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OPIOID CRISIS: CREATION OF AN AVOIDABLE AND PREDICTABLE LETHAL EPIDEMIC

By Clark Miller

Published July 23, 2018

Updated March 31, 2021

It’s expected that another 500,000 Americans will die over the next decade related to the opioid crisis, with additional social costs and with no evidence yet of validated, effective treatments in place despite reports and assurances.  Inside medical healthcare systems, a Look forward, not back attitude prevails, and the Surgeon General pleaded Big pharma made us do it. But Big Pharma wasn’t in the exam rooms writing the opioid prescriptions for chronic pain , a condition known to be generally driven by emotional and mental states, not physical causes, and with non-medical treatments . Would it make sense to trained medical professionals to trust drug manufacturers’ spin on research results for drug safety? Making excuses is no substitute for questioning and engaging in critical thought to understand the causes (“etiology”) of the opioid crisis and avoid repeating or continuing them.

We’ll see, below, that the Opioid Crisis did not emerge because correcting evidence became apparent or available only after evaluated, critically scrutinized, responsible clinical practices had already led to routine prescribing of opioid pain medications for centralized chronic pain.

Instead, it occurred in the face of those approaches being unsupported and without validation of safety or effectiveness from the beginning by all lines of available evidence and research, evidence longstanding prior to the runaway prescription of opioids. That’s an abdication of critical thought, accountability, and public responsibility that must be faced and become understood to avoid repeating.

Opioid pills in a bottle

To that point:  let’s look at what happened and why, but first, let’s consider how healthcare systems are responding – with a medical fix – and ask whether we’ve learned anything from the opioid crisis, an epidemic caused by the unsupported and inappropriate use of a medical fix for an entirely non-medical problem.

The response – are we learning?

In a rush to respond, manage the harm, and attempt to re-establish the appearance of competence and effectiveness in management of chronic pain, opioid use and related risks, the managed healthcare/medical industry has invested in a type of harm reduction strategy rebranded “Medication Assisted-Treatment”. In MAT the manufactured, prescription opioids methadone or buprenorphine (brand names Subutex, Suboxone) are dispensed and intended to provide the assisted part of Medication-Assisted Treatment, assisting by creating conditions for patients to feel and function better, in order to effectively access and benefit from the treatment part = effective (“evidence-based”) behavioral health therapies (the subject of multiple Upcoming Posts).

In medical and correctional settings and increasingly in emergency rooms, opioid abusers are started on courses of the drugs, which provide a reduced level of the euphoric and sedative effect of opioids like heroin and at least relief from the highly distressing withdrawal symptoms – in intent and in theory. In theory, and in some clinical trials under non-natural conditions, but not reliably in practice,   those effects are claimed to and promoted as minimizing risks, stresses, and problems functioning in life related to use of illegal, “street” opioids and other drugs, promoting effective use of the treatment part of MAT. In the real world, under realistic community program conditions, things are different, and research results are disconfirming the idea that Suboxone and MAT are beneficial.

That focused and seemingly universal confidence in and reliance on harm reduction and MAT is embraced by the popular media and is managed in medical settings under medical, versus evidence-based behavioral treatment models, driven by the fictional and invalidated model of problem opioid use and substance use in general as a disease or medical condition.  Predicting continued harm, MAT as currently implemented is driven by factors other than research and practices supported as effective by research for the actual treatment part of Medication-Assisted Treatment, because 1) research evidence for effectiveness of those presumed medication-based benefits is at best mixed, with recent studies showing overall treatment failure and 2) the “treatment” part of MAT, (the behavioral health therapies required to address the compulsive drug use) currently consists of traditional treatments, or “treatment as usual” (TAU), established by decades of research to provide no benefit or harm (Post: Why Addiction Treatment Doesn’t Work).

“What we simply need is a a nice bulldozer, so that we could level the entire industry and start from scratch . . . There’s no such thing as an evidence-based rehab. That’s because no matter what you do, the concept of rehab is flawed and unsupported by evidence.” 

