To solve the opioid crisis, go after Big Pharma, not drug users

President Donald Trump announced this month that he intends to formally declare a state of emergency regarding America’s opioid crises, which a White House advisory panel told him has reached unprecedented, catastrophic proportions. Many Americans eye Trump’s pronouncements warily, as they usually begin by stating a problem most of us agree is genuine and then swiftly veer into wild territory that seems to pop out of the president’s fertile imagination.

So here, Mr. President, are some basic solutions to the opioid crisis. Your advisory commission gave you many sage recommendations, which you should seriously weigh. Your Commission on Combating Drug Addiction and the Opioid Crisis was especially focused on preventing overdose deaths and helping people get off narcotics. But when you announced your intention to follow the commission’s primary recommendation by declaring an emergency, you added (from your vacation in Bedminster, New Jersey), “The best way to prevent drug addiction and overdose is to prevent people from abusing drugs in the first place.. . . So we can keep them from going on, and maybe by talking to youth and telling them: ‘No good, really bad for you in every way.’”

If your strategy is to stop addiction in the first place, rather than bring compassionate care and survival to those already using narcotics, you will distress first responders and emergency room professionals across the nation. They processed 142 overdose deaths per day in America in 2015 – a toll expected to soar when newer 2016-2017 statistics are tallied. That year, more than 52,000 Americans died of opioid overdoses, and early data indicates that the toll topped 60,000 in 2016.

Four years ago, before the dramatic surge in opioid use, deaths, hospitalizations, and productivity losses nationwide were estimated to cost some $78.5 billion. That’s likely low, as it understates hospitalization fees, which have skyrocketed: In 2014, alone, opioids accounted for 1.27 million emergency room visits nationwide. Also missing from this calculus are the costs of treatment and deaths soaring nationwide from needle-sharing among the addicted, spreading HIV, all forms of hepatitis, and a long list of other infections. You need only look to Vice President Mike Pence’s home state of Indiana, which is in the grips of the nation’s fastest-growing HIV epidemic, fueled by needle use that started during his tenure as governor.

Mr. President, even you noted in your remarks this month that “drug overdose is now the leading cause of accidental death in the United States, and opioid overdose deaths have nearly quadrupled since 1999.”

The war on drugs

But let’s take your vow to “prevent people from abusing drugs in the first place” seriously.

You list two policy directions – boost law enforcement against drug dealers and users committing crimes that endanger the public and tighten security at the border with Mexico. Reminiscent of Presidents Ronald Reagan and George H.W. Bush’s war on drugs, the approach blames Mexico and criminalizes drug users.

We’ve been there before, and it hasn’t worked, though it did substantially increase the size of our prison and jail populations, to the point where we lead the entire world for the numbers of people incarcerated. According to the U.S. Bureau of Justice Statistics, in 2015 there were 2.2 million adults in prisons and jails in this country, and another 4.65 million were on parole or probation. That same year, in the juvenile incarceration system, almost 50,000 kids are imprisoned. The number of incarcerated has more than quadrupled since 1980 and the start of the war on drugs, witnessing a twelvefold increase in the numbers of Americans imprisoned for nonviolent drug offenses.

By 2000, 22 percent of all federal and state prisoners were convicted for drug use, possession, or sale. Soon states were spending more on prisons than schools, as the costs of incarcerating thousands of marijuana smokers and those convicted of petty cocaine possession soared, topping $1 trillion in 2016. As judges and prosecutors around the country came to see that the war on drugs was merely creating overcrowded prisons and an entire class of underemployed and unemployable ex-con Americans – especially black and Latino men – prison sentencing for petty nonviolent drug crimes fell. Today, about 16 percent of our nation’s incarcerated prisoners were convicted for nonviolent drug-related crimes.

That “round ’em up and corral ’em” approach didn’t work. Let’s not go down that path again.

Here are some simple alternatives:

– Target the lawful manufacturers. Unlike the heroin that swept America during the Vietnam War, the cocaine that filled the noses of disco dancers in the 1980s, and the crack marketed in poor urban communities in the 1990s, today’s gateway drugs are manufactured by legitimate pharmaceutical companies, most of them located within the United States. The companies are making profits without apparent concern about how their products are used.

