BIGGEST SELLER

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a particular drug which is part of this epidemic.]

The next class of opioids this development will address is Oxycodone, including a derivative of this drug, OxyContin.  When it comes to recreational use of opioids among Americans, these two forms constitute the most used.  According to the US Department of Health and Human Services report, circa 11 million Americans consume an oxycodone drug for recreational or non-medical reasons.  As such, Oxycodone accounts for a large portion of this epidemic.[1]

          Oxycodone has its own history in the US.  It starts in 1939 when it was first made available on these shores.  But it took until 1970s before US authorities, in the Food and Drug Administration, to deem this drug as having a high probability of being abused and potentially causing addiction.  This government agency did this by classifying it as a Schedule II drug.  As the short history – provided in previous postings – indicates, the drug company, Purdue Pharma, began an active campaign to popularize a form of the drug in 1996.  To get around the addictive quality of the drug, this company introduced OxyContin. 

This “controlled release” formulation of the drug was meant to make the resulting product less apt to be addictive and the FDA approved it.  Unfortunately, it did not take a long time before consumers learned how to derive a purer oxycodone drug by simply crushing the controlled release tablets.  They then could consume the derived drug by various ways:  swallowing, inhaling, or injecting it.  Any of these modes renders a very powerful opioid.[2]

The derived drug, when consumed, results in an upgraded “high” that is described as being “morphine-like.”  Purdue’s eventual testing in 1995 demonstrated how users, by crushing their product, could extract a 68% oxycodone.[3]  All these developments cost Purdue dearly.  Eventually, in 2007, the company paid a $600 million fine for making false claims about their product specifically regarding its risks.[4]  Then, in 2010, the company issued a newer version.

In that year, Purdue introduced a reformulated OxyContin.  By using a polymer, they made their pills very difficult to crush or dissolve.  In turn, this made the product significantly less apt of being abused.  Predictably, documented use of the drug declined slightly.[5]

Despite this development, in 2012, Canada’s government decided to strip OxyContin from its approved drug list.  In 2017, the FDA requested the producers of oxymorphone, an injectable form of the opioid, to remove it from the domestic market.  The agency determined that the risk of the drug is greater than its benefits.  This marked a turning point for the FDA since it was the first time it issued such a request due to fears of abuse.

The next posting will look at fentanyl.

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[1] “Opioid Crisis Fast Facts,” CNN Library, June 16, 2018, accessed June 25, 2018, https://www.cnn.com/2017/09/18/health/opioid-crisis-fast-facts/index.html .

[2] Art Van Zee, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health, vol. 99, no. 2, (February 2009), 221-2273.

[3] Ibid.

[4] Barry Meier, “In Guilty Plea, OxyContin Maker to Pay $600 Million,” The New York Times, May 10, 2007, accessed June 29, 2018, https://www.nytimes.com/2007/05/10/business/11drug-web.html?mtrref=www.google.com&gwh=5EB54309CD06FBA620248E850CC5CC0B&gwt=pay .

[5] Catherine S Hwang; Hsien-Yen Chang; Caleb G Alexander, "Impact of Abuse-Deterrent OxyContin on Prescription Opioid Utilization," Pharmacoepidemiology and Drug Safety, 24, no. 2, 2015, 197–204.

AN OLD ENEMY

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a particular drug as a part of this epidemic.]

The class of drugs considered to be opioids include various drugs.  They include prescription pain relievers, heroin, and synthetic opioids.  Of special concern, fentanyl has caused heightened effect on the health of tens of thousands of Americans.  This effect can be measured in terms of deaths and economic costs.  Generally, the economic cost of misused prescription opioids is estimated to be $78.5 billion a year.  That includes healthcare, lower productivity, treatment, and criminal activity.[1]

          The last posting shared a set of statistics that gives one a sense of how extensive the problem of opioids is in the nation.  Here is another that reflects how centered the problem is in certain areas of the nation:  in 2016, West Virginia, the most affected state, had an overdose death rate of 52 per 100,000 population.  West Virginia was followed by New Hampshire and Ohio with each reporting 39 deaths per 100,000.[2]

          This posting begins the next phase of developing a unit of study suitable for an American government course.  That phase, after providing a short history over the last several postings, provides a set of factoids that can function to develop individual lessons.  These factoids will be organized around the various drugs that make up this crisis.  This posting will highlight heroin.

