When it comes to taking opioids, the United States has the dubious honour of leading the world.
For every one million Americans, almost 50,000 doses of opioids are taken every day. That’s four times the rate in the UK.
There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).
But take too many and you have a problem. And America certainly has a problem.
That figure includes deaths from heroin, an illegal opioid. But almost half involved a prescription opioid – that is, a painkiller available from a pharmacy with a note from a doctor.
So why does America – more than any country in the world – have an opioid problem?
There is more than one cause. But these are some of the most important.
American doctors prescribe – a lot
Unlike most European countries, the US does not have universal healthcare paid for by taxes.
Instead, Americans must get their own insurance – usually via an employer or the government.
“Most insurance, especially for poor people, won’t pay for anything but a pill,” says Professor Judith Feinberg from the West Virginia University School of Medicine.
“Say you have a patient that’s 45 years old. They have lower back pain, you examine them, they have a muscle spasm.
“Really the best thing is physical therapy, but no one will pay for that. So doctors get very ready to pull out the prescription pad.
“Even if the insurance covers physical therapy, you probably need prior authorisation (from the insurer) – which is a lot of time and paperwork.”
The CDC says opioid prescriptions have fallen by 18% from their peak in 2010. But the total is still three times higher than in 1999.
‘I saw this drug on TV’
The US and New Zealand are the only countries that allow prescription drugs to be advertised on television.
According to the research firm Kantar, spending on advertising by pharmaceutical companies in the US reached $6.4 billion in 2016 – a rise of 64% since 2012.
None of the 10 most-advertised brands in 2016 was an opioid. But mass-marketing of drugs has an effect, says Professor Feinberg.
“As a clinician, people will come and say ‘I saw this on TV – can you give me this drug’.
“Sometimes they were so confused, they were already on the drug – they were using the brand name, where I used the generic name.”
In 2015, the American Medical Association called for a ban on adverts for prescription drugs. It didn’t happen.
Three months later, the extent of America’s opioid culture was seen at half-time of the Superbowl – the country’s most expensive advertising slot.
A 60-second ad was devoted to opioid-induced constipation. The advert – paid for by AstraZeneca – advised sufferers to visit their doctor and “ask about prescription treatment options”.
President Obama’s chief of staff was not impressed.
Gifts to doctors
In the US, it is common for drug companies to court doctors, in an effort to promote their products.
“When you’re a doctor in the US, these detailing people (salespeople) come in from the industry,” says Professor Keith Humphreys from Stanford University.
“They are invariably smooth, friendly, attractive, sharply dressed, adorable, they’re giving out gifts to everybody. They host dinners, they sponsor conferences, they sponsor junkets.
“That is going to affect prescribing.”
For the past four years, the US government has published the amounts paid by drug and device companies to doctors and teaching hospitals.
The total in 2016 was more than $8bn. More than 630,000 physicians had payment records.
For example, Purdue Pharma – which makes OxyContin, a popular opioid painkiller – made almost 80,000 transactions in 2016, worth more than $7m in total.
In 2016, a study looked at the link between doctors, the free meals they received from drug companies, and the medication they prescribed.
The study found receiving free meals was “associated with an increased rate of prescribing the promoted brand-name medication”.
Pharmaceutical companies say their reps are merely sharing information with doctors. But Professor Humphreys says there is a “corrupting” influence.
“We need a pharma industry, it’s not that it’s wrong,” he says. “But you can’t let the fox guard the hen house.
“I would create completely clear blue water between the people that manufacture drugs and all the training and operation of the healthcare system.”
Pharmaceutical companies also spend money on health care workers and organisations in other countries.
In the UK in 2016, companies gave £116m ($153m) to health workers and organisations for non-research and development in 2016.
But, although the UK figure is 7% higher than in 2015, it is less than 2% of the amount paid in the US.
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Media captionThe grandparents’ burden: ‘We don’t resent the kids – but life’s hard’
Poor training
Dr Richard Frank is professor of health economics at Harvard Business School, and served in the Health Department from 2009 to 2016, during President Obama’s administration.
He thinks medical training in the US has not been good enough.
“Physicians have received almost no training in pain management,” he says.
“Until recently they have been under some pretty important misconceptions about how addictive various products are.”
He adds: “A couple of years ago I testified before congress when I was in government. One of the representatives, before going into congress, was a thoracic surgeon.
“He noted that he had gotten almost no training in pain management – and what he had learned came entirely from the nursing staff he worked with.”
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Media captionThe heroin-ravaged city in West Virginia fighting back against drug companies
Dr Frank says medical training isn’t the only reason for America’s opioid problem. “There’s plenty of blame to go round,” he says.
