Portal de Periódicos da CAPES

Solving One Crisis with Another

2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 12 Linguagem: Inglês

10.1097/01.eem.0000997340.40138.5c

1552-3624

Matt Bivens,

Computational Drug Discovery Methods

Figure: addiction, overdose, cocaine, heroin, rat park, alcohol, Cannabis, opioid abuse, drugs, COVID, deaths, binge drinking, liver failure, Centers for Disease Control and Prevention, OxyContin, cigarettes, guns, Purdue Pharma, Allergan, Johnson & Johnson, CVS, Walmart, Food & Drug Administration, endocarditis, Narcan, SuboxoneFigureScientists demonstrated more than 50 years ago that a rat alone in a cage offered a choice between clean water and drug-laced water will choose the drugs. Rats will drink cocaine or heroin steadily, obsessively, until they overdose and die. Later, a kinder scientist asked: What if the problem is not access to drugs but the loneliness and the cage? His team repeated the experiments, but they made the rat's home far less prison-like. In what came to be called the Rat Park, male and female rats were set up in a stimulating and vibrant community where they were free to explore, socialize, and have sex. (Pharmacol Biochem Behav. 1981;15[4]:571.) The rats mostly preferred plain water in this environment. Some would still partake of the available cocaine or heroin but more, uh, recreationally. And they never overdosed or died. Apparently, rats (like humans) need social relationships and a community. When we are denied these, when life feels unsatisfying, unfair, lonely, and inauthentic, we check out with intoxicants. Many millions of Americans became addicted to hard drugs and alcohol over the past 20 years. Millions more also embraced Cannabis as a new cure-all. When it comes to America's Rat Park, there's apparently a lot that's unsatisfying, unfair, lonely, or inauthentic, and so it's best checked out of. But is that the whole story? The Stress of COVID The soaring rates of opioid abuse and associated deaths provoked the declaration of a national public health emergency five years ago. Annual drug overdose deaths by that time had more than tripled, from about 20,000 a year in the 1990s to about 70,000 by 2017. Some of those deaths were driven by cocaine or methamphetamine, but more than 75 percent were from opioids. Then came the stresses and dislocations of the COVID-19 pandemic. Suddenly, there was a lot less cavorting, exploring, and socializing to be had. Workplaces closed. Vacations were cancelled. Book clubs, church services, gym classes, kids' schools and sports, and neighborhood cookouts were all curtailed. Weddings were canceled, and even funerals were unattended or virtual. It was like everyone had been yanked out of the Rat Park and shoved back into a cage of no socializing, complete with a choice of clean water from the tap or home delivery of every kind of intoxicant. (Brigham and Women's Hospital. June 28, 2023; https://tinyurl.com/zbduzd8x.) Alcohol consumption, particularly binge drinking, took flight. One study calculated that the early COVID-era increase in drinking would eventually cause 8000 additional deaths and nearly 20,000 additional liver failures or cancers. (The Harvard Gazette. June 14, 2022; https://tinyurl.com/3tydwxs4.) That's on top of the roughly 140,000 annual deaths that the Centers for Disease Control and Prevention already attribute to alcohol abuse: Yes, legal alcohol has all along had a far higher death toll than all illegal drugs combined. (CDC. July 6, 2022; https://tinyurl.com/37zrz6r5.) There's a good reason that we once briefly amended the U.S. Constitution to make alcohol illegal. Drug overdose deaths during COVID-19 also skyrocketed. Remember it was declared a nationwide emergency in 2017 when we saw 70,000 overdose deaths? We hit 92,000 in 2020 and 107,000 in 2021. It appears to have reached plateaus at this new shocking high for 2022 and 2023. Consider too that we revive 20-30 overdoses for every drug-overdose death, but how many of those have at least a mild hypoxic brain injury? (Drug Alcohol Depend. 