          Heroin is chosen as the first drug to be looked at because in the minds of most Americans, heroin has the longest history.  As the short history in the previous postings indicates, awareness by many Americans stretches back to the 1950s when it was known that there were groups of Americans addicted to this drug.  Those groups were inhabiting large urban centers.  As such, the problem for most Americans was troubling, but not imminent.

          While heroin has this longer history, in terms of understanding the opioids problem, it is more a result than a cause of the problem.  Two facts reflect this relation to opioids:  of those who misuse prescribed opioids, 4 to 6 percent “graduate” to heroin and 80 percent of those, who use heroin, previously misused prescription opioids.[3]  This latter development is because heroin is cheaper then prescribed opioids and can be readily obtained through black market outlets – without a prescription.[4]

          Other facts regarding heroin are: 

·        men are significantly more likely to use heroin;[5]

·        between 2012 and 2015, deaths due to heroin-use were more numerous than deaths due to other opioids even though among women, deaths were higher due to opioid medications;[6]

·        while the problem of cocaine deaths is a greater problem among black population, all types of opioids (including heroin) are responsible for more deaths among all races;[7]

·        an overlooked fact, due to the concern over opioids, there has been a shift of attention from other drug addiction problems to the opioid problem.  For example, attention to cocaine-use has suffered from this shift – along with a lack of effective medication to treat cocaine addiction.[8]

·        The last decade or so has seen significant increases in heroin use.  Those numbers include an increase from an estimated 374,000 Americans using heroin in the years 2002-2005 to 607,000 in the years 2009-2011.[9]  By 2014, as a reflection of a leveling-off progression, the number was estimated to still be over half a million.[10]

The next posting will highlight Oxycodone.

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[1] “Opioid Overdose Crisis,” National Institute on Drug Abuse, March 2018, accessed June 25, 2018, https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis .

[2] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[3] Deborah Dowell, Rita K. Noonan, and Debra Houry, “Underlying Factors in Drug Overdose Deaths,” JAMA, vol. 318, no. 23, 2295-2296. 

[4] Andrew Kolodny, David T. Courtwright, Catherine S. Hwang, Peter Kreiner, John L. Eadie, Thomas W. Clark, and G. Caleb Alexander, "The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction," Annual Review of Public Health, vol. 36, 2015, 559–574.  Accessed June 25, 2018, see https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957 .

[5] Austin Frakt, “Overshadowed by the Opioid Crisis:  A Comeback by Cocaine,” The New York Times, March 5, 2018, accessed June 25, 2018, https://www.nytimes.com/2018/03/05/upshot/overshadowed-by-the-opioid-crisis-a-comeback-by-cocaine.html .

[6] Ibid.

[7] Ibid.

[8] Ibid.

[9] Leigh Anderson, “Heroin,” Drugs.com, May 18,2014, accessed June 25, 2018, https://www.drugs.com/illicit/heroin.html .

[10] "What Science Tells Us about Opioid Abuse and Addiction," Abuse, National Institute on Drug, January 27, 2016, Drugabuse.gov. This site no longer posted.  See “Opioid Epidemic,” Wikipedia, https://en.wikipedia.org/wiki/Opioid_epidemic#cite_note-38 , footnote #43.

OPIOID CRISIS GRADUATES

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reviewing the history of this epidemic.]

