Mitigating the opioid addiction outbreak with communal design.

There are a plethora of reasons why the opioid addiction outbreak has caused so many deaths in the United States. First and foremost, as reported by the New York Times, was the greed of the pharmaceutical companies who aggressively marketed their drugs as being safe and non habit forming, while at the same time burying evidence of their addictive qualities. Secondly the well-organized illicit drug distributors who saw the opioid epidemic as an opportunity to create a new market of both prescription and non-prescription opioids. Lastly the lack of viable public health records that could help identify and stop the rampant over prescription by disconnected or nefarious physicians.

By the early 2000s the narrative from Purdue Pharma and its allies had changed from one of denial, to blame. Specifically blaming those that had become addicted to their products, claiming that they were criminal outliers and that normal individuals who took the recommended doses had no chance of becoming addicted. However, according to the New York Times, about five years later a Department of Justice (DOJ) investigation revealed that Purdue had known about the abuse of OxyCotin within a year of the products release, in 1996. After two years of investigation the DOJ agents recommended that the top three executives of Purdue Pharma be put in federal prison for their involvement in the birth of the opioid addiction outbreak. However, after a meeting with Purdue’s lawyers, former DOJ prosecutors, and a group of pharmaceutical lobbyists, the DOJ ended up settling out of court. Purdue ended up paying $636 million in fines and executives were plead guilty to misdemeanor charges for “misbranding” and had to perform community service. Many claim that if the DOJ would have pressed charges in 2007 against the Purdue executives, it would have sent a message to other manufacturers that there were consequences for careless drug manufacturing. However, the slap on the wrist that Purdue received gave the green light to the industry that they were free to continue business as usual. So long as they were willing to pay the $636 million bribe required by the DOJ. Thus, not only did Pharma executives realize there were minimal consequences to reckless production and marketing, but the public had been thoroughly convinced that the real criminals were the opioid addicts and they should be treated thusly.

This criminal treatment of opioid abusers, along with the cheaper price and higher availability of illegal opioids, created a pathway directly from prescription opioids to the black market. According to the CDC (2019) sales of heroin in the United States have increased exponentially since the late nineties, perfectly mirroring the rise in prevalence of prescription opioids. It was not until 2012 that these two substances decoupled, as the number of opioid prescriptions began dropping due to public awareness about the issue. However, the amount of heroin related overdose deaths continued to rise. J.K. Phillips discusses in his paper an even more addictive and lethal form of synthetic opioids that were introduced in 2015. Two of these synthetic opioids are, Fentanyl and Carfentanil, due to their potency they are 50 and 1000 times more likely to cause respiratory depression and death. The amount of people who have been killed by opioid related overdoses, has affected almost every family in the United States. It is not an isolated issue, however there are some promising developments being made that will hopefully start to finally slow down this epidemic.

One of the most promising developments in over prescription prevention is the introduction of prescription drug monitoring programs (PDMP). These systems are designed to track prescription drugs and alert physicians if their patient is going over their allotted number of opioids, or if they are getting prescriptions from multiple physicians. Unfortunately, there are many problems with the effectiveness of these systems. The first issue is that the systems are not easy to use and create more work for already overworked physicians. However, this software does not have to be a burden for physicians, if for instance pharmacies can embrace the ubiquitous computing ideas of Mark Weiser and embed every prescription bottle with either NFCor RFID technologies so that any time a prescription is filled the PDMP is automatically updated. Thus, physicians will be able to see how much of what drug each patient is being prescribed directly in their prescription writing portal. However, none of this will function properly across multiple providers, if unique medical identifiers (UMI) are not introduced.

The topic of UMIs has been hotly debated for decades now, however in July of this year the House of Representatives lifted a twenty year ban on funding the creation of a UMI system. This action was in response to the ongoing opioid crisis and is a promising sign that lawmakers are making the opioid epidemic a priority. If implemented correctly the identification system will allow all medical professionals to see an individual’s entire patient history. Ideally this would hold physicians accountable while at the same time preventing patients from obtaining opioids from multiple vendors at the same time. Furthermore it would allow physicians to be able to understand a patient’s medical journey as a whole and potentially reveal to them how they can help treat their patients pain more effectively, rather than prescribing pain medications. However as with all technological actants there are potential risks. With data leaks in the news almost every day it is hard to trust anyone with your personal data. This is a very real risk, however I believe that if designed and implemented properly the UMI system could keep patients records confidential, while also helping policy makers understand what areas need the most help. With this information hopefully we will be able to strategically target areas of the highest need and deploy addiction relief resources with maximum effectiveness.