Across America, attorneys general and local district attorneys have filed lawsuits against the pharmaceutical giants that make fentanyl, Percocet, OxyContin, Opana, oxycodone, and other synthetic opioids – compounds that are up to 10,000 times more addictive than medical-grade morphine. These suits are coming from red and blue states alike – places like Mississippi, Oklahoma, Kentucky, and New York. The suits allege that companies like Purdue Pharma (manufacturer of OxyContin) and Endo (maker of Percocet and Opana) knowingly downplay the addiction risk of their products when marketing the drugs to physicians and provide financial incentives to doctors to promote prescriptions. The suits stipulate that the manufacturers – pharmaceutical giants like Mylan, Johnson & Johnson, and Teva Pharmaceuticals – know full well that they are selling far more of their products than are legitimately used to alleviate pain.

Distributors are also being targeted with legal action. For example, the Cherokee Nation is suing retailers CVS, Walgreens, and Walmart and drug distributors McKesson, Cardinal Health, and AmerisourceBergen for flooding the Native American community with prescription opioids “in quantities that far exceeded the number of prescriptions that could reasonably have been used for legitimate medical purposes,” according to the lawsuit. The Cherokee claim underscores the profits drugstores and retailers are making off the crisis.

Consider these examples, Mr. President. Drugstores in tiny Clay County, Kentucky, (population 21,000) filled 2.2 million doses of prescriptions for hydrocodone, plus 617,000 doses of oxycodone in 2016. Assuming all those doses were used by county residents, that translates to 134 prescriptions per man, woman, and child per year. Either the poor folks living in Clay County are wracked by an extraordinary level of collective physical pain or all those pharmacists know full well that they are feeding addictions. In another example, authorities are asking why West Virginia’s whistle-stop town of Kermit (population 392) received 9 million doses of hydrocodone in 2015-2016, shipped to a single drugstore; surely, the manufacturer and distributor knew this was suspicious.

Sen. Claire McCaskill, D-Mo., charges: “This epidemic is the direct result of a calculated sales and marketing strategy major opioid manufacturers have allegedly pursued over the past 20 years to expand their market share and increase dependency on powerful – and often deadly – painkillers.”

Mr. President, if you are serious about stopping America’s opioid crisis, instruct Attorney General Jeff Sessions to have the Department of Justice join in these legal actions, bringing the investigatory and legal weight of the FBI to battle the multibillion-dollar pharmaceutical opioid industry and the largest distributors and retailers of the drugs. Don’t waste federal resources on isolated overprescribing doctors and puny drugstores – the states can handle those cases. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids.

– Stop the export of America’s opioid crisis. Since 2010, OxyContin sales have fallen 40 percent in the United States, as rival synthetic opioids have gained popularity. And thanks in part to Rush Limbaugh’s notorious addiction and drug arrest in 2006, the product has lost favor among would-be consumers and prescribing physicians. But that hasn’t stopped drugmakers from finding friendlier markets: The Los Angeles Times revealed an elaborate scheme on the part of the manufacturer Purdue to offshore both production and sales, targeting Mexico, Latin America, Russia, China, and Indonesia.

In May, a dozen members of Congress sent a letter to the director-general of the World Health Organization (WHO), warning that Purdue and its subsidiary Mundipharma International were exporting America’s opioid crisis abroad. “The international health community has the rare opportunity to see the future,” the letter warned, saying opioid export will increase and related addictions and deaths will likely “follow the same pattern as in the United States,” due to “irresponsible-and potentially criminal-marketing of prescription opioids.”

Mr. President, America cannot become the world’s addictive drug supplier. Our foreign policy and reputation have taken enough blows; you must not let U.S. pharmaceutical makers and drug retailers become the 21st-century Medellín cartel. You don’t want to be the 2017 version of the Colombian political leaders rendered laughingstocks by Pablo Escobar, who made hundreds of millions of dollars from cocaine exportation but tainted his country’s image in the process. You should instruct your Commerce Department and Drug Enforcement Agency (DEA) to collaborate in efforts to identify U.S.-based drugmakers that are building opioid export and trade deals and identify means to limit overseas sales to actual medicinal use for immediate pain relief.

