to affect prescribing." |
| For the past four years, the US government has published the amounts paid by drug and device companies to doctors and teaching hospitals. | For the past four years, the US government has published the amounts paid by drug and device companies to doctors and teaching hospitals. |
| The total in 2016 was more than $8bn. More than 630,000 physicians had payment records. | |
| For example, Purdue Pharma - which makes OxyContin, a popular opioid painkiller - made almost 80,000 transactions in 2016, worth more than $7m in total. | |
| In 2016, a study looked at the link between doctors, the free meals they received from drug companies, and the medication they prescribed. | In 2016, a study looked at the link between doctors, the free meals they received from drug companies, and the medication they prescribed. |
| The study found receiving free meals was "associated with an increased rate of prescribing the promoted brand-name medication". | The study found receiving free meals was "associated with an increased rate of prescribing the promoted brand-name medication". |
| Pharmaceutical companies say their reps are merely sharing information with doctors. But Professor Humphreys says there is a "corrupting" influence. | Pharmaceutical companies say their reps are merely sharing information with doctors. But Professor Humphreys says there is a "corrupting" influence. |
| "We need a pharma industry, it's not that it's wrong," he says. "But you can't let the fox guard the hen house. | "We need a pharma industry, it's not that it's wrong," he says. "But you can't let the fox guard the hen house. |
| "I would create completely clear blue water between the people that manufacture drugs and all the training and operation of the healthcare system." | |
| Pharmaceutical companies also spend money on health care workers and organisations in other countries. | Pharmaceutical companies also spend money on health care workers and organisations in other countries. |
| In the UK in 2016, companies gave £116m ($153m) to health workers and organisations for non-research and development in 2016. | In the UK in 2016, companies gave £116m ($153m) to health workers and organisations for non-research and development in 2016. |
| But, although the UK figure is 7% higher than in 2015, it is less than 2% of the amount paid in the US. | But, although the UK figure is 7% higher than in 2015, it is less than 2% of the amount paid in the US. |
| Poor training | Poor training |
| Dr Richard Frank is professor of health economics at Harvard Business School, and served in the Health Department from 2009 to 2016, during President Obama's administration. | Dr Richard Frank is professor of health economics at Harvard Business School, and served in the Health Department from 2009 to 2016, during President Obama's administration. |
| He thinks medical training in the US has not been good enough. | He thinks medical training in the US has not been good enough. |
| "Physicians have received almost no training in pain management," he says. | "Physicians have received almost no training in pain management," he says. |
| "Until recently they have been under some pretty important misconceptions about how addictive various products are." | "Until recently they have been under some pretty important misconceptions about how addictive various products are." |
| He adds: "A couple of years ago I testified before congress when I was in government. One of the representatives, before going into congress, was a thoracic surgeon. | He adds: "A couple of years ago I testified before congress when I was in government. One of the representatives, before going into congress, was a thoracic surgeon. |
| "He noted that he had gotten almost no training in pain management - and what he had learned came entirely from the nursing staff he worked with." | "He noted that he had gotten almost no training in pain management - and what he had learned came entirely from the nursing staff he worked with." |
| Dr Frank says medical training isn't the only reason for America's opioid problem. "There's plenty of blame to go round," he says. | Dr Frank says medical training isn't the only reason for America's opioid problem. "There's plenty of blame to go round," he says. |
| But his criticism is echoed by Professor Judith Feinberg. | But his criticism is echoed by Professor Judith Feinberg. |
| "Doctors didn't learn anything about addiction at medical school," she says. | "Doctors didn't learn anything about addiction at medical school," she says. |
| "That is now changing, but everyone who's a doctor already, didn't learn anything. I learned about opioid drugs in the part of pharmacology where we learned about anaesthesia. | "That is now changing, but everyone who's a doctor already, didn't learn anything. I learned about opioid drugs in the part of pharmacology where we learned about anaesthesia. |