As the twentieth century reached its latter years, there was an increasing demand for what is now called opioids.  In the 1970s two drugs particularly, and their names, started to become common and known by many if not most Americans.  Despite initial apprehension over prescribing Vicodin and Percocet, doctors began to regularly prescribe these drugs in the 1980s.  This despite the fact that there were warnings against readily prescribing these addictive drugs.[1] 

Unfortunately, in January 1980, a short letter appearing in the New England Journal of Medicine had a bit of influence and helped change the thinking regarding these opioids.  Apparently, the letter issued by a group of Canadian researchers indicated that these drugs were not as dangerous as initially thought.  Their findings determined that only a handful of people who took one of several opioids became addicted.[2]

Years later, a follow-up comment by this journal further explained that the Canadians were only reporting on research regarding hospitalized patients and not people out in the general public after hospital visits – an observation that seems obvious upon reading the letter.  An author of the initial letter claims that his intent was not to give a green light to prescribing these drugs.[3]

          As the 1980s progressed another drug took center stage.  Crystalized cocaine, a drug that became popular during the 1970s, has a history stretching back 3500 years in South America.  There the coca plant, from which cocaine is derived, has been grown over all those years and has been used for a variety of purposes such as fatigue, depression, and sexual dysfunction.

Eventually, a German chemist, Friedrich Gaedcke isolated and purified the drug from the plant back in 1855.  Further “improvements” found a way to better extract the drug and this was accomplished by a German grad student, Albert Niemann, who first used the name, cocaine, for this product.  His work was done in 1859.[4]

This cocaine chapter in the drug story is important because of the crack epidemic in the 1980s led to government policies that were in place to meet the opioid epidemic.  Crack consumption resulted in an almost 2 per 100,000 population death rate and, under the leadership of Vice President George H. W. Bush, led to CIA and US military interdiction policies.  This initiative was given the name, War on Drugs.[5]

Under that general governmental posture, the opioid crisis grew some years later and became central in the nation’s consciousness as it resulted in vast devastation to numerous American communities.  This development began to take hold in the late 1990s.  And central to that growth was a well-thought out marketing strategy (1996-2001) for the opioid, OxyContin.  That strategy was aimed at alleviating concerns over the addictive qualities of that drug.[6]

A private pharmaceutical company, Purdue Pharma, organized more than forty promotional meetings at three locations in both the southeast and southwest US.  They coined the term, “Partners Against Pain.”  This was a marketing strategy that offered bonus system to incentivize sales of OxyContin.  Part of the strategy was to downgrade beliefs in the addictive danger of the drug.  They claimed that addiction affected less than 1 percent of users.  Along with incentives, this claim encouraged doctors to liberalize prescribing the drug.[7]

Nationally, the uptake in prescribing and subsequent consumption led to the death of 10.3 per 100,000 population and, in New Hampshire death rate of 30 per 100,000 and West Virginia, a rate of 40 per 100,000.[8]  In a 2016 national survey, conducted by Substance Abuse and Mental Health Services Administration, it was reported that more than 11 million people in the US misused prescribed opioids.  In addition, one million used heroin and 2.1 million fell into addiction of either prescribed opioids or heroin.[9]

One final statistic to end this short history is the following:  from the year, 2010 to the present, overdoses of illicit opiates have tripled.  There are signs, as the dangers of this type of drugs have become more readily known, that upsurge has leveled off.[10]  This writer is beginning to see public service announcements informing viewers of the dangers involved.  This development of the unit of study will continue in the next posting with reports on the usage of various opioids.

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[1] Clare Waismann, “The Devastating Effect of Opioids on Our Society,” The Hill, August 26, 2016, accessed June 18, 2018, http://thehill.com/blogs/pundits-blog/healthcare/293473-the-devastating-effect-of-opioids-on-our-society .

[2] “Opioid Crisis:  The Letter That Started It All,” BBC, June 3, 2017, accessed June 21, 2018, https://www.bbc.com/news/world-us-canada-40136881 AND Jane Porter and Hershel Jick, M.D., “Addiction Rare in Patients Treated with Narcotics,” The New England Journal of Medicine, January 10, 1980, accessed June 21, 2018, https://www.nejm.org/doi/full/10.1056/NEJM198001103020221 .