– Dr. Mark Willengbring, former director of treatment and recovery research at the National Institute of Alcohol Abuse and Alcoholism (NIAAA)

How did that happen? What explanation is there for decades of ineffective “rehab”; standard addiction treatment (TAU) without benefit, and  steadily worsening national substance use epidemics ?

And – Why haven’t we able to respond effectively, or even respond in ways that makes sense and predict beneficial results based on research available for decades? We have the answers, but they force us to do the nearly impossible: to challenge THE WAY THINGS ARE, the official, authoritative, accepted and enforced “knowledge”, doxa, about the very nature of substance use and its treatment – the focus of upcoming  posts here.

Taking apart and replacing that made-up, false and invalidated “knowledge” about substance use and its treatment will be critical in understanding the broader national substance use epidemic and other threats to public health.

SUMMARIZING:  As purported, when buprenorphine (Subutex) or other substitute opioids work, MAT would, in theory, effectively provide a period of improved mood, thinking, and functioning in life that supports effective participation in the actual treatment part of MAT (evidence-based talk therapies for the intrapsychic conditions and stressors driving compulsive substance use, a focus of upcoming posts) by motivated patients, with predicted benefit.

When it fails to support patient engagement in effective treatment and change, as the research indicates it generally does, or is ineffective or harmful for other reasons, MAT distracts resources and attention from critically needed, fundamental changes to substance use treatment models and methods, from critically needed reformation of the conceptualization of “addiction” itself.

So far, not good

 

Medical Industry on the MAT response to the opioid crisis – But Look! Okay, never mind the “treatment” part for an entirely behavioral, psychosocial problem, we’re doing something, in medical clinics, with medicines! Always a good idea, right?

Sound familiar? Like what got us to the Opioid Crisis ? It should sound familiar, needs to be recognized as familiar, as MO of the Medical Industry – But Look. Okay, never mind the indicated “treatment” part for chronic pain, an entirely behavioral, psychogenic (generated by mental and emotional states) problem, we’re doing something, in medical clinics, with medicines!

We got this – prescribing opioid pain medications for common chronic pain, an entirely non-biomedical problem.

What could go wrong?

the Opioid Crisis did not emerge because correcting evidence became apparent or available only after evaluated, critically scrutinized, responsible clinical practices had already led to routine prescribing of opioid pain medications for centralized chronic pain.
Instead, it occurred in the face of those approaches being unsupported and without validation of safety or effectiveness from the beginning by all lines of available evidence and research . . . 

What went wrong ? 

But – How did that happen, and why are we avoiding that question?

There has never existed, not at any time, a body of research evidence to provide even preliminary support for the safe practice of prescribing opioid medications for chronic pain, or with the expectation of durable benefit for chronic pain.

See, for example:

Chou, R et al.  2015. The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop.  Ann Intern Med. 162:276–286.

From the beginning, well prior to explosion of runaway, widespread use of prescription opioids for centralized chronic pain, all lines of evidence pointed against and contraindicated their use. There was never support for their safe, effective use due to longstanding:

1)  lack of research evidence for effectiveness long-term

 2) evidence for the potential for hyperalgesia

Hyperalgesia – increased sensitivity to pain – induced by use of opioids (OIH) is known and described extensively, beginning late 19th century.

See, for example:

Lee, Marion et al. 2011. A Comprehensive Review of Opioid-Induced Hyperalgesia Pain. Physician 14:145-161

3) established addictive potential of opioids

The high abuse and addictive potential of opioids including those prescribed for chronic pain is long-established (1), generating a history of statutory control (2) e.g. Harrison Act (1914); Boggs Act (1951) and others.

The 1970 Controlled Substances Act (3) lists opioid drugs commonly prescribed for chronic pain as Schedule II Substances (4), highly controlled as “drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence”

4) understanding of the psychogenic nature of centralized chronic pain

Chronic pain (5) – long-lasting pain that is non-cancer, not caused by acute tissue damage or inflammation – is established by decades and multiple lines of evidence and research as psychogenic (generated by mental/emotional states) in nature and with indicated treatments that are psychological (behavioral health therapies), not biomedical.