But his criticism is echoed by Professor Judith Feinberg.
“Doctors didn’t learn anything about addiction at medical school,” she says.
“That is now changing, but everyone who’s a doctor already, didn’t learn anything. I learned about opioid drugs in the part of pharmacology where we learned about anaesthesia.
“Probably the whole topic of anaesthesia-like drugs was two hours. People don’t have much knowledge about opioids. There was no curriculum that includes addiction.”
Bad science?
In 1980, Dr Hershel Jick wrote a short letter to the New England Journal of Medicine.
It said that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction”.
The claim has been debunked, and the letter now carries an online warning note. But Dr Jick’s letter had a big impact.
This year, Canadian researchers said the letter had been cited 600 times – usually to claim opioids weren’t addictive.
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Media caption“We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis”
In the late 1990s the Veterans Health Administration – which runs healthcare for military veterans – pushed for pain to be recognised as the “fifth vital sign”.
This gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature.
Then in 2001, the Joint Commission – which certifies almost 21,000 US health organisations and programmes – established standards for pain assessment and treatment.
In 2016, the JC released a statement that claimed that “everyone is looking for someone to blame” for the opioid problem. It insisted that its 2001 standards did not “require the use of drugs to manage a patient’s pain”.
But Professor Feinberg says the VHA and JC’s moves meant doctors were under pressure to prescribe strong painkillers – such as opioids – when they may not have been necessary.
“By the time you reach middle age, it’s a rare person who doesn’t ache somewhere,” she says.
She adds that – in a country where patients rate their doctors, and low ratings can affect doctors’ earnings – the score can be influenced by whether patients receive opioids.
A culture of medication
Some Americans, says Professor Keith Humphreys from Stanford University, believe that life is “fixable”.
“I’m 51,” he says. “If I go to an American doctor and say ‘Hey – I ran the marathon I used to run when I was 30, now I’m all sore, fix me’, my doctor will probably try to fix me.
“If you do that in France the doctor would say ‘It’s life, have a glass of wine – what do you want from me?'”
In 2016, a study compared how Japanese and American doctors prescribed opioids. It found that Japanese doctors treated acute pain with opioids in 47% of cases – compared to 97% in the US.
“There is obviously a willingness, and a habit, of giving opioid pain relief that is not shared elsewhere,” says Professor Feinberg.
“Other countries deal with pain in much healthier ways.”
Image copyrightGrambling State UniversityImage caption The victims were shot in the courtyard of the dormitory on campus.
Two men have been shot dead on a university campus in the US state of Louisiana, police say.
They were fatally wounded in the courtyard of a dormitory at Grambling State University (GSU) following an altercation in a dorm room, according to university spokesman Will Sutton.
Police said a suspect fled the scene.
The victims, both 23, were named as Earl Andrews, a GSU student, and Monquiarious Caldwell, who did not attend the university.
Both men are from Farmerville, Louisiana, according to police.
“Earl didn’t bother nobody,” he said about his brother, adding that he had planned to move to Texas after graduation to be closer to his one-year-old son.
The Lincoln Parish Sheriff’s Department said it was assisting campus police with an investigation, and the sheriff has pledged “extra patrol on and around GSU campus for the foreseeable future”.
The maneuvering for the 2019 presidential race appears to have begun in earnest. Politicians particularly those in the ruling APC (All Progressive Congress) and the main opposition PDP (Peoples Democratic Party) have started their nocturnal meetings, working on different schemes and scams, crisscrossing the country on shuttle and not so shuttle diplomacy, and weighing the options (known and unknown) to determine where their self-interests would be best served. In a politics driven only by the ideology of grab-power-by-any-means-possible, and where the politician’s only idea of service is preying on public wealth, nothing is ever as it seems.
The line of difference between the ruling APC and the main opposition PDP is neither horizontal nor vertical; the line is rather blurred – it snakes through both parties as politicians decamp from one to the other, and vice versa, at the slightest of excuses. In the circumstance, different political groups from both parties have dissolved into camps of conflicting or coalescing interests with a view to negotiating across party lines. It is difficult to say at the moment how things would eventually play out.
There is even no indication yet that the ruling APC would necessarily offer President Muhammadu Buhari the right of first refusal for the 2019 race. The coalition that brought him to power in 2015 has since dissolved into the different power centres, all involved in cloak-and-dagger operations, their leaders undermining one another, moving and waiting while waiting and moving to turn the table against each other. Senate President Bukola Saraki has been expanding his political base on the platform of his office while revving up the engine of his influence. Former Vice President Atiku Abubakar, a serial contestant, hit the lecture and interview circuits early, making politically correct statements.
