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Commission on Opioid Crisis Calls for Urgent Changes in Marketing Pharmaceuticals, Managing Care

In the last 25 years, the United States and Canada have experienced an increasingly devastating opioid crisis that has cost more lives than World War I and II combined, with the cost to the United States alone estimated at $1 trillion. This epidemic of addiction and overdose remains unabated and may have worsened as a result of COVID-19. The deepening crisis led Stanford University School of Medicine and The Lancet to assemble a Commission on the North American Opioid Crisis.

In an article in The Lancet, the Commission presents its findings and recommendations. The group calls a number of changes to meet urgent public health needs. These include banning direct marketing to prescribers of drugs, decoupling pharmaceutical industry donations to universities and professional associations from control over medical education, and encouraging state medical boards and health accreditation bodies to refuse to accept pharmaceutical money.

“Millions of people have become addicted to opioids, which has triggered increases in other disorders, disability, family breakdown, unemployment, and child neglect,” says Jonathan P. Caulkins, professor of operations research and public policy at CMU’s Heinz College, who was a member of the Commission.

Created in fall 2019, the Commission comprised 18 members, half of whom are clinicians and scholars based at Stanford University and half of whom are based elsewhere in the United States and Canada. Members have expertise in addiction, law, neuroscience, pain medicine, public health, primary care, psychiatry, and emergency medicine. The Commission included current or former government policymakers; individuals who care for patients with addiction, pain, or both; and individuals who have experienced chronic pain or addiction.

In its report, the Commission provides a brief history of opioid use and addiction in North America, and describes the current landscape of opioid overdose mortality in terms of geographic, demographic, and social factors.

The Commission makes the following recommendations:

Reduce the influence of the pharmaceutical industry on prescribers’ practice and education: Ban direct-to-prescriber marketing of drugs and encourage Congress to remove the tax deductibility of pharmaceutical marketing. Curb industry influence between industry and regulators. Do not rely on industry to conduct monitoring and risk mitigation—move this function to the federal government. Encourage medical boards and accreditation bodies to refuse funding from the pharmaceutical industry. Reduce industry influence on the political process.

Recognize the risks and benefits of opioids in the drug approval process: Give greater consideration to the risk of diversion to illegal markets and unsupervised use, in addition to risks when the drugs are taken as directed. Conduct clinical trials on opioids’ risks and benefits. Address chronic pain by implementing strategies for managing pain. Improve the adverse impact of policies that restrict opioids. Promote opioid stewardship in medicine and use electronic medical record systems to monitor prescribing and restore trust. Expand opioid agonist therapy with reasonable controls.

Build integrated, well-supported systems for the care of substance use disorders: Standardize addiction care within health and social care systems, expand public and private insurance to adequately finance substance care of opioid use disorder, curtail provision of harmful treatments, and invest in addiction training for specialists and generalists. Expand Medicaid and enforce parity laws requiring coverage of addiction treatment by private insurers.

Improve the criminal justice system’s care for people addicted to opioids: Offer addiction-related health services during and after incarceration, do not incarcerate individuals for simple possession or use of illicit opioids, end collateral penalties for drug-related crimes and penalties for substance use during pregnancy. Pass the Medicaid Reentry Act, which would provide funding for the high-risk period between incarceration and re-entry into the community.

Create healthy environments that can yield long-term declines in addiction: Improve the quality of excess opioid disposal programs in the United States, integrate substance use prevention programs with programs targeting other problems, and expand early childhood enrichment programs for low-income families.

Stimulate innovation in the response to addiction: Implement policies that correct for failures in patent law and market incentives, prioritize opioid molecule redesign and non-opioid medication development, and weigh international data more heavily in medication approval decisions. Use strategies to disrupt fentanyl transactions and conduct out-of-the-box demonstration projects.

Prevent opioid crises beyond North America: Prevent U.S. pharmaceutical producers from exporting fraudulent and corrupting opioid promotion practices abroad, and distribute free, generic morphine for analgesia to hospitals and hospices in low-income nations.

“The current opioid crisis began when manufacturers like Purdue Pharma aggressively pushed to increase per capita prescriptions in the United States and Canada by 400% and fraudulently promoted OxyContin as less addictive than other opioids,” explains Keith Humphreys, chair of the Commission and professor of psychiatry and behavioral sciences at Stanford University School of Medicine. “But opioid manufacturers could do this in part because regulators, legislators, health care systems, and health professionals did not adequately resist them.

“There is plenty of blame to go around for the North American opioid crisis, and reversing it and preventing it from spreading abroad will not be easy. Implementing our recommendations can save lives and reduce suffering; the gains from these policies will last if they curtail the power of health care systems to cause addiction and maximize their ability to treat it.”

The Commission’s work was funded by Stanford University School of Medicine. 


Summarized from an article in The Lancet, Responding to the Opioid Crisis in North America and Beyond: Recommendations of the Stanford-Lancet Commission by Humphreys, K (Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System), Shover, CL (Stanford University School of Medicine and University of California Los Angeles David Geffen School of Medicine), Andrews, CM (University of South Carolina), Bohnert, ASB (University of Michigan Health System and Veterans Affairs Center for Clinical Management Research), Brandeau, ML (Stanford University), Caulkins, JP (Carnegie Mellon University), Chen, JH (Stanford University School of Medicine), Coderre, T (SAMSHA Region 1), Cuéllar, MF (Stanford Law School), Hurd, YL (Icahn School of Medicine), Juurlink, DN (Sunnybrook Health Sciences Centre), Koh, HK (Harvard T.H. Chan School of Public Health), Krebs, EE (University of Minnesota and Veterans Affairs Minneapolis Health Care System), Lembke, A (Stanford University School of Medicine), Mackey, SC (Stanford University School of Medicine), Ouellette, LL (Stanford Law School), Suffoletto, B (Stanford University School of Medicine), and Timko, C (Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System). Copyright 2022. All rights reserved.

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