While the Universal Medical Identification System shows a lot of promise for helping to track the movement of prescription opioids, it will not be as helpful for tracking illegal opioids. As long as nonprescription drugs are treated as a criminal problem instead of a public health issue, we will need another system to track the other half of the opioid crisis. Therefore, there also needs to be what I call a public outbreak database (POD) system, which was inspired by the California’s Opioid Overdose Surveillance Dashboard. However, instead of just focusing on deaths it will be an umbrella system that will incorporate data from all departments that have contact with public crises. This system will be implemented in the background of the existing reporting software used by local government employees. It would allow marking any interaction that government employees, such as police officers and social workers, have with community members as an opioid related incident. The POD data will be automatically compiled regularly and combined with the UMI data to show real time concentrations of legal and nonlegal opioids. This would give a much more detailed picture of the opioid crisis and which channels are interacting with it the most. Once the most vulnerable communities have been identified then policy makers can begin to distribute funds to pay for effective treatments, such as Naloxone for overdoses and medically monitored drug treatments. Yet even the most robust distribution of services will remain underutilized if those affected do not change the narrative surrounding opioid addiction.

Stigma has long been an issue that has surrounded any sort of addiction and the continued criminalization of illegal drug use has entrenched these stereotypes to a harmful degree. Not only are addicts afraid of being arrested for seeking out help, but they are also afraid of admitting to their family or friends that they need help. This is where we need to change the questions we are asking as a society from, how can we stop illegal drugs from coming into the country to how can we help those currently struggling with addiction in our communities. Furthermore as long as those suffering from addiction as portrayed as criminals policy makers will struggle to find support for their evidence based solutions. Those who picture opioid addicts as dangerous criminals logically do not want a safe injection site installed in their neighborhood, because they do not want dangerous individuals loitering where their children play. However, if we can reframe the image of those affected by drug addiction to one of a medical issue. Then families and communities may feel more comfortable with helping to deploy medical resources to help the addicts. Furthermore, if families begin to see addiction as a medical issue then they will be less likely to excommunicate those suffering with addiction and addicts may feel more comfortable discussing their issues before they become lethal.

Luckily, we live in a much more connected world today than we did in the early 2000’s, when the campaign against addiction victims first came out. Furthermore, we have seen many public opinion changing campaigns ran via social media within the last few years, so we know how effective such campaigns can be. Thus, we should reframe the narrative, as an institutional problem not an individual one. Furthermore, as a institutional problem we must demand that our legislator make infrastructure changes to prevent this from happening again. This campaign must use a multi modal approach, including social media, traditional media and in person conversations through professionals such as family doctors. 

While working on the campaign we need to rethink how we refer to the “opioid crisis”, because as it stands the crisis wording induces hopelessness any time someone sees a new story addressing it. I suggest instead that we use the term “opioid addiction outbreak” because the term outbreak is full of medical related connotations and adding addiction to the name diffuses the responsibility of the addiction to the community and not the individual. Furthermore, we need to present the outbreak in digestible chunks so that individuals are not overwhelmed with hopelessness, but rather can easily understand where they fit into the solution. If we can move away from the feeling of loss and hopelessness to one of hope and community, then we can begin picking up the pieces, together.

There have been countless moments of suffering caused by the greed of the pharmaceutical companies that fueled the opioid addiction outbreak, which was made worse by the criminalization of addiction, creating a funnel from prescription opioids to their illegal counterparts. There have been a few technological solutions proposed and implemented. However, as I discussed earlier the PDMP program will not be effective unless we also implement UMI’s as well as the POD program. Lastly, we need to reframe the outbreak as a community issue and not an individual failure. If we can make these changes, I believe we can begin putting broken communities back together and prevent an outbreak like this from ever happening again.