[3] Pamela T. M. Leung, Erin M. MacDonald, Matthew B. Stanbrook, Irfan A. Dhalla, and David N. Juurlink, “A 1980 Letter on the Risk of Opioid Addiction,” New England Journal of Medicine, vol. 376, no. 22, 2194-2195, accessed June 21, 2018, https://www.nejm.org/doi/full/10.1056/NEJMc1700150 AND “Opioid Crisis:  The Letter That Started It All,” BBC.

[4] Erik MacLaren, “Cocaine History and Statistics,” DrugAbuse.com, no date (some of the statistics reported through the year 2014), accessed June 21, 2018, https://drugabuse.com/library/cocaine-history-and-statistics/ .

[5] Peter Dale Scott and Jonathan, Cocaine Politics: Drugs, Armies, and the CIA in Central America (Berkeley, CA: University of California Press, 1991.).

[6] Art Van Zee, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health, vol. 99, no. 2, (Februray 2009), 221-2273.

[7] Ibid.

[8] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[9] Neil Doherty, Scott Gottlieb, Elinore McCane-Katz, Anne Schuchat, and Nora Volkow, “Federal Efforts to Combat the Opioid Crisis:  A Status Update on CARA and Other Initiatives,” National Institute on Drug Abuse, October 25, 2017, accessed June 21, 2018, https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/federal-efforts-to-combat-opioid-crisis-status-update-cara-other-initiatives .

[10] Deborah Dowell, Rita K. Noonan, Debra Houry, “Underlying Factors in Drug Overdose Deaths,” JAMA, vol. 318, no. 23 (December 19, 2017), 2295-2296.

A DRUG PROBLEM INITIATED

This is the second posting reporting the development of a civics unit of study regarding the opioids epidemic.  This development is in real time and this posting will begin looking at the history of the epidemic.  In reviewing that history, it is useful to make a distinction; a distinction that is no longer observed.  Historically, people used the term opiates to indicate all drugs derived from opium.  Later, the term, opioids, was used to distinguish between opiates from synthetic opiates.  Today, the term, opioids, is generally used to include both categories.

          This posting makes this distinction because this history of “opioids” stretches back to the nineteenth century when opiates were introduced to the US.  During the Civil War, morphine, an opiate, was an effective pain reliever.  Afterwards, the famous company, Bayar (as in Bayar aspirin) sold heroin (1898 to 1910) as a cough-suppressant; claiming it was non-addictive.

Apparently, experience with it proved otherwise and in due time concern among doctors were expressed by their increased reluctance to prescribe opiates. Shortly after, the US Congress enacted the Harrison Narcotics Act in 1914 which imposed a tax on opiates and, still later, the Anti-Heroin Act of 1924.  In this latter legislation, Congress made the importation or manufacturing of heroin illegal.[1]

In terms of general awareness among Americans, it was, at that time, quite limited.  One can detect during the 1950s a belief that an addiction problem existed among jazz musicians but not a problem affecting typical Americans.  Instead, the mere presence of heroin in the country was considered a frightening condition but limited to small groups within the population.[2]  As a young person, this writer can remember this general aversion to illegal drugs.

Then, during the years of Vietnam protest, there seems to have been a shift in public opinion.  In the 1960s and 1970s, one could readily detect the popularization of drugs among certain segments of the population – such as, on college campuses.  Chief among the favored drugs was marijuana and hallucinatory drugs, aka psychedelics.  The consumption of these drugs became common and, in popular media, often referred to and depicted.  There was even a much-highlighted event in which drug taking was featured; i.e., the Woodstock music festival.[3]

The war in Vietnam became a contributing factor since soldiers, coming home, often came with addictions, such as on heroin.  In Vietnam, these drugs were easily acquired.  In addition, there were highly publicized events, including the overdose death of Janis Joplin, that furthered the general awareness of the problem.  How extensive was drug-use among returning soldiers?  A Congressional report stated that 10 to 15 percent of returning vets were addicted to heroin.

