By Zafeer Baber, Pain Physician, Lahey Hospital
Six years after America’s Surgeon General declared that nicotine was as addictive as heroin and cocaine, executives of the seven largest tobacco manufacturers were called to testify before Congress.
When asked whether he believed nicotine was addictive, William Campbell, then CEO of Philip Morris USA, gave a firm ‘no.’
Less than two years later, in 1996, then Massachusetts Attorney General Scott Harshbarger filed a lawsuit against Big Tobacco claiming that the industry knowingly sold an addictive product and engaged in “a conspiracy to mislead, deceive and confuse” the people of Massachusetts about the dangers of cigarettes.
From the multi-state litigation came the now infamous Cigarette Papers that demonstrated that the tobacco industry believed in the addictive effects of cigarettes as far back as the 1960s. The Commonwealth was awarded more than $8 billion in damages.
Nearly 20 years later, the Commonwealth is facing a different public health crisis built on the deceitful marketing practices of another drug industry. In the 1990s and early 2000s, Purdue Pharma, the makers of Oxycontin, launched an aggressive campaign targeting both patients and physicians promoting the idea that the risk of opioid addiction among people with chronic pain was extremely low. Again, this was a lie. In 2007, the company and three of its executives pled guilty to misrepresenting the addictive and abusive potential of Oxycontin. More recently, in the wake of a leaked Justice Department report showing that Purdue Pharma had known for years that people were abusing its medication, Massachusetts Attorney General Maura Healey announced plans to sue the company, as well as its executives and directors.
The similarities between the two cases are striking.
Both industries have been accused of creating a public health crisis in the pursuit of profit. More than 200,000 people died from prescription-related opioid overdoses from 1996 to 2016, according to estimates from the Centers for Disease Control and Prevention, and more than five times as many people died in 2016 from prescription opioid overdoses than in 1999.
Both industries hid their addictive effects while exaggerating their benefits (R.J Reynolds once told their customers to smoke a Camel cigarette between each course of their Thanksgiving dinner as an “aid to digestion”).
The similarities between the two drugs go far beyond marketing. Studies have shown that the two have similar impacts on the brain, triggering the release of dopamine from the brain’s pleasure center – a key aspect of addiction.
Although there is no single panacea for all forms of addiction, many of the lessons learned from tobacco can be applied to the treatment of opioid addiction. Scientifically validated treatments exist for combating nicotine dependence, such as counseling, support groups, medications and Nicotine Replacement Therapy (nicotine gum, patches, etc.). Similarly, opioid substitution with medications like Methadone and Suboxone can be used to curb cravings and blunt the euphoric effects of opioids like Oxycontin, fentanyl, and even heroin.
The opioid crisis will require policy action at all levels. A decade ago, the Affordable Care Act provided increased access to smoking cessation programs. Congress must increase funding towards opioid dependence programs as well. Indeed, tobacco control organizations like the Truth Initiative have already expanded their public education campaigns to opioids.
Overly restrictive federal licensing laws limiting Suboxone prescriptions need to be relaxed. On the state level, the legislature needs to increase access to opioid addiction programs and make access to Naloxone, an overdose-reversing agent, less burdensome.
On the city level, local governments can take the lead by expanding needle exchange programs, which have been scientifically proven to decrease the spread of HIV among intravenous drug users. Just recently, Boston and Cambridge mayors Marty Walsh and Marc McGovern visited safe injection sites in Canada and expressed openness to the idea of bringing such sites here.
Finally, physicians need to have honest conversations with their patients about the addictive effects of opioids. Patients will also have to take control of their care by having realistic expectations about pain control and do everything in their power to make sure their prescription does not get into the hands of someone else.
There is definitely a role for opioids, including Oxycontin, in the treatment of pain such as end of life care, those who have terminal cancer or a recent surgery. But like tobacco, the best option is always prevention.