Peter Brindley and Matt Morgan: On the frontlines of the opiate crisis—no easy answers

Like the 1930’s comedy brothers Groucho, Chicho and Harpo, the political theorist Karl Marx was a funny old chap. The man who penned Das Kapital and the Communist Manifesto actually longed to be a drama critic. [1] Regardless, of how much you like or loathe his ideals, 200 years after his birth, you likely know his most famous quote: “Religion is the opium of the masses”. It’s an insightful head-scratcher and likely refers to any overly simplistic belief system, not exclusively religion. Regardless, after a sorrow-filled clinical week, we don’t need to be so figurative: It seems to us that opium is the opium of the masses.

In 2016 in Canada alone, there were almost 3000 opioid related deaths. Year on year these numbers are increasing at an alarming rate; so clearly we need to keep sounding the loudest alarm. For once, the word “epidemic” applies, but unless you work in a hospital you might not be aware of the extent. [2,3] Our emergency departments are grim places, and social workers are at their wits end. In Canada, it is common to have hallways containing intubated patients, tearful parents, and ashen paramedics as a result of opioid overuse.

In Canada, the anti-drug campaigns, well intentioned as they are, tend towards the self-righteous and simplistic. The narrative seems to be of a mustachioed villain called Fentanyl and a squared-jawed sheriff named Naloxone. But opiate addiction is so much more than just a battle between good and evil, agonist and antagonist. Real life is really hard and lots of people feel they have nothing to lose. A comatose patient awakening following naloxone is a remarkable thing to behold. Despite this Lazarus power, let’s face some sobering truths.

Naloxone cannot work once the heart has arrested. This means that the more potent the synthetic opiate the more likely we will be too late. In other words, medical practitioners are losing this battle to chemists, and more dangerous analogues are appearing all the time. We also need a more mature discussion about Naloxone. It cannot actually reduce population wide overdose rates. The sad inescapable logic is that it will almost certainly be associated with increased rates of opioid use because patients can overdose again. [4] Naloxone is a band-aid, and no amount of polemicizing changes that. Paramedics are even being called to the same addict several times per day. In North America, we are seeing “Narcan parties” (Narcan is the brand name for naloxone) where people congregate at malls because they assume the antidote is stocked. There are stories of people bringing Naloxone to a party in the same way we used to bring wine in a box.

Worst still, opiate publicity may not be scaring people away, but rather sucking them in. We hear stories of people seeking out dealers who sold to those that died. Perhaps this is because they assume that product must be the “real thing”, because they actually wish to die, or because they simply no longer care. In other words, this is as complex a problem as you will find anywhere in medicine. Moreover, opiates are a symptom as much as a disease. Johann Hari presents compelling arguments in his book, Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions, that society needs to accept its role as a “drug mule”, smuggling opioids to dull the pain left by lost connections between families, friends and communities. In short, to varying degrees many of us are somewhat complicit, just as none of us is entirely immune.

Despite, the Who arguing otherwise, the kids are not alright, and nor are the adults. Let’s go upstairs from the emergency room where patients are asking for enough codeine to fell an elephant. Elsewhere, successful business men are negotiating alcoholic delirium tremens. Millions are taking antidepressants. Moreover, on our campuses, more and more students are just saying “yes” to stimulants, and those that refuse to eat meat on ethical grounds care far less where Friday night’s cocaine came from. The search for endorphins and dopamine lies at the route of most human endeavors, and likely even explains ubiquitous mobile phone addiction. Regardless, in an impatient world, drugs are increasingly seen as a modern life hack.

When one of these authors (@docpgb) worked in Africa, he was forbidden from using the word AIDS. The argument was that shame would drive people away. We are no different now that we talk of “recreational drug use” rather than “drug abuse.” We will kill with euphemism if we suggest that there is a safe amount of street fentanyl, or that opiates are merely a lifestyle choice. Elsewhere, in suburbia, everything other than unmitigated joy is a medical condition for which we have a pill or purchase. There is always somebody willing to supply and somebody eager to buy. Compassion is in short supply, and straight talk even more so.

In more innocent times, doctors were taught to fear testosterone, alcohol, gunpowder, and gasoline. People haven’t changed, but clearly the poisons have. Clearly, we cannot use legal classifications and judicial sentences to solve the problem, and life shows no signs of slowing down. Nothing that we can emblazon on the side of a train, or shout through a megaphone, or like on Twitter will change the ubiquity of human despair, nor the eagerness to make a quick buck. If we could accept that awkward truth then it would be truly revolutionary. Instead, and like Karl Marx, we all prefer to be critics.

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, R&D lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @dr_mattmorgan

Competing interests: None declared.

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