– Stop the import of fake and copycat foreign-made opioids. In 2015, under pressure from the Barack Obama administration’s DEA, the Chinese government put 116 synthetic opioids on its controlled substances list. Clever Chinese drugmakers simply made minor changes in the chemistry of drugs like fentanyl, making the molecules different from those Beijing and Washington sought to regulate and, in some cases, rendering the drugs more powerful and addictive.

This year, Ohio saw an enormous spike in overdose deaths cause by Carfentanil, an opioid elephant tranquilizer manufactured by a Chinese lab. Left off Beijing’s controlled substances list, the drug is made and exported legally. When it hit the streets of Cincinnati in late 2016, the morgues started filling up. After Beijing added Carfentanil to its enforcement list, the makers simply went underground – joining the vast criminal laboratory network across China that makes fake Viagra, substandard antimalarial drugs, HIV “medicines” with no active ingredients, and phony blood thinners that kill cardiac patients.

The thriving fake drug industry dumps about $100 billion worth of bad products into the U.S. market annually, often with deadly consequences. Criminal labs exist all over the world, but the No. 1 supplier is China, with India hot on its heels. For example, the WHO estimates that in several African countries half of all drugs sold, including antimalarials, are fake medicines – most made in China or India. In China, the problem is so out of control that even the nation’s own military hospitals have fallen prey, unknowingly purchasing phony drugs and vaccines that have hurt or killed Chinese soldiers.

The DEA warns that unusually potent opioids made in China are now flooding U.S. markets. Bad as legitimately made fentanyl may be, the DEA says the Chinese drugs are far worse: more potent and more addictive. And the Chinese makers are openly shipping supplies to American drugstores, physicians, and even individuals via FedEx and other mailing services. In March, law enforcement officials seized 36 pounds of Chinese super-fentanyl that was mailed to New Jersey. Similar interdictions in posted Chinese fake fentanyl supplies have recently been made in New York, Ohio, Pennsylvania, Alaska, and Illinois – actually, in every state where the DEA has mounted a serious investigation. Nevertheless, addictive Chinese drugs can be ordered online and have been shipped to North America inside such things as printer ink cartridges.

Inside India, the use of all sorts of opium-derived painkillers is strictly limited, to the degree that it can be very difficult for cancer patients and other sufferers of acute pain to obtain alleviation. Like most people worldwide who are in acute pain and legitimately need relief, Indians cannot easily acquire morphine, any opioids, or even basic analgesics. But that doesn’t mean that India’s enormous pharmaceutical industry is missing out on opioid profits: Some have mirrored the Chinese practices, and their versions of OxyContin, fentanyl, and other drugs have reached the American market.

Mr. President, your admirers enjoy your get-tough approach to foreigners. But you need to direct your muscle to the proper targets. America’s street opioids aren’t coming across the Mexican border but through the mail from China and India. You should tell your diplomatic and trade negotiators in multiple federal agencies to let Beijing and New Delhi know that this will not be tolerated. Go ahead, get tough. When the DEA or local law enforcement identifies foreign-made opioids for sale online or distributed in the United States, notification must be directed immediately to counterparts in the countries of origin, and Secretary of State Rex Tillerson must insist that the respective governments arrest the manufacturers and distributors.

Some of your advisers, Mr. President, may be telling you that you should use the opioid state of emergency as reason to crack down on marijuanaa, fill our prisons with nonviolent drug offenders, and snarl at Mexico. They are wrong. Go after the real sources of America’s crisis – the drugmakers, distributors, and retailers inside the country and overseas – and bring them to their knees. If you do so, tens of thousands of American lives will be saved, small towns across Appalachia and the Midwest will come back to life, and you will be rightly praised. But handle this state of emergency the wrong way, and you will see the death tolls rise, prison populations swell, and the reputation of the United States as the planet’s addiction supplier solidified. You don’t want that, do you?

Garrett is senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.



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