Opioids, deaths, and capitalism: It's the capitalism, people!

The opioid epidemic is real. Far more opioids (the term that includes opiates, naturally-derived from opium, and synthetic drugs) are consumed than could conceivably be used for medical reasons, whether for short-term use post-surgery or injury, or chronic use for terminal diseases like cancer. The explanation, at one level, is the excessive use of opioids for pain relief for chronic conditions (like back pain, for which other drugs are often more effective) or excessive duration for what should be short-term (acute) reasons, and the fact that they are very addictive. This last has led to the creation of new addicts, who have been placed on prescription opioids for pain, and means that they can be used to substitute for opiates (such as heroin) for those who became addicted to street drugs. This is especially true with the increased availability of extremely potent synthetic opioids, such as fentanyl (50-80 times more potent than morphine), but can go both ways; when those who have become addicted to prescription opioids find the supply drying up, they often move to heroin.

But, like most things, it is complicated. The biggest complication is that many of those who have become “hooked” on opioids are suffering in pain, and opioid withdrawal is, to put it mildly, not fun. The pain relief is greater than that of other pain relievers, for many (but not all) problems, but opioids increase tolerance, so the doses people need to take to relieve their pain, or get their high, continually increases. The “consensus” pendulum has swung, from the message that people are not getting sufficient pain relief (“pain is the fifth vital sign”) to “doctors are creating addicts by overprescribing opioids”. Patients – people -- are caught in the middle.

Another complication is, as is usual in any big issue in the US, race. Opiate addiction and problems were a focus more of criminalization than treatment when it was perceived as mainly a problem for minority populations. The increasing revelation of white, albeit often poorer, less educated, and more rural, white people suffering from the prevalence of opioid abuse, has changed the discussion. Not that this is unimportant – the message that for the first time in a century a portion of the population – middle aged white people – have an increasing death rate (discussed in Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015, and based on the work of Case and Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”) is shocking. So is the finding that poor white women born in 1950 will live shorter lives than their mothers born in 1920 (“Life expectancy, socialism, and the determinants of health”, February 14, 2016). None of this to deny or ignore the fact that death rates for minorities, although dropping are still higher than those of whites.

The New York Times has had a series of exposé articles on the opioid crisis, and a recent installment completely pulls back the curtain on the marketing and sales practices of opioid manufacturers. “3,271 Pill Bottles, a Town of 2,831: Court Filings Say Corporations Fed Opioid Epidemic” reveals that many manufacturers, not simply Purdue, the maker of Oxy-Contin®, and many pharmacies including all the big chains, have been complicit in the spread of this epidemic. Its content is damning, and the evil acts of these companies are made public, and the information needed to ascertain the reason for the problem is clear.

But the Times does not explicitly call it out. That is because the problem is capitalism, specifically “unfettered” capitalism, essentially unregulated capitalism that not only permits, but encourages, anything that will make more money, regardless of the cost, including (and perhaps especially) the human cost. These corporations are responding to the pressure of Wall St. and their stockholders not only to make more money, but to “exceed expectations”. The value of a stock is not based on whether the company is actually earning a profit, but whether it is earning enough of a profit to please the casino players. This is augmented by the incentives for often huge bonuses for the top management based upon – how much profit the company makes. There are no bonuses for actually helping more people, or even not killing them, or not destroying the world. Sorry, you who die from opioids or suicide, you are collateral damage. Oh, yes, you also, future generations.

To be clear, this is not a result of Republican or Trumpian policies, although they have been both more open about it and have further pushed the envelope with their gargantuan tax cuts for corporations and the 0.1%. It has been the policy of every government at least since Reagan in the 1980s, Clinton and Obama certainly included. Of course, every US government has been pro-capitalist, but for much of the 20^th century, starting with (Republican) Teddy Roosevelt, there were both implicit and explicit limits set. Even conservative economic guru Milton (“the only goal of a business is to maximize shareholder profit”) Friedman believed that monopolies were ultimately not a problem because technology and the market would take them down. He was wrong; there are no limits to what they will do for more money.

So we have Americans dying by the tens of thousands from opiate and opioid overdose, and from the “suicides of despair”. We have children being separated from their parents and migrants being housed in prisons because it makes money for the private prison industry, a major donor to politicians. (Kudos to Illinois for being the first state to ban private prisons.) We have the environment being irreparably destroyed for the profit of some companies, with government complicity. We have wars being fought across the globe, killing hundreds of thousands, and each being the potential spark that could destroy the world more quickly through nuclear war. We continue to increase the defense budget although we already spend several-fold more than all our potential adversaries put together, because it is the way that the federal government subsidizes US industries.

Why do we do these things? Our oligarchs (a term the media seems to reserve only for foreigners, especially Russians, even though the US has so many more of them) demand it, and pay for it, essentially through kickbacks. They care not for the future, even for their grandchildren, or for whether there is a world.

They must be stopped. Our health, and our lives, depend upon it.

Baselga, graft and corruption in medical research: why should we tolerate it?

On September 8, 2018, the NY Times reported that José Baselga, MD, Chief Medical Officer at the prestigious Memorial Sloan-Kettering Cancer Center in New York, and a world-renowned cancer researcher, had received at least hundreds of thousands of dollars in payments from drug companies and manufacturers of radiation equipment bought by his hospital. The number of companies from which Dr. Baselga was receiving payments turned out to be in the dozens. The emphasis in this article was not so much that he had received the money, for him personally, but that he had not reported this conflict of interest (COI) to the many journals that had published articles he had written. These articles were often studies of drugs produced by the companies that had paid him money.

