Stanford-Lancet report calls for sweeping reforms to mitigate opioid crisis

Even in the era of COVID-19, the opioid crisis stands out as one of this century’s most devastating public health disasters, according to a Stanford-Lancet report published Feb. 2.

The report, two years in the making, calls for immediate action to quell the rising tide of addiction and overdose deaths in the United States and Canada, especially now that the pandemic has pushed the crisis to new heights.

“Unrestrained profit-seeking and regulatory failure instigated the opioid crisis 25 years ago, and since then, little has been done to stop it,” said Keith Humphreys, PhD, the Esther Ting Memorial Professor and professor of psychiatry and behavioral sciences at Stanford Medicine. Humphreys chairs the 17-member commission that produced the Stanford-funded report in coordination with The Lancet. The commission brings together a variety of Stanford scholars with other leading health experts from the U.S. and Canada.

“This problem is now everywhere across our two nations,” said Humphreys, who has 30 years of experience in public policy as an addiction researcher. “It crosses borders and economic levels. Find me a family that it hasn’t touched in some way.”

The statistics are startling. Since 1999, more than 600,000 people in the U.S. and Canada have died of an opioid overdose, exceeding the mortality rate of the worst of the HIV/AIDS epidemic, the report says. The number of U.S. and Canadian deaths due to opioids is greater than the number of those countries’ citizens who died in World War I and World War II, and estimates of the epidemic’s financial costs have reached $1 trillion. During 2021, fatal drug overdoses spiked in the two nations, reaching 100,000; 70,000 alone were opioid-related deaths in the United States.

The commission’s model projects that, from 2020 to 2029, opioid deaths will total 1.22 million in the U.S. if no new action is taken to address the epidemic.

“The COVID pandemic cut off a lot of things that protect people,” Humphreys said. “Social contact, daily structure, 12-step recovery programs were replaced by fear, anxiety, sometimes bereavement or economic stress — things that drugs temporarily take away, that cause individuals with addiction to relapse.”

The fallout has been two nations mourning losses compounded on top of more losses, Humphreys said.

“It’s heartbreaking when you lose a person to this disorder, and the pain and anguish of being a family member of someone addicted can be enormous,” said commissioner Christine Timko, PhD, clinical professor of psychiatry and behavioral sciences at Stanford. But, she added, there is hope. “People can and do recover.”

“Our fundamental way of thinking about an addiction as a moral failing rather than as a health problem has to change,” Humphreys said. “Yes, this is an illness. Yes, it is treatable. And yes, you have a chance to recover.”

The commission proposes far-reaching reforms to medical education, health care and regulation of the pharmaceutical industry to curb opioid addiction and overdose deaths, and to prevent future epidemics at home and abroad.

Our fundamental way of thinking about an addiction as a moral failing rather than as a health problem has to change.

“We’ve ignored this problem for far too long,” said commissioner Jonathan Chen, MD, PhD, assistant professor of biomedical informatics at Stanford. Citing the report’s recommendation to require addiction-medicine education for health workers, including physicians and physicians-in-training, he said, “This report is a call to action.”

“Opioids are both essential to modern medical practice and, at the same time, potentially dangerous,” the report says. The drugs activate brain pathways that reduce pain but also slow breathing, which can lead to death, and produce euphoria, which can lead to addiction.Among other changes, it calls for a better understanding of the dual nature of opioids as a benefit as well as a health risk.

Insufficient regulation

Beginning in the late 1990s, insufficient regulations allowed marketing campaigns by the pharmaceutical industry to influence physicians to prescribe opioids while fraudulently reassuring the medical community that the risk of harm to patients was low, the report says.

“This form of marketing comprises in-person office visits, large and small gifts (e.g., branded office supplies, meals and receptions at conferences, travel expenses), and direct financial payments for endorsing industry products in lectures and case conferences,” the report says.

The prescription opioid OxyContin, first sold in 1996, was the subject of the most lavishly funded promotional campaign in pharmaceutical history, leading to a quadrupling of opioid prescriptions, the report says. OxyContin alone is estimated to have generated revenues of more than $35 billion for Purdue Pharma and its owners, the Sackler family.

“Pharma companies are all being sued, and they deserve to be sued, but we have to remember they exploited weaknesses in our health care regulatory system that are still there,” Humphreys said. These included failures at the Food and Drug Administration, which approved OxyContin based on a fraudulent description of the drug as “less addictive” than other opioids, the report says.

Around 2010, drug traffickers began to market heroin, an opioid made from morphine, in small cities with a growing population of residents addicted to prescription opioids. Early efforts to limit opioid prescriptions and reduce the illegal sales of narcotics prompted many opioid-addicted individuals to shift to heroin, which is cheaper than prescription opioids.

Four years later, in 2014, there was a rise in addiction and fatal overdoses involving synthetic opioids such as fentanyl, a cheaper, more deadly alternative to opium-derived narcotics. Many with opioid-use disorder were unaware that the narcotics they used were laced with fentanyl or other synthetic options, the report says. Homeless people and those leaving prison experienced particularly large increases in overdose deaths, the report says. The problem has now spread into all corners of the two countries.

Recommendations

The commission’s recommendations include improving or changing regulations, building enduring medical care systems for those with substance-abuse disorders, minimizing adverse effects of the criminal justice system, and preventing the North American crisis from spreading globally. Among specific reforms recommended for both nations:

• • Eliminate the marketing of controlled substances to prescribers and curtail pharmaceutical companies’ marketing of these drugs to consumers. Stop allowing the industry to claim tax deductions on the tens of billions it spends on marketing medications. 
• • After approval of a drug by the FDA, make the government responsible for continued follow-up research on safety and for educating physicians about risk reduction. These responsibilities are currently taken on by industry.
• • Medical education about managing addiction — and about the risks of prescribing addictive medication — should be required before any health professional is granted a license to prescribe controlled substances.
• • End incarceration for illicit possession of opioids or drug-use equipment intended for personal use, including for pregnant women. Incarceration of people who have opioid addictions raises the risk that they will die of overdoses.

Although the present crisis is concentrated in Canada and the U.S., similar crises could emerge in any nation if regulations fail to prevent pharmaceutical companies from employing aggressive marketing strategies overseas, the report says. Investigative journalists have reported that this is already happening.

Because the opioid crisis has been long in the making, fixing it is far from simple, Humphreys said.

“It took more than a generation of mistakes to create the North American opioid crisis,” the report says. “It may take a generation of wiser policies to resolve it.”