It is no secret that the United States has a problem with opioids. These are drugs that come in many forms (OxyContin, Vicodin, morphine, fentanyl, and heroin are all classed as opioids) and are primarily used as painkillers. Historically, doctors found these drugs useful for helping cancer patients cope with the pain resulting from their illness. However, because of the association with opium dens and heroin, they were loath to prescribe opioids for most other conditions.
This started to change in the early 1990s as doctors began to see a potential for using opioids to treat chronic pain. Some doctors began to advocate for expanding their use, and this support was echoed by pharmaceutical companies that stood to earn billions of dollars from producing these drugs. Together, they argued that opioids had the potential to dramatically alleviate suffering from chronic pain, and they downplayed the potential risks, such as abuse or addiction.[1]
Their campaign was successful, and ever since the early 1990s the prescription and use of opioids has rapidly increased. In 1990, doctors wrote 2–3 million opioid prescriptions; in 2017, more than 191 million prescriptions for opioids were filled.[2] And these are only the numbers of prescriptions; they do not account for the use of illicit opioids, such as heroin.
In tandem with this increase in prescribing has been a precipitous rise in opioid addiction and opioid-related death. The CDC reports that nearly 450,000 people died from overdoses involving opioids between 1999 and 2018,[3] with over 46,800 deaths in 2018 alone, accounting for almost 70 percent of all drug overdose deaths.[4] Worse yet, there are now questions as to whether opioids are even effective for treating chronic pain, with some arguing that they are ineffective at best and may even exacerbate the pain experience.[5]
The sheer scope of this problem led President Trump to declare the opioid crisis a public health emergency in October 2017.[6] Nor is this unique to the U.S.; the World Health Organization reports that opioid overdoses are a major problem worldwide.[7]
One Dubious Solution
So great is the concern over the growing mortality rate from opioid overdoses that some doctors have shown willingness to try almost anything to alleviate the problem—even some questionable methods. One such intervention comes from Vancouver, Canada. The brainchild of Dr. Mark Tyndall, who dubbed it the MySafe Project, the initiative involves using an ATM-like machine to dispense pharmaceutical-quality opioids to those with an addiction.[8]
There are currently several stringent criteria for making use of the machine. The initial trial has only 14 participants, all of whom have been prescribed Dilaudid (an opioid with about twice the potency of heroin). The machine uses biometric scanning for security, and it can be used by an individual up to four times per day. The basic goals are to increase personal autonomy and reduce overdose deaths by providing those addicted to an opioid with a standardized dosage and a clean, regular supply.[9] In a February 2020 Tweet, Tyndall said that “the over-riding objective is allowing people the chance for stability and reflection by disrupting the endless cycle of trauma, violence and despair.”
Tyndall’s initiative ties into Vancouver’s overall scheme of harm-reduction for those with illicit drug addictions, exemplified by the city’s supervised injection site program, where drug addicts can have medical supervision while taking drugs to ensure there is a trained professional on hand should they overdose.
These types of interventions pose several ethical problems, however.
First, while MySafe argues that there is little risk of participants selling or giving away their drugs, the evidence is not yet in. And even if no one in the initial trial abuses his easy access to opioids, a trial involving only 14 participants is far too small to form a basis for making predictions about what would happen if the initiative were to be implemented city-wide, as its proponents hope. In addition, there is the possibility of people feigning need in order to receive a supply they can sell; feigning a medical need to receive opioids is already a major problem in hospitals and would likely be exacerbated by the more impersonal MySafe system.
Second, even if these concerns could be surmounted, others remain. While the MySafe Project may be safer for participants in the short run than chasing after illegal street drugs, its focus is purely on helping people live with their addictions, not overcome them. Additionally, MySafe has not addressed the long-term effects of taking opioids, nor the potential for building up a tolerance, which could result in drugs from MySafe being mixed with illicit ones, negating the system’s entire purpose.
Finally, though Tyndall claims that the goal of the initiative is to provide people with space for “stability and reflection,” nothing in the promotional information gives any indication as to how that support will be offered. MySafe, at least at this stage, is concerned about stabilizing only. This has led some doctors to come out strongly against it, saying it is “in effect ushering users towards death, rather than treating curable conditions.”[10] Though the goal of harm reduction is a noble one, this type of initiative has a great risk of trying to treat a deadly problem with a Band-Aid solution.
