The recent decision not to prosecute the doctor who prescribed pills to rock musician Prince, who subsequently died of an overdose, raises the question of who is, or should be, held responsible for opioid-related deaths.
Unfortunately, Prince wasn’t the only musician who recently died of a drug overdose—so did Tom Petty and Michael Jackson—or the only US citizen. According to a report by the Centers for Disease Control and Prevention, 63,632 Americans died of a drug overdose in 2016.
Prince, Jackson and Petty were all performers, all famous, all suffering from physical injuries (and possibly psychological ones, too). They were all addicts, all under medical care—and yet they suffered the same tragic end as any of the lesser known, poorer Americans who have been victims of our opioid epidemic.
The deaths of such famous A-listers highlight the larger question of culpability in a crisis that continues to defy our efforts to control it.
Surely, if their doctors knew the performers were addicts, and precautions weren’t taken against their possible misuse of prescriptions, then negligence should certainly be considered a factor.
In the Prince case, Dr. Michael Schulenberg, who treated the rock icon during his final two weeks, agreed to pay a fine of $30,000 after prosecutors determined he broke federal drug rules by filling out an oxycodone prescription “in the name of an individual, knowing that the controlled substances were intended to be used by another individual.”
But no criminal charges were laid. According to reports of the case, it couldn’t be determined who was feeding the 57-year-old singer the fentanyl-tainted painkillers that were held responsible for his death.
A jury and judge did find Jackson’s physician, Dr. Conrad Murray, guilty of involuntary manslaughter. Prosecutors claimed Murray put Jackson in a drug-induced coma every night for two months with propofol, a surgical anesthetic. It was intended to let Jackson rest, but experts say it actually deprived Jackson of the REM (rapid eye movement) deep dream sleep state everybody needs to be healthy and sane. Dr. Murray served two years in prison.
In the days leading up to his death, Jackson was exhibiting all the symptoms of sleep deprivation including paranoia, anxiety, loss of balance, and forgetfulness. If he hadn’t overdosed, experts speculate, he may have died within days anyway.
Dr. Murray protested his innocence, claiming he actually was weaning Jackson off the propofol he had been using since before Murray became his physician. He blamed Jackson’s death on self-administered propofol, Demerol and other benzodiazepines he says he never prescribed to Jackson.
But the failure to find direct complicity in their patients’ opioid deaths saved the doctors who treated Prince and Petty from a guilty verdict. Both Prince and Petty were taking additional medications, at least some of them illegally obtained.
The fake fentanyl-laced pills that killed Prince were probably obtained on the street without knowledge of its true potency. If you think you are taking a Vicodin and take fentanyl instead, you can easily overdose. Celebrity addiction specialist Dr. Drew Pinsky says “fentanyl was designed for cancer patients who are going to die.” (It also is used in surgery.)
Petty also used fentanyl, though in his case it was prescribed in the form of a transdermal patch for pain control. Since he was an opioid addict, that is a controversial choice, but by itself, it shouldn’t have killed him.
He was taking multiple other drugs, however, including benzodiazepines, an antidepressant, and another form of fentanyl that is not legally prescribed in the US. Opioids and benzos can be a lethal combination, even when fentanyl isn’t involved.
What about the suppliers of the pills?
Police could not find out who supplied Prince with the faux Vicodin, but in Petty’s case, amazingly, they never even tried. Because he didn’t die at home, the police never gathered drugs from the scene or started an investigation into how or why he had been prescribed so many medicines with interaction risks.
The medical examiner ruled that Petty, in extreme pain due to a broken hip, took an accidental overdose that caused “multisystem organ failure”.
If their doctors weren’t negligent, maybe the pharmacists were. On April 24 it was announced that Prince’s heirs were suing Walgreens for “dispensing prescription medications not valid for a legitimate medical purpose” and failing to provide him with reasonable care.
Prince’s heirs also are suing a hospital that treated Prince for an earlier overdose (it was apparently another fentanyl-laced faux Vicodin pill) for not diagnosing it or offering addiction counseling. It’s not clear if they truly believe the hospital is culpable.
One goal of the suit, according to a statement, according to their lawyer’s statement, is “to shed light on this epidemic and how to better the fight to save lives. If Prince’s death helps save lives, then all was not lost.”
That leaves us with another possible culprit.
Since the drug that is believed to have killed Prince—and maybe Petty—wasn’t legally prescribed, maybe the authorities should be pursuing the drug dealers or the dealers’ suppliers. That seems to be the preference of the US government. President Donald Trump has led the chorus of voices urging severe penalties for drug dealers—even, in some cases, the death penalty.
Aside from the question of whether such sentences work —a November 2017 Drug Policy Alliance (DPA) report found that “punitive sentences for drug offenses have no deterrent effect”, including “drug-induced homicide laws”—there’s the question of whether dealers truly are to blame.
True, they sold the drug, but they may not have known it was lethal.
