The Surgeon General was on the verge of alerting the public about opioids 13 years ago. The effort quickly evaporated and there’s no real answer to why.
Two of the government’s top scientists detected the first signs of the emerging opioid crisis back in 2006 and tried to warn health officials and the public of the coming catastrophe, according to a confidential document obtained by POLITICO.
The effort didn’t lead to any real action, and the toll of death and addiction climbed. More than 133,000 people have died from prescription opioids since then — and hundreds of thousands more from street drugs including heroin and illicit fentanyl.
The scientists’ March 15, 2006 memo, obtained under the Freedom of Information Act, shows that the directors from the National Institute on Drug Abuse and the National Institutes of Health flagged “disturbing” data showing a dramatic uptick in opioid addiction — including among teenagers — and requested urgent action. The agency directors wanted then-U.S. Surgeon General Richard Carmona to alert the public to the dangers of prescription drug abuse.
The memo from NIDA Director Nora Volkow led Carmona to agree to issue an official call to action — the most urgent and powerful tool his office has — to capture the public’s attention and raise awareness about emerging public health issues. Similar calls have been used to address threats including tobacco and to urge the public to wear seat belts.
“Given the startling statistics, efforts to heighten awareness of this problem should be a top public health priority,” Volkow wrote. But the action she initially sparked with the memo faded in months as the health agencies focused on other issues. Public health officials, including some who worked on substance abuse and mental health, didn’t fully grasp how much the problem would grow.
Instead, an emerging crisis exploded — metastasizing from overuse of legally prescribed drugs to illicit pill mills and black markets for those drugs, to heroin, a cheaper and sometimes more easily obtainable opioid. Then came fentanyl, a powerful synthetic opioid that has been the driving factor behind overdose spikes in recent years.
Carmona told POLITICO in a phone interview this week that staff from various health agencies had assembled to lay the groundwork. He had a number of meetings to discuss issuing the call to action with officials from former Health Secretary Mike Leavitt’s office, where President Donald Trump’s current Health and Human Services Secretary Alex Azar served as deputy at the time, as well as George W. Bush’s White House Domestic Policy Council. But Carmona's term ended a few months after Volkow sent her memo. An acting surgeon general took over. What little momentum had built for a public warning evaporated. Azar's office declined to comment and Leavitt did not respond to requests for comment.
Had the call to action succeeded it would have been the first major attempt by the federal government to counteract the aggressive marketing of pharmaceutical companies that had led doctors to liberally — too liberally, in retrospect — prescribe the painkillers.
Other issues ultimately took precedent. Some public health officials during that era said that health agencies working on drug policy were consumed by the meth epidemic sweeping rural America.
“We were dealing with global health, national preparedness after September 11th, bioterrorism,” Carmona said, adding that his focus as surgeon general was also on the country’s obesity epidemic. “The crisis was in its infancy. It wasn’t like we dropped the ball,” Carmona said, adding that Volkow’s memo flagged early signs of trouble but health officials didn’t have the kind of granular data that exists now.
Volkow’s memo to Carmona, however, included a number of statistics pulled from federal data showing signs of the emerging crisis, specifically noting an uptick in abuses of OxyContin, Vicodin and other prescription drugs among high schoolers.
“NIDA’s 2005 Monitoring the Future Survey revealed that approximately 1 out of 10 high school students will have abused Vicodin before graduating,” Volkow wrote. “This statistic is alarming, especially when one considers that this drug is not the only prescription being abused.” She pointed to a separate NIDA study that found more than 1.6 million American teens and young adults had misused a prescription stimulant during a 12-month period and 75,000 became addicted. She also included data from the National Survey on Drug Use and Health that showed an estimated 6 million people in 2004 reported current non-medical use of a prescription psychoactive drug.
“We have seen increases in the abuse of sedatives and OxyContin among 12th graders as well as a disturbing levels of abuse of prescription stimulant medications,” she wrote. Former NIH Director Elias Zerhouni, who is now retired, also signed the memo. He could not be reached for comment.
Volkow, a well-respected physician and scientist still at NIDA’s helm, declined to be interviewed about the events of 2006, although a spokesperson confirmed her meeting with Carmona. While she has spoken privately to officials and publicly about the opioid scourge, she did not explain whether or how she had tried to draw high-level attention to the opioid crisis.
“I regularly brief NIH and HHS leadership on developing substance use trends, particularly among teenagers and young adults since they are the ones most vulnerable to the effects of drugs, as I did at a meeting in 2006 with then Surgeon General Richard Carmona,” Volkow said in an emailed statement. “The Surgeon General was receptive to the concerns outlined in the meeting.”
