Should We Blame Pharmaceutical Companies for America's Opioid Epidemic? Here's What the Science Says.

Legal evidence is needed to pin addiction and death on opioid manufacturers, but the science suggests that a large and ready supply of legal prescription painkillers led to many addictions.
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Several studies indicate that the ready availability of prescription opioid painkillers was a key factor in creating the current opioid epidemic.

Several studies indicate that the ready availability of prescription opioid painkillers was a key factor in creating the current opioid epidemic.

Purdue Pharma, the company that makes OxyContin, has been taking some legal hits lately. Last week, the company settled a lawsuit with the state of Oklahoma for $270 million, the largest amount yet in a state opioid suit. Over the past several weeks, an ongoing case with the states of Massachusetts and New York has revealed the extent to which the Sacklers, the wealthy family that owns Purdue, were personally involved in plans to market and profit from OxyContin. Suits like these allege that Purdue advertised OxyContin as less addictive than it really is, leading to an epidemic of opioid use disorder and overdoses. Purdue and the Sacklers deny these claims.

So what's the evidence that Purdue Pharma and its marketing of OxyContin led to high rates of opioid addiction in the United States? While it's up to the courts to decide to what extent Purdue is legally responsible for America's opioid crisis, the science has been building for several years now to support the idea that the ready availability of legally manufactured, prescribed opioid painkillers was a critical force in creating the epidemic in painkiller and heroin addiction today. Below are some of the most important studies showing that link, as well as studies that illustrate the current state of the opioid epidemic.

For a Decade, As Opioid Prescriptions Rose, So Did Opioid Addiction and Deaths

In 2011, the Centers for Disease Control and Prevention (CDC) documented that, between 1999 and the late 2000s, sales of opioid painkillers—like OxyContin, Vicodin, and Percocet—quadrupled. At the same time, overdose deaths involving opioids almost quadrupled, and the proportion of people showing up in addiction treatment centers saying they had an opioid addiction went up 600 percent.

States helped provide a natural experiment showing the effect of painkiller sales on misuse and death. States with higher-than-average opioid sales tended to have higher-than-average death rates, too, the CDC found. Unscrupulous "pill mill" doctors could have a big effect on the painkiller supply in some states, CDC researchers argued, pointing to a 2011 study of California doctors who treat injured workers. That study found that 3 percent of doctors accounted for 62 percent of opioid prescriptions.

More Aggressive Opioid Marketing Is Associated With More Opioid Prescribing and Overdoses

Long after the CDC published its first figures showing how overdose deaths rose along with opioid prescriptions, a new study, published earlier this year, found that, the more money pharmaceutical companies spent on marketing opioids to doctors in a county, the more opioids doctors in that county would prescribe. Opioid overdose deaths were associated with marketing spending as well.

A Minority of People Who Are Prescribed Opioid Painkillers for Chronic Pain Become Addicted

In a review, Nora Volkow, the head of the National Institute on Drug Abuse, and Thomas McLellan, a former deputy director of the Office of National Drug Control Policy, estimated that about 8 percent of people who take prescribed opioids for chronic pain become addicted. About 15 to 26 percent act in ways that doctors consider unhealthy, but may not qualify as addiction, such as aggressively hounding doctors for prescriptions and taking more pills than they're supposed to.

Others Began Their Opioid Misuse and Addictions by Taking Prescribed Pills That Weren't Intended for Them

People with addictions to opioid painkillers are often lumped together with people with addictions to heroin because the chemicals are similar, produce similar feelings, and misuse of one can lead to misuse of the other (more on that below). But the large majority of Americans who misuse opioids take pills only, according to the latest figures from the National Survey on Drug Use and Health.

The most common source of pills for misusers is "from a relative or friend for free," according to an analysis by the Substance Abuse and Mental Health Services Administration. Together with the CDC data about high opioid prescribing rates in America, this study suggests generous prescriptions led to a ready supply of pills that people gave to their friends and family, who then used them for non-medical reasons (although the majority of respondents to the 2016 National Survey on Drug Use and Health said they misused pills to deal with pain).

A Crackdown on Pills Can Lead to Heroin Use

Because heroin is chemically similar to opioid painkillers, and will relieve withdrawal symptoms, people who are cut off from their pill supply for some reason may turn to heroin instead. One of the earlier pieces of research to demonstrate this was published in 2012, when researchers interviewed 103 people with opioid addictions. At the time, Purdue had recently introduced a version of OxyContin that was difficult to crush and dissolve in water for injection. Interviewees said they definitely preferred the old Oxy, and two-thirds said they disliked the new Oxy so much, they'd moved on to another opioid, most commonly heroin. "Most people that I know don't use OxyContin to get high anymore," one interviewee said. "They have moved on to heroin [because] it is easier to use, much cheaper, and easily available."

Journalist Sam Quinones' book Dreamland also documented this phenomenon.

Prescriptions Have Been Falling Lately, but Overdoses Are Still Rising

After nearly a decade of studies demonstrating opioid painkillers' risks, America's doctors seem to be slowing their prescribing. In 2017, the CDC reported that the number of scripts doctors wrote for opioids fell 13 percent between 2012 and 2015, although they remain much higher than in 1999.

Yet opioid-related overdose deaths continue to rise, reaching nearly 48,000 in 2017.

Now the Deadliest Opioids Are Likely Street Drugs, Not Prescribed Pills

The most common cause of fatal opioid overdoses is now fentanyl, a very strong opioid that is available by prescription. However, officials believe much of what's killing people comes not from pharmaceutical companies, but from illicit labs in China and Mexico. Drug traffickers may mix illicitly produced fentanyl with other drugs, such as cocaine, or press it into counterfeit pills.

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