 ‘Dr. Baselga did not dispute his relationships with at least a dozen companies. In an interview, he said the disclosure lapses were unintentional. He stressed that much of his industry work was publicly known although he declined to provide payment figures from his involvement with some biotech startups. “I acknowledge that there have been inconsistencies, but that’s what it is,” he said. “It’s not that I do not appreciate the importance.”’

He in fact DID let it affect his science, as the article reports:

‘At a conference this year and before analysts in 2017, he put a positive spin on the results of two Roche-sponsored clinical trials that many others considered disappointments, without disclosing his relationship to the company. Since 2014, he has received more than $3 million from Roche in consulting fees and for his stake in a company it acquired.’

This is important stuff. He took bribes from drug companies and spun the data to make their drugs look good. This is corruption. It is important to separate this from conflict of interest. COI, as I discussed on August 20, 2010 (“The AAFP, Coca Cola, and Ethics: Serving the public interest?”), exists when you have – surprise – conflicting interests! As when you receive money from your employer, and also money from some other company, thus creating a conflict. As medical ethicist Howard Brody, MD, pointed out in his article on the AAFP:

‘imagine that a judge who is sitting on a case involving a contract dispute between two companies is discovered to own $100,000 worth of stock in one of the companies. The judge cannot divert criticism of this conflict of interest by saying, ‘But you haven’t waited until I delivered my verdict—how do you know that I won’t rule against the company in which I own stock?“

He has a conflict of interest. You don’t have to actually do anything to the detriment of one of your funders to be in COI; most journal policies require reporting it so that readers can be aware of the COI, but it does not necessarily mean that if impacts your work. In Baselga’s case, however, it obviously did.

I guess he realized it. On September 13, 2018, the Times reported Baselga’s resignationfrom Memorial Sloan-Kettering. You can just imagine the Sloan-Kettering board of directors holding their breath to see if this would just blow over, and I am sure mostly that it would not affect donations from rich people. On that same day, the Times also published several letters from readers about the topic, all of them critical of Baselga, but emphasizing different issues. Charles Fried, a law professor from Harvard, notes that Baselga received $1.5 million in income from his employer, Sloan-Kettering, and wondered “Why isn’t $1.5 million enough?” Of course, for some people, nothing is ever enough. But the important point here is that Baselga was scarcely a penniless medical researcher barely scraping by and thus in need of this graft to pay a mortgage on a modest home, or buy a second bass boat. He was just really greedy.

Other letters emphasize other aspects of this practice, noting that Baselga may be a famous and particularly corrupt example, but that he is far from the only one receiving payoffs. Daniel J. Brauner, MD, a geriatrician and ethicist from the University of Chicago, notes that revealing COI is insufficient, observing that ‘The sad fact is that the current system of medical research and care conducted by physician-scientists like Dr. Baselga is fundamentally flawed and does an extreme disservice to patients, who deserve an unbiased accounting about the true worth of potential treatments.’  Frances M. Visco, president of the National Breast Cancer Coalition, bemoans the fact that ‘Breast cancer patients are tired of “breakthrough” therapies that do not extend life for even a day but do bring millions of dollars to industry, medical institutions and the doctors who care for us,’ and demands that researchers and journals ‘Just stop circling the wagons, focusing on financial gain and fame.’

On September 16, 2018, the Times published a full-column editorial on the issue in its widely-read Sunday Review. It notes how common the practice of paying corporate money to doctors and researchers is, observing that ‘A 2015 study in The BMJfound that a “substantial number” of academic leaders hold directorships that pay as much as or more than their clinical salaries.’ In addition, it report that ‘nearly 70 percent of oncologists who speak at national meetings, nearly 70 percent of psychiatrists on the task force that ultimately decides what treatments should be recommended for what mental illnesses, and a significant number of doctors on Food and Drug Administration advisory committees have financial ties to the drug and medical device industries.’ In its analysis of the problem, the editorial leaves out one major issue: much, or most, of the basic research that is done and leads to the production of these hugely-profitable drugs is funded by the federal government through the National Institutes of Health (NIH); that is to say, you and me. The drug companies pick up the work later when they think that the drug may represent a big financial boon for them.

The Times calls for greater safeguards to protect the public, with several suggestions including: 1. Ban paid appointments to outside boards, 2. Create uniform reporting standards, 3. Establish real consequences for violations, and 4. Build a culture of transparency. These are good suggestions, and should be implemented, although how one does #4 is not entirely clear, and the likelihood of #1 happening is low. But the real issue is the degree to which we, the American people, are willing to tolerate graft and corruption. We may – or may not -- dislike it when it occurs in the private sector (certainly President Trump was a major practitioner in his pre-Presidential years). We condemn it when it involves politicians, though it is rampant in federal, state, and local government (although what is illegal graft for state legislators is legal, if sometimes embarrassing, for Congressmen), but we expect it when it comes in the form of “campaign contributions”. And we should not be surprised when it infects medical researchers and physicians, who we hope have our health interests, not their own financial interests, at heart in what they do.

Corruption and graft is corruption and graft. It happens, and shouldn’t, and won’t stop until we demand it. And it won’t stop in health care until we get the profit incentive out of it.