This drew the attention of the president; he, President Nixon, declared drug abuse as the nation’s number one enemy.[4]  And the noted statistics did not undermine the conclusion.  In 1973 the estimate was that 1.5 deaths per 100,000 population were due to overdoses.[5]  What was not known, at the time, was that this level of drug-taking was only an introduction to what was to follow.  The next posting will continue this history and how the emphasis shifted to prescribed opioids.

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[1] Sonia Moghe, “Opioid History:  From ‘Wonder Drug’ to Abuse Epidemic,” CNN, October 14, 2016, accessed June 18, 2018, https://www.cnn.com/2016/05/12/health/opioid-addiction-history/ .

[2] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[3] Ibid.

[4] “Interview:  Dr. Robert DuPont,” Frontline, 2014 (estimated), accessed June 18, 2018, https://www.pbs.org/wgbh/pages/frontline/shows/drugs/interviews/dupont.html .

[5] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction.”

A DEFINITE CRISIS

One of the suggestions this blog has offered is for civics teachers to use local civic problems to illustrate governmental action and to provide opportunities for students to engage in some sort of political engagement.  Unfortunately, one such problem is the opioids epidemic that has ravaged many communities across the US.  Starting with this posting, this blog will report, in real time, the development of a unit of study that looks at this epidemic.

          As way of background, this blog did a similar development with another issue area, foreign trade.  That issue was one that could be considered an international issue and was treated as such.  The opioids epidemic could either be treated as a national problem or a local one.  This treatment will treat it as a local concern.  As such, if the resulting unit were to be situated within a course of study, it is recommended that it be placed toward the beginning of the course.

          Picking up on the recommended approach this blog has described, there are three main elements upon which a course should be built. 

·        One, the course should highlight political problems or issues suitable for students to participate with politically relevant action. 

·        Two, the course, in a progressive way, should develop from discussion to formal debate.  As the course provides appropriate instruction, the students should be expected to participate in more sophisticated modes of discussion. 

·        Three, the course should tackle political conditions – usually one per unit – that offends federalist values. 

The regular readers of this blog know that it has dedicated significant space explaining each of these elements.

          The overall approach has been given the name, historical dialogue-to-action.  As a reminder, here is what the blog had to say about the “dialogue” aspect of this approach:

In terms of the total course, this development is to advance by students, at the beginning of the course, engaging in discussions.  This is followed by students participating in arguments or the development of arguments.  In the final phase, students compete in, to some degree, formal debates. 

This development is one that has students, during the arguing stage, choose between offered opinions, usually between two polar-opposite opinions that address a chosen topic.  The goal in this initial phase would be to have students identify and defend supportive data – factual information.

In the second phase, students argue a position that should be more specific than one in which they espouse by expressing a broader opinion.  This is of course, to a great degree, determined by the questions asked by the teacher.  The general aim should be to ask questions that get students to be more concrete and policy directed:  should the government do X or Y or, as the students become more sophisticated, Z or be able to choose from even more options.  In terms of foreign trade, an example would be:  should the US manipulate the value of its currency to help its balance of trade with other countries?

In the final phase, the one that would align with the final unit, students take on the responsibility to conceptualize the issue area into subtopics and policy considerations.  This is more complex, and a teacher should exercise judgement as to what his/her students are prepared to do as the course evolves over the term(s).  In all of this, the process is organized by what constitutes a logical argument.[1]

Since this unit is about a local problem, the unit would arise early in the course.  Therefore, dialogue would mostly zero-in on the first phase of this progression.

          With that bit of background, this development can begin.  The opioids crisis seems to many Americans as a sudden mushrooming problem that befell the nation all at once.  But there is a history to it and knowing and understanding that history seems essential to finding solutions that meet its challenges.  The detrimental use of prescription and non-prescription opioid drugs to notable numbers began in the late 1990s.  Since then, as the statistics below demonstrate, their use escalated.

