As published in The Hamilton Spectator newspaper, Opinion

For the original unabridge version, click here

North Amer­i­cans are the high­est opi­oid users per capita in the world.

A 2019 re­search study found sur­gi­cal pa­tients in the U.S. and Canada had a sev­en­fold higher rate of opi­oid pre­scrip­tions filled com­pared to sim­i­lar pa­tients in Swe­den who un­dergo the same surg­eries. There is no ev­i­dence to show that North Amer­i­cans ex­pe­ri­ence more pain than peo­ple from other coun­tries, so why the sub­stan­tial dis­crep­ancy? The an­swer seems to lie somewhere be­tween cap­i­tal­ism and cul­ture.

Mor­phine, the orig­i­nal opi­oid, is iso­lated from the opium poppy plant and has been used for mil­len­nia in Mid­dle Eastern so­ci­eties by an­cient priests and physi­cians. To­day, we have de­vel­oped syn­thetic opi­oids such as fen­tanyl which are a hun­dred times more po­tent than mor­phine. Opi­oid drugs are listed by the World Health Or­ga­ni­za­tion as an es­sen­tial medicine, in­di­cated for the treat­ment of acute pain, pain caused by can­cer, and pal­lia­tive care. How­ever, in North Amer­ica, many pa­tients with chronic non-can­cer pain are pre­scribed opi­oids, and some­times this has re­sulted in opi­oid de­pen­dence and sub­se­quent il­licit opi­oid use. A 2019 re­search study pub­lished in the Lancet de­scribes the prob­lem:

“From the 1990s to around 2011, ag­gres­sive pro­mo­tion, un­der-reg­u­la­tion, and over-pre­scrib­ing of phar­ma­ceu­ti­cal opi­oids caused a sub­stan­tial in­crease in opi­oid de­pen­dence and over­dose deaths.”

In fact, in Jan­uary 2020, the CEO and founder of the phar­ma­ceu­ti­cal com­pany In­sys Ther­a­peu­tics was con­victed of en­gag­ing in a rack­e­teer­ing con­spir­acy to in­crease the prof­its from his com­pany’s sub­lin­gual fen­tanyl spray, in­clud­ing the brib­ing of doc­tors to pre­scribe the med­i­ca­tion to pa­tients be­yond the ap­proved use for can­cer pain. In Novem­ber 2020, OxyCon­tin maker Pur­due Pharma pleaded guilty to three crim­i­nal charges in­clud­ing pay­ing doc­tors a kick­back to en­cour­age them to pre­scribe more painkillers, as well as im­ped­ing the U.S. Drug En­force­ment Ad­min­is­tra­tion.

The worst part of it is this: although opi­oids are pow­er­ful, they have not been shown in the lit­er­a­ture to be su­pe­rior to nono­pi­oid anal­ge­sia (Tylenol and Advil) for chronic non-can­cer pain. Iron­i­cally, opi­oid use may even cause more pain, a phe­nom­e­non called “opi­oid-in­duced hy­per­al­ge­sia.” The longer pa­tients are on opi­oids, the more likely they are to ex­pe­ri­ence more pain, and con­se­quently need more and more opi­oids — a nev­erend­ing deadly cy­cle.

The other fac­tor that con­trib­uted to the opi­oid cri­sis was the Amer­i­can, and by ex­ten­sion, North Amer­i­can cul­ture. Amer­ica has al­ways been an in­no­va­tor in in­stant grat­i­fi­ca­tion. For ex­am­ple, fast food is a sta­ple of Amer­i­can cui­sine, and with Ama­zon Prime Now, cus­tomers can get items de­liv­ered to their door within just a cou­ple hours of click­ing a but­ton on­line. As a so­ci­ety, we want things now, and we would rather pay than have to wait. In medicine, both pa­tients and doc­tors tend to look for a pill to solve ev­ery prob­lem, which is of­ten eas­ier than do­ing the less glam­orous and dif­fi­cult work of long-term pre­ven­tive life­style changes. The same con­cept ap­plies to pain and pain con­trol.

Opi­oids, like all drugs, carry risks. Mild, tol­er­a­ble side ef­fects in­clude con­sti­pa­tion, nau­sea and vom­it­ing, but more se­ri­ous risks in­clude ad­dic­tion, de­pen­dence and death. There were more than 19,000 opi­oid-re­lated deaths in Canada in the past five years, ac­cord­ing to the Pub­lic Health Agency of Canada. Many fam­i­lies were torn apart by opi­oid ad­dic­tion that first be­gan with a seem­ingly harm­less post­sur­gi­cal pre­scrip­tion; sto­ries about fam­ily mem­bers find­ing their loved ones dead from un­in­ten­tional over­doses are un­for­tu­nately too com­mon.

I once read a New York Times piece ti­tled, “Af­ter Surgery in Ger­many, I Wanted Vi­codin, Not Herbal Tea.” The au­thor, an Amer­i­can who im­mi­grated to Ger­many, writes about how she was sur­prised she was only of­fered ibupro­fen (Advil) for pain con­trol af­ter her hys­terec­tomy, and re­calls her anes­the­si­ol­o­gist ex­plain­ing:

“Pain is a part of life. We can­not elim­i­nate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are heal­ing. If I give you Vi­codin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overex­ert your­self be­cause you are no longer feel­ing the pain sig­nals. All you need is rest. And please be care­ful with ibupro­fen. It’s not good for your kid­neys. Only take it if you must. Your body will heal it­self with rest.”

The opi­oid cri­sis was cre­ated due to ag­gres­sive and un­eth­i­cal phar­ma­ceu­ti­cal mar­ket­ing, as well as the North Amer­i­can cul­ture of in­stant grat­i­fi­ca­tion and “hack­ing” away in­con­ve­niences such as pain. It has re­sulted in pa­tient deaths and ad­dic­tions, a grow­ing il­le­gal trade, and fi­nally in 2020, the crim­i­nal con­vic­tions of phar­ma­ceu­ti­cal ex­ec­u­tives. If more doc­tors were brave enough to rec­om­mend rest over opi­oids, and more pa­tients will­ing to ac­cept it, maybe, just maybe, the opi­oid cri­sis could have been avoided.