The unusual indifference of the Lion of Bourdillion to happenings in the APC and the polity should not be mistaken for withdrawn submission; behind Bola Tinubu’s silence may emerge an unpredictable and deafening roar. There is the perception that the APC would be making a strategic mistake to re-present Buhari for the 2019 race partly because of the party’s inelegant leadership and the apparent collapse of the 2015 coalition, and partly because of the president’s age and the handling of his prolonged illness, his underwhelming performance, and his rabidly pro-north agenda. Although Buhari has not said anything about his plans for 2019, he began softening the grounds for re-election the moment he took the oath of office in 2015.
In what appears a carefully marshaled strategic onslaught, Buhari, since his inauguration in 2015, has embarked on a demolition exercise of anybody or group that might create a problem for him in the 2019 election. I have lately been re-reading Robert Greene’s The 33 Strategies of War and could not but notice Buhari’s preparations for 2019 leap out of the pages. I limit myself to four of those strategies within the context of their application to achieve Buhari’s re-election objective. In he calls the Polarity Strategy, Greene explains that to fight effectively, you need to identify or create some enemies, learn to smoke out those disguising their intentions or pretending to be on your side, then declare war on them. According to Green, “As the opposite poles of a magnet create motion, your enemies – your opposites – can fill you with purpose and direction.
As people who stand in your way, who represent what you loathe, people to react against, they are a source of energy.” As military leader between 1983 and1985, Buhari could not hide his disdain for politicians, the media, and the judiciary. For politicians, his tribunals jailed some ex-governors for 100 years on bogus claims of enriching their parties. For the press, he promulgated Decree 4 in which two journalists were jailed for publishing stories, which though true but which the administration at the time found embarrassing. And for the judiciary, he ensured there was a Decree 2 that not only permitted the indiscriminate arrest and detention of citizens, but more crucially outlawed the courts from adjudicating in the case of anybody so arrested and detained.
Who did Buhari declare as enemies in 2015? Politicians. Journalists. Judges. In living up to the polarity strategy, Buhari had to first make the PDP the enemy. When the Buhari administration increased fuel price from N87 to N148, it attributed the inevitability of the increase to the massive corruption in the fuel subsidy regime of the Jonathan administration. When the foreign exchange crashed from about N200 to above N500, Buhari and his men blamed Jonathan for not saving for a rainy day. When power supply collapsed, it was as a result of 16 years of PDP misrule. For more than two years in the saddle, Buhari and his key aides kept blaming the PDP for every of its difficulties and challenges and failures and inactions, even with former top members of that party major players in the new administration.
Then the EFFC (Economic and Financial Crimes Commission) made disclosures after disclosures of billions of money recovered from PDP members without any successful prosecution. In taking on the media, members of the Newspaper Proprietors Association of Nigeria (NPAN) were accused of collecting N10 million each from the Jonathan administration and forced to make the refund. The government, however, failed to disclose that the NPAN payment was a negotiated settlement to ward off impending litigation from the disruption of newspaper operations in Abuja by security agents. And for the judiciary, some judges were accused of corruption with security agents breaking into their homes in ungodly hours. Almost all those judges have been discharged in court due to lack of evidence.
From external enemies, Buhari took on key coalition leaders in his party, the APC. First was Saraki who emerged the senate president in spite of the party, and was forced to fight a long scorched earth judicial battle at the Code of Conduct Tribunal on charges of false declaration of assets. Saraki mostly held Tinubu responsible for the party’s prolonged non-acceptance of his election and his CCT trial. This fits Greene’s prescription perfectly: “Having enemies gives you options. You can play them off against each other. Make one a friend as a way of attacking the other, on and on.” Tinubu championed Senator Ahmed Lawan who was Buhari’s candidate for senate president. Having won the election through a political sleight of hand with the party refusing to accept his victory, and Buhari pretending to be uninterested, Saraki assumed Tinubu was the problem and accused him of instigating the CCT trial.
As the trial became prolonged and Saraki dug in, creating an alternate power base in the process, Buhari made Tinubu the new enemy. John Odigie-Oyegun, the man Tinubu helped make the party chairman soon turned against his benefactor; Tinubu’s associate James Faleke who was Abubakar Audu’s running mate in Kogi governorship polls was prevented from being the inheritor of the joint ticket following Audu’s death; a coalition of Buhari’s ground troops in the Villa and the party leadership backed by Saraki stopped Tinubu’s candidate from winning the Ondo governorship ticket; and Babatunde Raji Fashola and Kayode Fayemi who could be described as Tinubu’s protégés in the cabinet have since abandoned him. Another coalition leader Atiku, completely cut off from the party administration and government, could only cry out in frustration that he had been used and dumped.