          What are opioids?  They are a collection of painkillers and originally – and of late – are prescribed to relieve both short-term pain – as for example in post-surgery treatment – and chronic pain.  They include the following:  oxycodone, hydrocodone (Vicodin), and the synthesized drug, fentanyl.  In terms of killing pain, they work well and, therefore, despite their addictive qualities, they are sought after by patients in pain.

          As an addictive set of drugs, they are also popular for recreational purposes.  And overdosing has potentially fatal effects.  Here is part of the biology involved:  their sedative qualities are caused by the effect on that part of the brain – the respiratory center in medulla oblongata – that controls breathing.  If taken in high enough doses, they can function to depress respiratory processes, potentially resulting in respiratory failure and even death.[2]  That has been the fate for many who consume these drugs.

          How many?  The US Drug Enforcement Administration has described the levels of these deaths with this characterization:  “overdose deaths, particularly from prescription drugs and heroin [another related, illicit drug], have reached epidemic levels.”[3]  What adds to the tragedy of these deaths is that there is evidence of related abuses among the medical corps:  almost half of those deaths in 2016 resulted from consuming opioids attained through prescriptions.  This practice smacks of a scandal.

          Here are some initial statistics: 

Males account disproportionally for number of deaths lowering their overall life expectancy from 76.3 years to 76.1 years.[4]

In 2015 almost 53,000 died from overdoses, 38,300 people died in car accidents that year; in 2016, more than 64,000 died of overdoses, a 21% increase over the year before.  The death figure in 2010 was 16,000 and in 1999 it was 4,000.[5]

With those types of figures, one can readily understand why the term epidemic is being used to describe the problem.  It turns out that the numbers are concentrated in certain localities.  It is those communities that might find it useful for students to take a close look at what is happening and ask what should happen regarding this unfortunate state of affairs.  An appropriate look in their civics classrooms is judged as a legitimate place to do so – not because it is a “popular” issue, but because it offends federalist values.  Next posting will continue this effort.

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[1] See posting “A Progressing Process,” August 8, 2017.

[2] “Information Sheet on Opioid Overdose,” World Health Organization (UN), November 2014, accessed June 14, 2018, http://www.who.int/substance_abuse/information-sheet/en/.

[3] “2015 National Drug Threat Assessment Summary,” Drug Enforcement Administration, US Department of Justice, October 2015, accessed June 14, 2018, https://www.dea.gov/docs/2015%20NDTA%20Report.pdf.

[4] Lenny Bernstein and Christopher Ingraham, “Fueled by Drug Crisis, U.S. Life Expectancy Declines for a Second Straight Year,” Washington Post, December 12, 2017, accessed June 14, 2018, https://www.washingtonpost.com/national/health-science/fueled-by-drug-crisis-us-life-expectancy-declines-for-a-second-straight-year/2017/12/20/2e3f8dea-e596-11e7-ab50-621fe0588340_story.html?utm_term=.975df0e5e2cc .

[5] Josh Katz, “Drug Deaths in America Are Rising Faster Than Ever,” The New York Times, June 5, 2017, accessed June 15, 2018, https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html AND “Provisional Counts of Drug Deaths, As of 8/6/2017,” United States:  Centers for disease Control and Prevention Source – lists of US totals for 2015 and 2016 by states, accessed June 15, 2018, https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf AND German Lopez, “In 2016, Drug Overdoses Likely Killed More Americans Than the Entire Wars in Vietnam and Iraq,” Vox Media, accessed June 15, 2018, https://www.vox.com/policy-and-politics/2017/7/7/15925488/opioid-epidemic-deaths-2016 AND Dan Nolan and Chris Amico, Frontline, February 23, 2016, accessed June 15, 2018, https://www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/ AND “America’s Addiction to Opioids:  Heroin and Prescription Drug Abuse,” National Institute on Drug Abuse (NIDA), May 14, 2014..