Geoffrey Laredo, a former senior adviser at NIDA who worked closely on the early call to action efforts, said his agency's work on that project had been completed and the language vetted. He was never told why the work didn’t go anywhere.
"As far as I was aware, we were finished, and the language got vetted. Why it then didn’t happen is still a mystery to me,” Laredo said, adding that he and his colleagues at NIDA who had worked for months on the call to action were frustrated that it never materialized.
“There was absolutely frustration,” He said. “We were facing what we believed was a public health crisis that needed to be addressed and we had what we thought was an agreement with the surgeon general to do a thing. We produced that thing … and then it never saw the light of day.”
NIDA and NIH’s warnings in 2006 were not the only warnings to government officials on the prescription drug crisis at the time. The New York Times reportedlast year that a confidential document from that same year shows lawyers from the Justice Department believed Purdue Pharma, the maker of OxyContin, knew that the drug was fueling a rise in addiction and took steps to mislead the public and lawmakers on Capitol Hill. That memo was never made public and charges against the drugmaker never progressed. The company is now embroiled in opioid litigation.
Between 2006 and 2012, roughly 76 billion prescription painkillers poured into communities across the country, according to federal data recently obtained by the Washington Post through a court order. Many counties, concentrated in Appalachia and other rural communities that received a disproportionate share of opioids, had higher-than-average rates of overdose deaths.
In addition to the memos, government officials also had access to the Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network reports, which showed spikes in emergency room visits related to prescription drug abuse as early as 2003 and 2004.
The problem was also flagged in the White House’s Office of National Drug Control Policy 2006 National Strategy. “The abuse of prescription drugs, including OxyContin (oxycodone), has become the second most prevalent form of drug abuse,” the report said.
John Walters, who served as the agency’s director for nearly the entirety of the George W. Bush administration, said he was never aware of a call to action but said some kind of public messaging from the surgeon general or health department could have made a meaningful difference.
“I can’t imagine it would have done anything other than make things better,” Walters said of the call to action. “Would it have ended the crisis? Probably not. But it would have increased awareness. More people would have known the dangers. We would have saved more lives.”
Instead the crisis deepened under both the George W. Bush and Obama administrations. More than 542,000 people died of a drug overdose between 2006 and 2017, according to CDC figures.
Walters said the Bush administration was working behind the scenes to address prescription drug abuse, like setting up a pilot program for screening and increasing access to treatment and propping up state prescription drug monitoring programs to prevent doctor shopping. But he acknowledged that heightened public awareness would have made their work easier.
“The real problem was awareness and maintaining the necessary training and knowledge to carry out the screening and referrals,” he said.
During the Obama administration, the Office of National Drug Control Policy released a strategy targeted at painkiller abuse in 2011. Later that year, then-CDC Director Tom Frieden said overdoses from prescription painkillers were at “epidemic levels” and called on the health industry to help stop the crisis. Yet the death toll kept climbing and the issue didn’t get labeled as a major public health crisis until a few years later.
President Barack Obama pushed Congress for legislation to address the epidemic in 2015 and signed two bills into law that expanded access to treatment in 2016, his final year in office. That year, his administration issued CDC guidelines for opioid prescribing, intended to curb liberal prescribing of pain medications, and it also released a surgeon general’s report on addiction — roughly 10 years after the initial discussions about a call to action on the issue.
Then opioids became a key campaign issue in the 2016 presidential election for President Donald Trump, who swept states like West Virginia that have been hit especially hard by drug addiction. Trump made the issue a top priority for his administration and declared the crisis a national public health emergency in 2017, when overdose deaths hit a peak of 72,000.
Since 2016, Congress has passed three major pieces of legislation to address the crisis and directed more than $6 billion to states. Azar, now at the helm of HHS, has prioritized the issue and touted the administration’s efforts as preliminary CDC data for 2018 shows deaths appear to be slowing though final numbers will be released later this year. Though early reports suggest deaths from prescription opioids are dropping, deaths connected to fentanyl and other drugs including meth and cocaine have risen in recent years.
The topic of addiction already has become an issue in the 2020 presidential race. Democratic candidates including Elizabeth Warren and Amy Klobuchar have unveiled their own proposals to tackle the epidemic.
Asked whether a public call to action 13 years ago could have changed the trajectory of the deadly crisis, Carmona demurred.
“Would it have made a difference? It’s hard to say. I don’t have a crystal ball,” he said. "But I’d like to think all surgeon general communications make a difference.”
This story originally was published on August 21, 2019, by Kaiser Health News