The opioid epidemic in the United States: missed opportunities and policy failures

Citation

Das, R. (2023), "The opioid epidemic in the United States: missed opportunities and policy failures", International Journal of Law and Management, Vol. 65 No. 4, pp. 368-370. https://doi.org/10.1108/IJLMA-07-2023-323

The Opioid Epidemic in the United States: Missed Opportunities and Policy Failures is perhaps one of the most exhaustive scholarly endeavours on the policy aspects of dealing with the American opioid crisis. It is unmatched in its characterisation of the crisis, encompassing historical, political, institutional and legal viewpoints. Through their eight chapters, Kant and Rushefsky take us through the life cycle of this policy problem that has turned out to be $1tn’ worth of a public health debacle.

Public policy, as commonly defined, is a series of decisions or discrete choices made in the public interest. In the context of public health in the USA, these discrete choices are taken both at the federal and state levels, implying that often political coordination is a much bigger problem than design per se of the policy instrument or the implementation of the same. Kingdon (1984; 1995) suggests that successful policy change occurs only when the three streams, problem definition, policy choice and political situation, converge. The book is devoted to fleshing out these three streams and thereby assessing the successes and failures of the opioid policy program. Chapter 1 places some of the features of the American policy ecosystem in context to better help us navigate the subsequent discussion in the book. Together with Chapters 5 and 6, it describes the political situation around the problem. Chapters 2–4 take us through the historical chronology of the problem. They thus help to define the problem in a thorough way. Finally, Chapters 7 and 8 dwell on the policy choices per se and present the authors’ evaluation of the same.

Patel and Rushefsky point out that the opioid crisis is hardly the first of its kind in American history. In fact, the “first” such crisis (Chapter 2) started as far back as in the 1860s, extending till the 1920s. This era was defined by the drugs: opium, morphine, heroin and cocaine. The policy response was a mistaken sanctioning program against Chinese immigrants. The second crisis, between the 1960s and 2000, was dominated by heroin, crack cocaine and marijuana. Crime skyrocketed during this time and the policy response was a widespread criminalisation of addicts. The third crisis starting in 2000 and is extending till date; it is the crisis we face today. This one is radically different from the previous ones because it originated from a legitimate medical concern, a concern to treat “pain” among patients of cancer and other chronic diseases and because physicians were involved in it from the very beginning.

At a national level, a triumvirate of entities [Big Pharma, Food and Drug Administration (FDA) and Drug Enforcement Administration (DEA)] were responsible for the debacle under discussion (Chapter 6). Large pharmaceutical companies (“Big Pharma”) purposefully misled the public and physicians regarding the addictiveness of opioid-containing pain medicines; the FDA failed to issue necessary warnings on these products; and the DEA failed to contain the influx of illicit drugs into the country. Chapter 5 reminds us that while the Federal Government can design and disburse “model” laws and broad policy guidelines, it is really up to the states to decide on their specific strategic responses in public health care. This makes eminent sense in respect of the opioid epidemic because the manufacturing industry driven states in the north and north east of the country are considerably more hit than the rest. However, financial resource allocation still remains a federalist prerogative. The Affordable Care Act tried to channel resources to states by asking that Medicaid, the states’ insurance programs, be expanded. While some states complied, others did not. Expectedly, the results in terms of insurance coverage and access to addiction treatment have been disparate.

In Chapter 7, the authors look briefly at the international context of the crisis. Although this public health problem hit the USA the hardest, followed by Canada, it also touched a few other nations in different ways. Interestingly though, these nations are different kinds of stakeholders in the opioid supply chain and the nature of their ongoing or impending problems differ hugely. For instance, Mexico and Nigeria have tremendous availability of the drugs within their geographies. However, rather than rampant usage, their considerable socioeconomic issues stem from the illicit trafficking enterprise around these drugs. India, another country studied by the authors, is an example in contrast. It is neither a prolific producer nor trafficker; however, there are pockets in the country, namely, Punjab and Mizoram, which are seeing drug abuse emerging as a major social menace. It is a legitimate producer of generic drugs including pain medication, but there may be unaccounted leakages and diversion occurring.

Seen in the backdrop of the previous chapters, the USA’ response to the current opioid crisis seems to be not just different but also hope invoking (Chapter 8). One of the biggest accomplishments of the Obama Administration in this issue has been changing the re-orientation of the American drug policy from a punishment-based model to a public health model. Consequently, in its current version, the public health apparatus in the USA has dedicated considerable resources to harm reduction and overdose death prevention strategies. Time will tell if the US policy response may be successfully replicated by other nations suffering from similar issues. Beyond this book though, the opioid crisis is evolving till date, if one follows the most recent updates and the reports by US public health agencies. It has now become apparent that opioids (such as oxycontin) and prescription pain medicine have given way to synthetic opioids such as fentanyl, which are considerably more potent and dangerous. Additionally, in policy circles, there is an increasing realisation that rather than taking a supply-side approach with law enforcement such as had been the traditional government agenda, it is more prudent to adopt a demand-side focussed multi-pronged strategy (Stephenson, 2022).

The authors, Patel and Rushefsky, have produced a highly acclaimed treatise on US health policy previously, which is currently in its fifth edition (Patel and Rushefsky, 2019). The current book (Patel and Rushefsky, 2019), under review, follows in the footsteps of the previous one, in terms of both the rigor of the enterprise undertaken and the details woven into each step of the opioid chronology. The book is written in a scientific style rather than a journalistic style. This essentially means that each assertion and inference in the volume is backed by an empirical fact. This is borne out by the exhaustive bibliographies at the end of each chapter. Additionally, at the end of the book, the appendices section provides exhaustive lists for narcotics laws in the USA, documentaries, books, etc. produced on the issue, celebrity news stories and the like. I want to conclude with references to two of my favourite books that can serve as further reading for the discerning reader, on this rather important topic. American Pain: How a Young Felon and His Ring of Doctors Unleashed America’s Deadliest Drug Epidemic (Temple, 2015) is the true account of a pain management clinic (or a “pill mill” as derivatively nicknamed) in Florida between the years 2008 and 2010. Taking advantage of a loophole in prescription painkiller laws of the state, three enterprising men created one of the largest drug-dealing networks in the east coast. It all eventually collapsed when the DEA raided it and shut it down. The second book is Empire of Pain: The Secret History of the Sackler Dynasty by Keefe (2021). This one goes to great lengths to lay out the shenanigans of Big Pharma, in this case, specifically the Sackler family, which was the promoter of Purdue pharmaceuticals and one of the main players in the opioid crisis.