See, for example:

Dersh, Jeffery et al. 2002. Chronic Pain and Psychopathology: Research Findings and Theoretical Considerations. Psychosomatic Medicine:  64: 773-786

[Numbers 1 – 6 in parentheses in boxes link to online sources listed at bottom of post.] 

5) evidence for cognitive behavioral therapies (CBT) as the indicated treatment for chronic pain

Extensive and longstanding research (6) establishes that effective and durable CBT treatments for centralized chronic pain (long-lasting pain that is non-cancer, not due to acute tissue damage or inflammation) are psychological (behavioral health therapies), not biomedical, fundamentally targeting underlying beliefs and mood states associated with pain. 

See, for example:

Cherkin, DC et al. 2017. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA. 317(6):642–644. doi:10.1001/jama.2016.17814

For a critical review of the current evidence: Doxa Deconstructed:  Chronic Pain is Not What You Think

All relevant lines of evidence existed decades prior to emergence of runaway misuse of opioids and the current crisis.

Again –

the Opioid Crisis did not emerge because correcting evidence became apparent or available only after evaluated, critically scrutinized, responsible clinical practices had already led to routine prescribing of opioid pain medications for centralized chronic pain.

Instead, it occurred in the face of those approaches being unsupported and without validation of safety or effectiveness from the beginning by all lines of available evidence and research, evidence longstanding prior to the runaway prescription of opioids.

That can only be explained by an abdication, a failure of critical thought and critical discourse and of ethical reasoning and accountability, allowing the opioid crisis to be generated by other cultural forces, forces with the cultural capital (status, authority, legitimization by the mass media) to create accepted, fake “knowledge” in the face of contradicting and invalidating evidence – made-up “knowledge” that protects status, power, interests.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

Fundamentally the Opioid Crisis largely represents the predictable failure and harms of the unsupportable medicalization of common chronic pain, an entirely non-medical condition, without medical treatments, against all available evidence.

From all appearances, health care systems have not learned from the crisis and its underlying social and institutional dysfunctions, despite projections for 500,000 related deaths over the next decade. For example, chronic pain continues to be managed medically, with routine referrals to invalidated biophysical interventions despite lack of supporting evidence and at enormous costs.

Nor are there reasons to believe that those errors, and the resulting costs continuing to accumulate, have begun to shift care systems or practices more generally toward long-established evidence-based practice (EBP) therapies evidenced as effective and predicting benefit for problem substance use, instead continuation of treatment as usual (TAU) without predicted  benefitprovided by a multi-billion dollar medically-managed treatment industry.

More basically and predicting continuation of a national epidemic of problem substance use, human costs of the opioid crisis are not generating apparent insight or motivation for change in understanding of the very nature and effective treatment of substance use, despite the “disease” and “hijacked brain” medical models having been invalidated over past years and decades by all lines of evidence including: biology, neurobiology, epidemiology, logic, and the nature of substance dependence and relapse.

Failure to re-think problem opioid use, learn from the causes of the crisis, re-think problem substance use, or “addiction”, to align with decades of established research outcomes, and replace treatment as usual (TAU) with evidence-based practice (EBP), predicts continuation of harm and of increasingly lethal national substance use epidemics.

Numbered links to sources

1 – The high abuse and addictive potential of opioids including those prescribed for chronic pain is long-established

2 – generating a history of statutory control

3 – The 1970 Controlled Substances Act lists opioid drugs commonly prescribed

4 – Schedule II Substances  are highly controlled as “drugs with a high potential for abuse”

5 – Common chronic pain is established by the evidence as psychogenic, not physical

6 – Extensive research establishes cognitive behavioral therapy (CBT) as the indicated treatment for chronic pain

See the Nation’s top medical authority blame pharmaceutical companies for medical professionals prescribing addictive drugs for chronic pain, a non-medical, non-physical condition, below:

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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