We pretty much have been told the names of the villains in the opioid epidemic.  They are the companies such as Purdue Pharma, Johnson and Johnson and a number of others which pushed doctors to prescribe opioids for pain without disclosing their addictive nature.  They are defendants in thousands of lawsuits brought by states, municipalities and individuals.  By far, the biggest name is Purdue Pharma which is owned by the Sackler family whose original patriarch was Arthur M. Sackler.

Mr. Sackler died 8 years before the opioid, OxyContin, was marketed by Purdue Pharma, a company that was owned by his brothers.  Purdue Pharma is the defendant in numerous lawsuits and is now being taken into bankruptcy as part of a deal with numerous states and municipalities to resolve a majority of those claims.

The Sackler name – once admired – is now the object of derision.  Since 1997, the Louvre’s Collection of Persian and Levantine artifacts has been housed in a wing known as the Sackler Wing of Oriental Antiquities.  The wing was made possible by the donation of $4 million toward construction by Arthur M. Sackler.  The Louvre has now removed the Sackler name from the wing which he built and to which he donated 1,000 objects.  The Louvre apparently believes that the Sacklers should be ashamed of their “dirty” money but it is not now ashamed of taking that money nor has it made an offer to return it.

And the Louvre is not alone.  Numerous museums ‒ in a righteous display of sanctimony ‒ have indicated that they will not take any Sackler money in the future but none are planning to return that already taken.  Senator Jeff Merkley (D-Oregon) recently requested that the Smithsonian Institution remove the Sackler name from the Asian Art Museum saying “it has no place in taxpayer-funded public institutions.”  The Senator did not say whether the construction money ($4M) and donated objects (about 1,000) should be returned. 

So the opioid epidemic is laid at the feet of the drug manufacturers and their overly aggressive marketing of opioids.  They are, as a practical matter, the only deep pocket defendants available and they are guilty as charged. 

But are others to blame?  You betcha!  How about doctors who were not attuned to the addiction problem and patients who were given opioids for pain but then continued after the pain was gone because they were either addicted or wanted to stay high.

The “butterfly effect” is the popularization of a theory developed by Edward Lorenz to the effect that a small change in one state of a deterministic non-linear system can result in massive changes thereafter or, as expressed more commonly, the fluttering of a butterfly’s wings in Western Africa can ultimately deliver Katrina to New Orleans. 

The “butterflies” in the opioid epidemic were three groups.  One was the American Pain Society (APS), a professional association of healthcare providers involved in the treatment of pain; another was the U.S. Veterans Administration and – perhaps most importantly – a group called the Joint Commission.  These three groups were just what the doctor ordered for the sales people at Purdue Pharma and other opioid manufacturers. 

In 1995, Dr. James Campbell, in his Presidential Address to the APS, proposed that pain be considered the “fifth vital sign,” the first 4 being temperature, pulse, blood pressure and respiration rate.  Unlike the first 4, there is no objective measurement for pain and so the patient is asked to rate their pain on a 0 to 10 scale.  Dr. Campbell’s proposal was accepted by many in medicine but nowhere was acceptance more important than at Veterans Administration hospitals and at the Joint Commission. 

The Joint Commission published a book in 2000 for purchase by doctors as part of required continuing education seminars, and that book cited studies claiming that there was no evidence that addiction is a significant issue with respect to opioids.  In addition, the Joint Commission published its “Pain Management Standards” in 2001 giving a momentous lift to pain as a fifth vital sign.

What is the Joint Commission?  The Joint Commission is a nonprofit, tax exempt organization that accredits more than 21,000 U.S. health organizations and programs.  The great majority of U.S. state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements.  All member healthcare organizations and laboratories are surveyed every 2 to 3 years and accreditation is then renewed if justified.  Joint Commission accreditation has been criticized as not actually improving patient outcomes as well as for the fact that accreditation is rarely denied even when there are serious problems.

However, one thing is sure:  Joint Commission accredited institutions follow its rules and standards.  As someone who has been in several hospitals, physician related clinics and rehab facilities plus too many doctor visits to mention in the last five years, I can attest that my “fifth vital sign” has been asked and re-asked about continually.  In hospitals and rehab facilities, the 0 to 10 question on pain is asked at least once a day (and sometimes 3x a day on every shift change).  And, you guessed it, the best medicines for serious intractable pain are opioids.

Opioids were a true breakthrough for patients with intractable and disabling pain.  Their addictive qualities were not originally explained and, for some people, addiction is still worth the relief and improved function they give.  However, for too many people addiction is a very real problem and must be addressed.

Arthur Sackler’s name may be removed from other institutions.  Meanwhile, the Veterans Administration and the Joint Commission continue to chug along although both have been involved in lawsuits over their opioid practices and recommendations.  The APS has filed bankruptcy in order to avoid responsibility in the opioid lawsuits.  While these groups will certainly contribute some monies to settle lawsuits, it will be far and away much less than perhaps merited.  The reality is that these groups set the table for the opioid epidemic.

Finally, back to Paris.  A small demonstration precipitated the Louvre’s action.  Protesters unfurled a sign in front of the iconic glass pyramid reading “Take down the Sackler name.”  This proved too much for the Louvre to resist, once TV cameras captured the “optics” of the Sackler association.  Arthur Sackler’s widow has complained ‒ to no avail ‒ that he was long gone and not involved with the sale of OxyContin.  Perhaps she should stop complaining and be grateful that the French no longer use the guillotine on those who have fallen out of official favor.