According to Ken Solek of the Minneapolis office of the Drug Enforcement Agency (DEA), fentanyl, often pressed into pill form or encapsulated, is sold as some other drug, such as Vicodin or OxyContin, because it is “cheap to produce” and can be “sold as pricier prescription pain pills.”
Due to the crackdown on legal prescriptions, intended to contain the opioid epidemic, fentanyl is now easier to obtain (such as through the mail from China).
But even dealers have dealers, and the dealer who supplied Prince may not have known what he was getting either. Most dealers don’t want to kill their customers, which is almost an inevitable risk of substituting fentanyl for a less powerful drug. Dealers fill a need.
That’s why punitive measures against dealers who are found to be responsible for opioid deaths don’t work. The demand for their product still exists.
In addition, the DEA points out that more than two-thirds of all opioid overdose deaths are caused by mixing two or more drugs or alcohol. Proving which drug actually caused the death would be difficult, maybe impossible.
What about friends?
The person who provided Prince with the pills may not have been a dealer, only the customer of a dealer, maybe a friend or acquaintance of Prince. The fake Vicodin might have been a gift and. if so. whoever gave it to him certainly meant no harm—and may have thought it was an act of kindness because Prince was in such pain.
Elizabeth Brico, a heroin addict, wrote on Vox about her own overdose experience. The person who sold her the heroin was a homeless fellow addict, who was supporting his habit by selling some of his stash to her. Because she was in a room full of drugs, she knew no one would call 911 for fear of being arrested.
She was lucky that another addict somehow got her heart beating again.
The idea that someone else might be punished for her drug addiction and behavior appalled Brico. “They didn’t trick me into overdosing.”
Finally, there are the pharmaceutical companies.
Less applicable to Jackson, Prince, and Petty than to the overall epidemic of opioid deaths is the industry that makes and distributes the (legal) painkillers that start individuals on the path to addiction. Many blame the current epidemic of opioid deaths and addiction on the introduction of OxyContin by Purdue Pharma in 1996.
Physicians were assured at the time the drug produced no euphoria or withdrawal pains. Purdue acknowledged that claim was incorrect and paid a $634 million fine in 2007.
It wasn’t the first time Big Pharma was wrong about the addictive potential of its products. Heroin was introduced by Bayer in the 1890s as a safer, less addictive morphine substitute.
Blaming Big Pharma for the opioid epidemic, its death and costs, some 215 cities and all 75 counties in Arkansas announced in March a joint civil lawsuit against 52 pharmaceutical manufacturers and 13 distributors. Last year 250 cities, counties and states individually sued various opioid enablers.
The federal government may follow suit.
Proponents of this strategy compare it to the suits against the tobacco companies in 1998, but others argue that there is a difference: people who die from an overdose of a drug are taking it in larger doses or more often than prescribed. The manufacturer, therefore, cannot be held liable when a product is used other than as intended.
The other side of the argument is that if Big Pharma sells you something based on the claim that it is not addictive, but while acting based on that claim you become addicted, then Big Pharma seems to be at least partly responsible.
Americans love to place blame.
That’s one reason addiction is still widely seen as a moral failing, although the best evidence is that it’s more of a pre-existing predilection, if not condition. Former US Surgeon General Vivek Murthy wrote that “addiction is a chronic neurological disorder … not a character flaw” that “we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” as well as hypertension and asthma.
That doesn’t mean addicts don’t bear any responsibility for their actions.
Jackson, Petty and Prince all seem to have been addicted to both prescribed and illegally obtained drugs and to have engaged in doctor shopping to conceal the extent of their drug use/abuse. Petty admitted to an addiction to heroin, an opioid, and died from “mixed drug toxicity,” including at least two opioids, one prescribed.
Clearly, they bear some responsibility for their own deaths.
What’s unclear is how much of that responsibility belongs to others. Dr. Pinsky argues that “doctors are the ones who be held accountable,” specifically the ones who “don’t understand addiction.” Such ignorance is no longer acceptable in the midst of a still-growing opioid epidemic.
All medical personnel need to be at least acquainted with the signs of addiction and aware of dangerous interactions.
Dealers will go away when there is no demand for their product on the black market. The current wave of cannabis legalization suggests that violence associated with illegal drug trade goes down when the product is legally available. (So seemingly do opioid deaths from overdoses.)
The same might apply to other drugs. Portugal has benefited from decriminalizing all drug use.
Big Pharma also has a lot to answer for. A $600 million fine doesn’t impress them when they’ve made more than $35 billion, mostly from OxyContin. But cutting the supply of legal opioids hasn’t made the problem go away.
It has just increased the use of illegal opioids.
Better and more available opioid and heroin rehabilitation centers are needed, and they must be evidence-based. Twelve-step programs and abstinence don’t often work by themselves. Medication-assisted treatment (MAT) with methadone and buprenorphine (Suboxone) are important tools that need to be used more often.
So is cognitive behavioral therapy. Friends can help.
But jail, shaming and “Just Say No” won’t cut it any longer.
Stephen Bitsoli, a Michigan-based freelancer, writes about addiction, politics and related matters for several blogs. He welcomes readers’ comments.