A Different Approach
A second intervention, from the Rockefeller Neuroscience Institute in West Virginia, takes a very different approach to curbing opioid addiction. Described in some reports as a “cyborg technology,” researches are experimenting with a chip implanted into a participant’s brain that uses deep-brain stimulation to target the reward centers responsible for addiction. By using electrical impulses from the device, they hope to stabilize the level of dopamine, a hormone linked to drug cravings.[11]
Though referring to it as a “cyborg technology” may make it sound scary, the technology is quite similar to that of pacemakers, which have been used for years to assist patients with abnormal heartbeats. In this context, all that “cyborg” means is that the technology is internal to, rather than external to, the patient. The researchers themselves dispute that it is “cyborg” at all, since their goal is not to enhance or augment the physiological functioning of their patients, but simply return them to a “normal” level of functioning.
It should also be noted that while adaption of the technology for those with opioid use disorders is new, the technology itself is not. Similar deep-brain stimulation devices have already seen some success in treating Parkinson’s disease, epilepsy, and obsessive-compulsive disorder.[12]
Though the research on this approach is still in the very early stages, it, too, calls forth a number of ethical considerations. While this particular intervention might be innocuous, it raises the question of how, as a society, we want to approach the melding of humans and technology. There is also the question of when one has crossed the line between treating a person and “enhancing” him; while stabilizing dopamine levels may fall short of enhancement, the same brain-stimulation technology, if used to target other parts of the brain, could cross that boundary. And again, there is the risk of misuse. While, for now, participation is voluntary, it is not hard to imagine scenarios in which governments or insurance companies would force such an intervention on those who frequently abuse drugs or who have had medical events caused by a previous drug overdose.
On the individual level, there are questions regarding how much of a person’s own personality and judgment such a technology could override, and whether it is morally permissible to let it do so, even if it is thought to be for the patient’s own good. There are also practical issues—the procedure is estimated to cost around $75,000, much more than the majority of those who struggle with drug addiction could ever afford. And even if the cost were significantly reduced, it would still be prohibitively high for people in developing nations who struggle with the same addictions. Given the relatively small number of opioid users who could even avail themselves of such a drastic intervention, it is doubtful that, on its own, it would be enough to turn the tide of the epidemic.
Room for Reflection
It is, of course, never enough to assess an intervention only by its positive or its negative potentials; one must consider both to fully tease out the implications of the intervention for society as a whole. While MySafe raises a number of concerns regarding how a society should approach the issues of drug use and addiction, it does have the potential to prevent overdoses and save lives in the short run. And while there are numerous scientific, ethical, and financial hurdles to be overcome regarding the use of brain implant technology, it has the potential to offer hope and recovery to those who have been unable to break free from the chains of addiction using other currently available methods.
Both of these initiatives highlight the need for better responses to drug addiction generally and the opioid epidemic specifically. Whether they are ultimately scrapped or widely implemented, they demonstrate an attempt to try something new and to move forward in the struggle against addiction, and that, at least, can be supported.
Notes
[1] Chris McGreal, “The Making of an Opioid Epidemic,” The Guardian (Nov. 8, 2018): https://www.theguardian.com/news/2018/nov/08/the-making-of-an-opioid-epidemic.
[2] Teresa A. Rummans et al., “How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis,” Mayo Clinic Proceedings (March 2018): https://www.mayoclinicproceedings.org/article/S0025-6196(17)30923-0/fulltext; CDC, “Prescription Opioids”: https://www.cdc.gov/opioids/basics/prescribed.html.
[3] CDC, “Understanding the Epidemic”: https://www.cdc.gov/drugoverdose/epidemic/index.html.
[4] CDC, “Drug Overdose Deaths”: cdc.gov/drugoverdose/data/statedeaths.html.
[5] Mariam Alexander, “Opioids don’t work for most people with chronic pain. So why do we still prescribe them?” The Guardian (Jan. 21, 2019): https://www.theguardian.com/commentisfree/2019/jan/21/opiods-chronic-pain-prescribe.
[6] “Ending America’s Opioid Crisis”: https://trumpwhitehouse.archives.gov/opioids/.
[7] World Health Organization, “Information sheet on opioid overdose” (August 2018): who.int/substance_abuse/information-sheet/en.
[8] Colin Askey, “MySafe”: https://vimeo.com/377612110.
[9] William Turvill, “Opioid Vending Machine Opens in Vancouver,” The Guardian (Feb. 17, 2020): https://www.theguardian.com/science/2020/feb/17/opioid-vending-machine-opens-vancouver-mysafe-canada.
[10] Ibid.
[11] Coral Murphy, “‘Cyborg’ technology aims to reduce the opioid epidemic one chip at a time,” USA Today (Jan. 20, 2020): https://www.usatoday.com/story/tech/2020/01/20/opioid-crisis-can-emerging-cyborg-technology-help-stop-it/2636189001/.
[12] Vincent Wood, “Man has chip implanted in his brain to help tackle opioid addiction,” The Independent (Nov. 7, 2019): https://www.independent.co.uk/news/science/opioid-addiction-man-chip-brain-implant-head-west-virginia-a9191501.html.