Fatal overdoses of prescription opioids were rare before 1999. Then doctors, influenced by pharmaceutical industry marketing, began prescribing them for chronic non-cancer pain. By the end of 2016, prescription opioids — not illicit heroin or fentanyl — had claimed 200,000 lives.
Now, at last, the opioid wave has crested. Per capita usage declined for the sixth straight year in 2017, according to IQVIA Institute for Human Data Science , a health-care consulting group. Changes in public policy, including long-awaited prescribing guidelines issued by the Centers for Disease Control and Prevention (CDC) in March 2016, promise to sustain this life-saving progress.
Or maybe they’ll lead to human rights violations. Believe it or not, that’s the premise of a new investigation by the New York-based nonprofit Human Rights Watch (HRW), known for its exposés of war crimes around the world.
HRW is seeking evidence that the CDC guidelines and other efforts to modulate opioid prescribing result in patients being cut off from vital medication, in violation of their right to appropriate health care.
The group “is looking for testimonials from chronic pain patients who have been forced or encouraged to stop their opioid medication by physicians or pharmacists,” the Pain News Network reported in March.
“The CDC clearly knows what’s going on and they haven’t taken any real action to say, ‘That is not appropriate, involuntarily forcing people off their medications. That’s not what we recommended,’ ” Diederik Lohmann, director of health and human rights for HRW, told the network, which says two-thirds of its readers take opioids, mostly for chronic, non-cancer pain. “When a government puts in place regulations that make it almost impossible for a physician to prescribe an essential medication, or for a pharmacist to stock the medication, or for a patient to fill their prescriptions, that becomes a human rights issue.”
Human Rights Watch is not alone; a recent cover story of the libertarian magazine Reason denounced “America’s war on pain pills.” And, of course, patients who have become dependent on opioids must be treated compassionately.
But even after the recent decline in prescriptions, the U.S. opioid rate of consumption in 2017 — 676 morphine milligram equivalents per adult — was five times the 1992 rate. It’s double or triple that of other advanced countries. People who really need them can get licit opioids in the United States.
And the drugs still killed 46 people a day in 2016, according to the CDC.
In any case, alleged unintended consequences of justifiable and, indeed, moderate public-health policies just do not belong in the same moral conversation as deliberate human rights violations such as police brutality or torture.
Article 12 of the International Covenant on Economic, Social and Cultural Rights does indeed exhort governments to guarantee the “highest attainable standard” of health; in that sense, there is a human right to health. Whether it can be defined with sufficient objectivity for this situation is another story. Assuring health is exactly what the CDC is trying to do — not through “regulations,” but through evidence-based recommendations.
To be sure, HRW acknowledges that opioids have been overprescribed in the past, in part due to deceptive industry marketing; a key focus of its current research is ensuring non-opioid alternatives for patients weaned off the drugs, Lohmann told me.
One ought not to prejudge the HRW report, due later this year, even if Lohmann’s comments to the Pain News Network implied that the CDC is blameworthy, and even if the organization funding the study, the U.S. Cancer Pain Relief Committee, is headed by a five-member board of pain specialists who are well-known advocates of opioid use for chronic non-cancer pain.
Two of them, Russell Portenoy and Richard Payne, have received financial support from opioid manufacturers. In late 2015, Payne spoke out against the CDC guidelines in a government advisory group’s deliberations before they were adopted. (Efforts to reach board members were unsuccessful.)
Note that the CDC guidelines specifically address opioid use for non-cancer pain only. The government encourages palliative care for cancer and hospice patients.
The U.S. Cancer Pain Relief Committee has previously underwritten HRW reports on the developing world, the theme of which is that AIDS and cancer patients are being denied access to morphine due to international and national rules intended to prevent opioid misuse. Palliative care in poor countries is a legitimate concern — among the many urgent health-care deficits that such countries face.
Here’s another legitimate concern: Poor and middle-income countries may be vulnerable to the same kind of pro-opioid campaign that wreaked such havoc in the United States.
Mundipharma, a network of companies controlled by the same closely held family business that introduced Purdue Pharma’s OxyContin to the United States, is engaged in aggressive opioid marketing in China, Colombia, Egypt, Mexico and the Phillipines, according to a recent Los Angeles Times report.
As Keith Humphreys, Jonathan P. Caulkins and Vanda Felbab-Brown write in the May/June issue of Foreign Affairs, the U.S. experience shows that “legal drugs pushed by corporations can bring death on a scale vastly surpassing the effects of illegal ones.” And no human right is more important than the right to live.
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