2021;226:108838; https://tinyurl.com/2u94mztp.) And for every 100,000 deaths, are there also, say, a million near-death patients who are a cognitive step slower afterwards? Perhaps; it's not well-studied. Is OxyContin Worse than COVID? It's hard to compare the death toll of COVID-19 with that of addictive substances. These are moving targets, and mortality falls disproportionately on different populations. Is it fair to equate the premature coronavirus death of a 99-year-old to the premature fentanyl death of a 20-year-old? How about the virus death of an active, pillar-of-the-community retiree compared with the overdose death of someone who engaged in substance abuse, repeatedly refused addiction care, and was in and out of prison for violence? (What about morbidity? How do we compare the suffering of a long COVID or COVID-associated pulmonary embolus patient with that of a patient with drug-associated endocarditis or a spinal epidural abscess?) All nuances aside, 1.4 million Americans died from COVID-19 over two and a half years. That equals about 450,000 a year against about 230,000-240,000 annual deaths from drugs and alcohol. But COVID-19 appears to be less relevant every day (fingers crossed) while the misery of addiction only grows. And we haven't even talked about nicotine addiction. The CDC says the annual U.S. death toll of cigarettes is 480,000 people, five times higher than the opioid death toll and comparable with a COVID-19 pandemic every year for decades. (July 29, 2022; https://tinyurl.com/mry57zte.) The deaths just from secondhand smoke total a staggering 41,000 people a year. That's deadlier than motor vehicle crashes or firearms. Americans are literally in more danger from other people's cigarettes than from other people's guns. What is an EP to Do? COVID-19 is basically over, and everyone has been released from the cages and back into the wilds of America's Rat Park, the place that was already so unsatisfying to so many. Coronavirus-exhausted doctors and public health experts are now turning a weary gaze back to the old pandemics of deadly addictions. But there's an uncomfortable reality awaiting us: The evidence is overwhelming that millions of Americans became addicted because some in the house of medicine eagerly encouraged that outcome for their own profit while the rest of us mostly stayed silent. The chief villain remains the Sackler family-owned Purdue Pharma. But many others made millions selling addiction, including pharmaceutical companies like Allergan and Johnson & Johnson, retail pharmacies like CVS and Walmart, and various corporate sharks like those at Mackenzie Consulting. They were helped along by corrupt officials at the U.S. Food and Drug Administration, by the pompous and ignorant Joint Commission (which calls itself “a trusted partner in patient care“), and by physician shills like those with the Purdue-financed American Pain Society. The medical profession's response has been a continued deafening silence. We prefer not to talk about it much; we'll just leave it to the lawyers. Instead, we have our own solution to the opioid crisis: more for-profit drugs. Narcan intranasal is now available over-the-counter, usually as a two-pack, for the introductory price of about $45. (WBUR.org. Aug. 30, 2023; https://tinyurl.com/prer6r5x.) Generic injectable naloxone costs about $6 a dose, but the proprietary plastic squirt gun of intranasal Narcan somehow justifies a sevenfold upcharge. (Drugs.com. October 2023; https://tinyurl.com/4msbdjyk.) (It's mind-blowing that Purdue's international wing also sells a pricey brand-name naloxone abroad.) (WGBH.org. Dec. 15, 2019; https://tinyurl.com/82yyaudf.) Suboxone is also being aggressively marketed by all of us in the emergency department. (Did you not know you were in marketing and sales?) Addiction and Debt I can't argue against expanded use of buprenorphine. The data, it must be said, are so far over relatively short-term horizons that it shows it prevents death and disability. Of course, it is also addictive. So, the plan we confidently propose is to stay on this admittedly ingenious and excellent medication at an average cost of about $150 a month ... forever. Yet I wonder: How does all this come across to everyone else in the American Rat Park? Our fellow citizens watch “Painkiller” on Netflix and “Dopesick” on Hulu, read Patrick Keefe's bestselling “Empire of Pain,” and shake their heads ruefully over the latest overdose death in the news. Then we solve the crisis that was created by aggressively selling addictive medication by ... aggressively selling more medication? This is happening as more than half of adults have been pushed into debt by medical bills, and one in five of them says they'll never be able to pay them off. (Texas Tribune. June 16, 2022; https://tinyurl.com/bdks3fx8.) Medical overbilling is a catastrophe and a major reason why people living in the American Rat Park opt by the millions to get drunk or stoned. How about we doctors try offering a little therapeutic honesty along with the pills? Next month: I'll take a closer look at America's Rat Park, particularly at some of its white coat-wearing denizens. DR. BIVENS works at emergency departments in Massachusetts, including St. Luke's in New Bedford and Beth Israel Deaconess Medical Center in Boston. He is double-boarded in emergency medicine and addiction medicine. Follow him on X @matt_bivens. Share this article on X and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].