The Opiate Beast: Res Ipsa Loquitor

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From 1999 to 2017, almost 400,000 people in the US died by using or misusing prescription and illicit opioids. The graph below (https://www.cdc.gov/drugoverdose/epidemic/index.htm holds a black line indicating numbers of deaths related to “natural, commonly prescribed, and illicitly manufactured opioids”; deaths increased very rapidly beginning in 2013; by 1917 these black line opioid related deaths are roughly equal to the combined total opiate deaths from all other causes. That impacts me personally because the fentanyl deaths include a grandson of mine.

Yet obviously opiate users contribute to their own demise; who knows why self loathing or self destructive behavior is attractive or rewarding. Making opiates illegal has not paid off. We seem unaware that social rules are far more effective than laws, as the War Against Drugs, or our own Prohibition experience suggests. Healthy behavior cannot be imposed; but self destructive behavior could become socially scorned, like smoking has recently; everyone used to smoke in movies 50 years ago; (I always chuckle when I see a driver chastely holding a lighted cigarette out the window!) Today attractive young women snort cocaine in many movies or TV shows.

Years ago I was in Nepal on an assignment for Peace Corps. Drugs of all sorts were available, and some volunteers enjoyed pot, but were avoided by locals who saw that as the offensive and base behavior of undesirables.

Recently I took a job with a drug investigational research operation. It quickly became clear that protocols for ‘research’ were devised and intended to justify new drug applications before the Federal Drug Agency. They were artfully crafted and brilliantly concieved, but biased.

The corporation that hired me was hugely profitable to the owner. I, as a critically important MD employee meritied special consideration, though the pay was modest. My first shock was being sent to ‘symposiums’ that were informational sessions for investigators. At a typical one in Florida the benefits were lush digs, sumptuous meals, and proffered sexual favors. I found myself, one evening, after a long day and a dinner with dance band, in an elevator with an attractive young woman who had been at my table. She explained that she had no place to stay the night. That required some fast action by me. I abruptly stepped out of the elevator as the door was closing as if not realizing the floor that was not mine, and so deserted my would be roomate. Whoah! A new drug application to FDA requires a lot of talent and work of different sorts!

Nonetheless, I was fascinated by the details of drug trial protocols. Several were very interesting and absorbing. Yet some were third stage trials of new opiate formulations. Trials require people–.subjects who had been recruited through advertizing– for testing of a new drug up for FDA review. In this case the drug was described as a ‘non addicting’ (opiate) pain medication. Participants were required to be already using opiate pain meds for their problems. They would be provided free opiates in the dose they usually needed or a slightly increased dose if required by the study. They would not only benefit humanity by participating for several months, but be provided with the opiates, and paid while they completed the study.

One day I was asked to evaluate and examine a new applicant. He was an 18 year old who had a remote very minor back strain many months prior. He was still using large doses of opiates. After completing the exam I felt an obligation to ask him if he really had thought about the risks of long term opiate use. But he was not at all interested in the question. Additionally, he mentioned my comment to his ‘handler’. Handlers are very capable people, who work hard with several subjects for a given project; they are expected to supervise the subjects and encourage adherence to, and completion of the protocol. Where opiates are concerned, that was, arguably, a multiway partnership between handler, opiate user, the physican businessperson, and the drug manufacturer. Everyone wins. Every subject required some investment by the research company, but brought a very substantial bounty to the physican owner, and a benefit to the handler involved. My comment to the new subject, had he changed his mind, jeapordized several dozen thousands of dollars of net income to the business.The next day I was, of course, terminated.

I have nothing against money. In fact I like it a lot, the more the better. Still, money is the fount of many illegal activities, even those that grow within the womb of the law. Money is the mother’s milk not only of politics but of the opiate industries. The ultimate goal of drug producers seems to be to sell drugs by grooming the public and prescription writing Physicians. While physicians often swear by the Oath of Hippocretes, and aspire to follow the adage primum non nocerum— do no harm we can be bought off by a drug industry that is very adept at the procedure.

For many years huge quantities of opiates have been made and promoted by drug makers and distributors and by physician dealers. Very tiny pharmacies have sold millions of opiate tabs yearly, far more than their whole state could use. This sort of thing has been well known for years, but continues. Certainly by now legislators, drug companies, distributors, and many physicians know the facts. But the government has been unable or unwilling to interfere effectively even though much could be done quickly and simply.Here are a only few suggestions among many:

  1. Confine pharmacies to reasonable numbers based on local population.
  2. Prevent physicians from selling and distrubuting opiates from their own offices.
  3. Require a new hand written physician prescription for a refill of an opiate.
  4. Limit prescritptions to 30 opiate tablets unless a ‘triplicate’ style prescritption is used. (Triplicates are outmoded but useful in this respect. They are bothersome!)
  5. Require Drug distributors, at their own expense, to provide pharmacies with 4 mg Narcan Nasal spray to be available without prescription to anyone with valid identification.
  6. Require Drug distributors to provide all county health departments with 100 Narcan 4 mg Nasal Spray sets at no cost to the health department. It could be used for distribution to high schools, individuals, homeless shelters, and even college health services.
  7. Permit drug distributors to buy low cost Narcan Nasal Spray offshore.
  8. Prohibit direct to consumer advertizing of drugs. ( So far as I know only US and New Zeland allow it. Besides, it would make TV ads less offensive)
  9. Prohibit Drug “Detailing” of physicians (food, samples, camraderie and literature provided by attractive salespersons.)
  10. Require that Continuing Medical Education (CME) to be funded by physician attendees, rather than as now, subsidized heavily by Drug companies who also apparently buy the speakers.
  11. Prohibit all drug company funding of medical research and CME because that subverts, co-opts, and brainwashes physicians and administrators.
  12. Create a national patrimony for medical research using drug company opiate abuse fines or heavy taxes. CDC could be an ideal administrator.

No doubt these are contentious suggestions; they would, in the unlikely event they are ever seriously considered beyond these pages, cause outrage and loud objections. Nonetheless, I believe they are worth considering. Res Ipsa Loquitor, I think, means The Beast Speaks For Itself; despite that being a legal term, it may be that our lawyers can allow me to use it here. After all, legislators are mostly lawyers and all lawyers are mostly legislators.

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