What caused the overdose crisis in the United States-physician prescribing or drug prohibition and policy?
That was the subject of the June 2022 Soho Forum debate, held at the Sheen Center in downtown Manhattan. The Soho Forum is a monthly debate series offered by the Reason Foundation. The series features topics and aims to enhance social and professional ties within the New York libertarian community.
Adriane Fugh-Berman, MD, defended the proposition, "America's overdose crisis is the result of doctors over-treating patients with opioids." She argued that the overdose crisis traces back to pharmaceutical companies convincing doctors that opioids were safe and effective, causing rising rates of addiction.
Jeffrey Singer, MD, a surgeon and Senior Fellow at the Cato Institute, took an opposing stance. Singer argued that the rate of overdoses and the rate at which doctors prescribe opioids are not correlated. The real culprit, he said, was drug prohibition, which led to greater black market selling of drugs that were stronger and more lethal. Singer took the position that opioids should be available over the counter to any adults to prevent overdoses from illicit drugs that could be too potent and thus lethal.
The debate was moderated by Soho Forum Director Gene Epstein. The live audience voted the winner to be Fugh-Berman, who argued that physicians did indeed cause the opioid crisis, if inadvertently, because they were manipulated by the opioid pharmaceutical industry.
At the end of the debate, Epstein revealed the results, which were interesting in that each speaker persuaded listeners to vote differently at the end of the program than they did before it began. In other words, at the end of the debate, 45.35% of the audience voted that yes, physicians did cause the overdose crisis, an 8.14-point increase. And 39.53% voted no to that question, presumably agreeing with Singer at least in his case that physicians did not cause the crisis, and that percentage of no votes was also 8.14 points higher than the initial vote.
Fugh-Berman said pharmaceutical companies were able to manipulate many physicians' beliefs about opioids and convince them that they were undertreating patients and causing them harm.
"Although physicians didn't single-handedly cause the opioid epidemic, they were ... manipulated by pharmaceutical companies to become the primary contributor to the crisis of addiction and overdose that we have today," Fugh-Berman said.
She went through the history of pharmaceutical companies increasing the use of representatives and other paid physician "influencers" to convince physicians that opioids could be prescribed safely for noncancer pain and chronic pain. Doctors who were still reluctant to prescribe opioids for noncancer pain were called "opioid-phobic," Fugh-Berman said.
After going into more detail about the shift in prescribing that occurred in the late 1990s and early 2000s, Fugh-Berman concluded by reiterating that "Opioids are the main driver of overdose deaths in the United States, and physicians are the main supplier of the initial opioids that hook people."
She said, "Many doctors, meaning no harm, inadvertently addicted patients to opioids. We would not have this crisis of opioid addiction and death today if it were not for physicians overtreating patients."
Singer then began his opposing argument by saying, "I'm not here to defend the business and marketing practices of the pharmaceutical companies."
However, he laid out his argument that "Drug prohibition makes nonmedical use of drugs more dangerous, because the black market is a dangerous place to buy drugs. There's also something economists call 'the iron law of prohibition.' As law enforcement becomes more intense, the potency of the prohibited substance increases."
Some of the reasons, Singer said, are that smaller volumes of more potent illicit drugs in concentrated form are easier to hide from law enforcement. Fentanyl began replacing heroin, he said.
When prescribing by physicians went down, patients shifted to fentanyl and other street drugs.
"Blaming the overdose rate on bad behavior, careless choices, devilish doctors, or corrupt chemical companies just evades the truth," Singer said. "The great bulk of damage done by nonmedical drug use is the result of drug prohibition, And until we end drug prohibition, the overdose rate will inexorably increase."
Singer argued that even heroin should be available for sale over the counter, to adults.
Each speaker had time to refute what the other had said, and a lengthy Q and A session followed.
The audio recording of the debate can be heard on the Reason podcast and on the web at http://Reason.com. The live event included graphs and charts that the speakers refer to, although those were not apparently available on the http://Reason.com website.
Fugh-Berman is a Professor in the Department of Pharmacology and Physiology and in the Department of Family Medicine at Georgetown University Medical Center (GUMC). She also is the director of PharmedOut, a GUMC research and education project that "promotes rational prescribing and exposes the effect of pharmaceutical marketing on prescribing practices," according to her Georgetown bio.
Fugh-Berman is the lead author on key articles on physician-industry relationships, including exposes of how ghostwritten articles in the medical literature are used to sell drugs, an analysis of drug rep tactics, and an explanation of industry publication planning. Fugh-Berman and her team developed an educational module, "Why Lunch Matters," that her bio on the Georgetown University website says is the first to document a significant change in physicians' perceptions about their own individual vulnerability to pharmaceutical marketing.
Singer is President Emeritus and founder of Valley Surgical Clinics Ltd in Arizona, and has been in private practice as a general surgeon for more than 35 years. In addition to his role with the Cato Institute, he is a visiting fellow at the Goldwater Institute in Phoenix and a member of the Board of Scientific Advisors of the American Council on Science and Health. (See Epstein G. Did Prescription Opioids Cause The Overdose Epidemic? https://reason.com/podcast/2022/06/10/did-prescription-opioids-cause-the-overdos Published June 10, 2022. Accessed June 23, 2022.)