The two-and-a-half minute trailer for the new Hulu miniseries Dopesick might be all it takes to resurrect the false narrative behind America's failing opioid policy. That policy drives non-medical drug users to dangerous and deadly black market drugs, and stigmatizes pain patients while plunging them into anguish, despair, and sometimes suicide.
The new miniseries, based on journalist Beth Macy's powerful 2018 book Dopesick, along with Sam Quinones 2019's book Dreamland, validated policymakers who subscribe to the false narrative that America's overdose crisis is the direct result of doctors over‐treating their pain patients with opioids and turning them into "addicts." In full disclosure, I haven't yet watched the series, but the trailer makes clear that the story is about good versus evil: compassionate doctors with hard-working blue-collar patients getting manipulated by deceitful pharmaceutical company executives who are unconcerned that they may be condemning patients to the nightmare of addiction. The lack of nuance raised alarm bells for doctors like me who have read and published research on the opioids issue.
Convinced they knew the source of the overdose crisis, state and federal policymakers embarked on a concerted effort to reduce opioid prescribing, hoping this would stem the rising tide of overdose deaths. Prescriptions of opioids per 100 persons have dropped nearly 50 percent since 2012. Almost simultaneously, the overdose rate has surged from roughly 40,000 in 2012 to 93,000 in 2020.
Viewers of the trailer see Purdue pharma sales reps instructed, "Your most effective talking point are these magic words: 'less than 1 percent.'" This is followed by a montage of sales reps repeating "less than 1 percent" to various physicians, encouraging them to prescribe the opioid to their patients who would later become addicted. Dramatic music accompanies an investigator saying, "Purdue continues to lie about the drug's safety—to doctors, patients, and the FDA." Dopesick author Macy, who served as executive producer of the miniseries, states the scenes with Purdue executives are not word-for-word, but are based on extensive research.
Yet at least two Cochrane systematic reviews (which meet the most rigorous standards of medical research) have shown addiction rates from long-term opioids among chronic non-cancer pain patients to be somewhere in the vicinity of 1 percent. And none other than doctors Nora Volkow and Thomas McLellan of the National Institute on Drug Abuse wrote in the New England Journal of Medicine in 2016 that "unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids—even among those with preexisting vulnerabilities."
Part of the problem with the false narrative is the tendency of many to equate physical dependence and tolerance (the two are closely related) with addiction. Many drugs, when taken long term, cause physiologic adaptation such that increased doses may be required to reach the desired result, and abrupt withdrawal can cause serious, even life-threatening, withdrawal reactions. Beta blockers, used to treat high blood pressure among other conditions, are a perfect example. Abrupt withdrawal can be fatal. Yet no serious person would stigmatize people with hypertension controlled by taking beta blockers daily for years as "beta blocker addicts." Many other drugs, including antidepressants and antiepileptics, also cause dependency and tolerance. Addiction, on the other hand, is defined as compulsive use despite adverse consequences. Addiction is a compulsive behavioral disorder, usually associated with psychological traumas during early development and preexisting psychoneurological comorbidities.
The narrative also fails to note that overdoses were steadily increasing long before the Food and Drug Administration approved the opioid OxyContin in 1996. Researchers at the University of Pittsburgh provide clear evidence that overdoses from non‐medical drug use have been growing exponentially since at least the 1970s, with different drugs predominating among the overdoses at different points in time.
Policymakers locked on to the narrative after media reports of overdoses increasingly occurring among white middle-class people who were non-medically using prescription opioids "diverted" to the black market.
In her book, Macy states, "Americans, representing 4.4 percent of the world's population, consume roughly 30 percent of its opioids." As doctors were (correctly) encouraged to overcome the opiophobia that caused them to neglect pain, more prescriptions were written and dispensed, which in turn meant more prescription opioids could be diverted to the black market. H.L Mencken famously said, "there is always a solution to every problem—neat, plausible, and wrong." Attributing the overdose crisis to the "evil" drug makers and reckless doctors seemed to make sense. And powerful stories like those put forth in Dopesick and Dreamland fueled such solutions. Yet as Jacob Sullum, Michael Schatman, and I pointed out in the Journal of Pain Research in 2019, government data show no evidence of any correlation between the number of opioids prescribed and the non‐medical use of opioids or of opioid addiction.
To be sure, some doctors, pharmacists, and other health care providers used their degrees and licenses as cover for the lucrative drug dealing business. But don't blame doctors treating pain patients for that: Blame drug prohibition. Prohibition provides powerful incentives to corrupt doctors, pharmacists, and drug company sales reps who seek profits offered by the underground trade.
At the end of the day, extracting a pound of flesh from the main villain of Dopesick, the Sackler family's Purdue Pharma, won't stop the overdose rate from climbing. Non-medical drug users have long ago moved on from diverted (and much safer) prescription pain pills. Of the 93,000 overdose deaths that occurred in 2020, roughly 70,000 were opioid‐related, 83 percent of which involved illicit fentanyl. The black market, fueled by prohibition, very efficiently meets demand.
Based upon a neat, plausible, and wrong narrative, policymakers cast in stone the then‐controversial Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, etching into law what the CDC explicitly stated was not "settled science," but what were instead meant to be general rules of thumb to aid practitioners.
Aware of the misinterpretation and misapplication of its 2016 guidelines, the CDC issued an advisory in April 2019. The agency announced in December 2019 that it planned to update its guidelines. And the FDA held a "public workshop" last August to ask if dosing based on morphine milligram equivalents was even evidence-based.
The Drug Enforcement Administration just ratcheted down production quotas for all prescription opioids for the sixth consecutive year while doctors are terrorized into undertreating pain, or abruptly tapering and cutting off chronic pain patients from a medication that has allowed them to enjoy meaningful and productive lives.
Sadly, pain patients are the real victims of the false narrative, with documented increases in mental anguish and suicide from untreated or under‐treated pain. Suicides among veterans are skyrocketing as opioid treatments have been curtailed in the Veterans Health Administration system.
If the last 20 months of the COVID-19 pandemic have taught anything, it's that biological science is rarely settled, that it is usually nuanced, and that neat and simple explanations are usually wrong. Just when those responsible for our misguided opioid policy may be coming to this realization and reevaluating their approach, Hulu releases a miniseries aimed at stirring the passions that might breathe new life into the false and failing narrative.