| "Probably the whole topic of anaesthesia-like drugs was two hours. People don't have much knowledge about opioids. There was no curriculum that includes addiction." | "Probably the whole topic of anaesthesia-like drugs was two hours. People don't have much knowledge about opioids. There was no curriculum that includes addiction." |
| Bad science? | Bad science? |
| In 1980, Dr Hershel Jick wrote a short letter to the New England Journal of Medicine. | In 1980, Dr Hershel Jick wrote a short letter to the New England Journal of Medicine. |
| It said that "despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction". | It said that "despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction". |
| The claim has been debunked, and the letter now carries an online warning note. But Dr Jick's letter had a big impact. | The claim has been debunked, and the letter now carries an online warning note. But Dr Jick's letter had a big impact. |
| This year, Canadian researchers said the letter had been cited 600 times - usually to claim opioids weren't addictive. | This year, Canadian researchers said the letter had been cited 600 times - usually to claim opioids weren't addictive. |
| In the late 1990s the Veterans Health Administration - which runs healthcare for military veterans - pushed for pain to be recognised as the "fifth vital sign". | In the late 1990s the Veterans Health Administration - which runs healthcare for military veterans - pushed for pain to be recognised as the "fifth vital sign". |
| This gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature. | This gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature. |
| Then in 2001, the Joint Commission - which certifies almost 21,000 US health organisations and programmes - established standards for pain assessment and treatment. | Then in 2001, the Joint Commission - which certifies almost 21,000 US health organisations and programmes - established standards for pain assessment and treatment. |
| In 2016, the JC released a statement that claimed that "everyone is looking for someone to blame" for the opioid problem. It insisted that its 2001 standards did not "require the use of drugs to manage a patient's pain". | In 2016, the JC released a statement that claimed that "everyone is looking for someone to blame" for the opioid problem. It insisted that its 2001 standards did not "require the use of drugs to manage a patient's pain". |
| But Professor Feinberg says the VHA and JC's moves meant doctors were under pressure to prescribe strong painkillers - such as opioids - when they may not have been necessary. | But Professor Feinberg says the VHA and JC's moves meant doctors were under pressure to prescribe strong painkillers - such as opioids - when they may not have been necessary. |
| "By the time you reach middle age, it's a rare person who doesn't ache somewhere," she says. | "By the time you reach middle age, it's a rare person who doesn't ache somewhere," she says. |
| She adds that - in a country where patients rate their doctors, and low ratings can affect doctors' earnings - the score can be influenced by whether patients receive opioids. | She adds that - in a country where patients rate their doctors, and low ratings can affect doctors' earnings - the score can be influenced by whether patients receive opioids. |
| A culture of medication | A culture of medication |
| Some Americans, says Professor Keith Humphreys from Stanford University, believe that life is "fixable". | Some Americans, says Professor Keith Humphreys from Stanford University, believe that life is "fixable". |
| "I'm 51," he says. "If I go to an American doctor and say 'Hey - I ran the marathon I used to run when I was 30, now I'm all sore, fix me', my doctor will probably try to fix me. | "I'm 51," he says. "If I go to an American doctor and say 'Hey - I ran the marathon I used to run when I was 30, now I'm all sore, fix me', my doctor will probably try to fix me. |
| "If you do that in France the doctor would say 'It's life, have a glass of wine - what do you want from me?'" | "If you do that in France the doctor would say 'It's life, have a glass of wine - what do you want from me?'" |
| In 2016, a study compared how Japanese and American doctors prescribed opioids. It found that Japanese doctors treated acute pain with opioids in 47% of cases - compared to 97% in the US. | In 2016, a study compared how Japanese and American doctors prescribed opioids. It found that Japanese doctors treated acute pain with opioids in 47% of cases - compared to 97% in the US. |
| "There is obviously a willingness, and a habit, of giving opioid pain relief that is not shared elsewhere," says Professor Feinberg. | "There is obviously a willingness, and a habit, of giving opioid pain relief that is not shared elsewhere," says Professor Feinberg. |
| "Other countries deal with pain in much healthier ways." | "Other countries deal with pain in much healthier ways." |
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