It is therefore clear that Buhari declared carefully selected wars on real and imagined enemies to undermine group opposition, as in PDP, the media and the judiciary, to his quest for re-election in 2019; the president equally tried to weaken possible individual opponents (Saraki, Tinubu and Atiku) in his party. He has also effectively used this strategy for public distraction in line with Greene’s admonition thus: “Leaders have always found it useful to have an enemy at their gates in times of trouble, distracting the public from their difficulties.”
The second is the Alliance Strategy in which Greene enjoins you “advance your cause with minimum of effort” by creating “a constantly shifting network of alliances, getting others to compensate for your deficiencies, do your dirty work, fight your wars, spend energy pulling you forward.” In three consecutive election cycles, Buhari could not win on his own steam despite his massive popularity among the ordinary people in the north. But for the 2015 election, he became the flag bearer of a complicated alliance with principal characters in the APC – Tinubu, Saraki, Atiku, Chibuike Rotimi Amaechi – rebranding him, raising funds for his campaign, doing his dirty work, making up for his weaknesses, and burning considerable energy to pull him across the victory line. Buhari’s only contributions to that election victory were no more than his touted integrity and cult followership in the north, the same qualities that had failed him thrice. On becoming president, however, Buhari entered into a fresh network of alliances involving parochial family members and provincial friends, which he has strongly deployed to implement an open pro-north agenda.
The third point, in applying Greene’s Misperception Strategies, the administration has been adept at controlling people’s perception of reality by deploying ambiguity, mixing fact and fiction, and manufacturing a reality in line with national expectation. To feed the national narrative of massive corruption in the Jonathan administration, the EFCC regularly serves the public a salad of truth and falsehood by getting carefully selected media to publish stories mostly attributed to anonymous sources, humongous amount of money found in somebody’s account or property, or refunded to government. In the circumstance it is difficult to separate fact from fiction blended seamlessly in a manufactured reality constantly promoted and celebrated by the administration’s spokesmen. Curiously, the agency has not successfully prosecuted any treasury looter, or officially made public how much stolen funds it has recovered and from whom.
Four, the Buhari administration has been good at using acts of terror to sow uncertainty and panic, in what Greene calls The Chain-Reaction Strategy. Writes Greene, “Terror is the ultimate way to paralyze a people’s will to resist … Such power is gained through sporadic acts of violence that create a constant feeling of threat, incubating a fear that spreads throughout the public sphere.” The application of this strategy has been strengthened by what Greene describes, in Deterrence Strategies, as (the leader) creating a reputation of being “a little crazy” to fight off aggressors.
As military leader in the early ‘80s, Buhari had built up a reputation for being tough, mean, ruthless and unbending. Perhaps in the military organized massacre of over 347 Shia followers of Ibrahim el-Zakyzaky who impeded the movement of the Army chief on December 12 2015, Buhari may have taken to heart Greene’s admonition: “Create this reputation and make it credible with a few impressive – impressively violent – acts.” There was Buhari’s initial tough stance against Niger Delta activists and the military occupation of some communities in that part of the country; an economically crippling bombing of oil installations in a counter action forced government to abandon that approach and opt for negotiations.
How about the Army’s Operation Python Dance in the southeast when government found the activities of Nnamdi Kanu and his IPOB (Indigenous People of Biafra) unbearable? Apart from these acts of physical violence in the application of terror, there is also the use of psychological violence as manifest in the indefinite detention of el-Zakyzaky and immediate past NSA (National Security Adviser) Sambo Dasuki despite repeated court orders that they be released.
Although there are other strategies one could apply from Greene’s 33 Strategies of War, I wouldn’t want to go beyond the four discussed so far. I do not know if the manifestation of these strategies in the actions or inactions of the Buhari administration is a product of the president’s background, training and experience, or the distillation from the strategy sessions of his trusted aides. Or is it simply coincidence at work?
Nigerian-born artist Njideka Akunyili Crosby is one of 24 people to be awarded a $625,000 (£500,000) MacArthur Genius grant, which recognises “exceptional creativity”.
Main image courtesy: Njideka Akunyili Crosby/MacArthur Foundation.
Video producer: Robert Spencer
Note: This story is auto-generated from ‘BBC News’ syndicated feed and has not been edited by Africa Prime News staff.
[unable to retrieve full-text content]Note: This story is auto-generated from ‘BBC News’ syndicated feed and has not been edited by Africa Prime News staff.
[unable to retrieve full-text content]Note: This story is auto-generated from ‘BBC News’ syndicated feed and has not been edited by Africa Prime News staff.
[unable to retrieve full-text content]Note: This story is auto-generated from ‘BBC News’ syndicated feed and has not been edited by Africa Prime News staff.
