The New York Times International - 30.08.2019

12 | FRIDAY, AUGUST 30, 2019 THE NEW YORK TIMES INTERNATIONAL EDITION

The decision on Monday by an Okla-
homa judge to fine Johnson & Johnson
$572 million for its role in the state’s
opioid crisis is only the first step in what
promises to be years of complex litiga-
tion. In ruling that pharmaceutical
marketing caused a “public nuisance”
by increasing addiction and overdose
deaths, Judge Thad Balkman created a
strong precedent.
What this decision should not do,
however, is further distort our under-
standing of the causes of the crisis and
add to the misery of people in pain.
Drug companies like Johnson &
Johnson twisted the truth about the
potential risks of these medications.
That caused great harm. Nonetheless,
for many — including people with
chronic pain or at the end of life — opi-
oids are the only drugs that seem to
work. Understanding the facts about
these drugs is critical to resolving the
crisis and making pharma pay for solu-
tions that work.
The reality is this: 80 percent of those
who begin misusing prescription opi-
oids are taking drugs obtained illegally
— from theft, dealers, friends, relatives,
the internet or other people’s medicine
cabinets, not from doctors. And nearly
three out of four young people who
misuse opioids have previously taken
cocaine or crack repeatedly. Indeed,
researchers say that prior recreational
drug use is a much larger risk factor for
opioid addiction than medical exposure.
That is not to say that there aren’t some
whose addictions begin with a prescrip-
tion — but this group is a decided minor-
ity.
This shouldn’t deflect blame from the
pharmaceutical industry — as Judge
Balkman’s decision suggests, mislead-
ing marketing might have helped quad-
ruple medical opioid sales from 1994 to
2006 in Oklahoma. Where those drugs
ultimately went and who got harmed,
however, is a more complex story than
we’ve been led to believe.
Part of the confusion comes from this:
Addiction rates vary tremendously
depending on factors like age, mental
illness and history of use of alcohol and
other drugs. Consequently, studies that
exclude people with these risk factors
show very low rates of addiction.
Take, for instance, the 2010 Cochrane
review of clinical trials of opioids for the

use of chronic non-cancer pain. Coch-

rane reviews are among the most rig-

orous and respected in medicine, in-

tended to help physicians and countries

with national health care determine the

best treatments. Among the 2,613 par-

ticipants who were evaluated for possi-

ble addiction, the authors found a risk

that was little more than one-fourth of

one percent.

When drug companies cite such

studies to doctors, they aren’t exactly

lying: The risk of addiction in carefully

screened patients is indeed low. But the

result can be to elide

the differences be-

tween people who go

through extensive

screening to partici-

pate in a clinical trial

and those who just

stroll in to their gen-

eral practitioner’s

office.

Doctors don’t seem

to be adequately

screening their pa-

tients for addiction;

indeed, many have

received scant education on such

screening in medical school and conse-

quently often rely on stereotypes. This

can mean that many doctors simply

assume that the nice patients that they

have been seeing for years aren’t at risk

of addiction. So they might not ask

unpleasant questions about possible

past misuse of alcohol or other drugs.

The result, however, is that they wind

up treating a population that has a risk

for addiction estimated at 8 percent to 12

percent. It is worse for doctors who deal

with teenagers and young adults: The

risk of addiction for them is at least

double that of older people.

Further, since people who misuse

drugs often deliberately seek them from

doctors, addiction rates in pain prac-

tices can be many times higher than in

the general population — not because

the doctor has caused addictions, but

because addicted people go where the

drugs are.

So, yes, the pharma industry was the

source for these opioids and its market-

ing convinced many doctors to write

large prescriptions, helping to create an

addiction epidemic. But it wasn’t pri-

marily pain patients who got hooked.

The policy response, then, needs to

focus on getting appropriate treatment

to people with addiction — not on taking

medication from the pain patients who

most need it.

Today, illicitly manufactured fentanyl

is causing an increasing percentage of

overdose deaths. This is probably be-

cause when the medical supply of opi-

oids began contracting, as doctors

sought to reduce prescriptions, large

numbers of addicted people switched to

illegal heroin and fentanyl — often

because they were already familiar with

illegal drug markets.

Pharma must pay for its role in creat-

ing these markets. But simply cutting

people off from opioids treats neither

pain nor addiction. What they most

need is access to effective anti-addiction

medications.

To solve this problem, funds from the

Johnson & Johnson settlement — as

well as from any settlement with Pur-

due Pharma or other major manufactur-

er of opioids — must go toward support-

ing effective treatments, including

providing proven addiction medica-

tions. (Johnson & Johnson is appealing

the decision.)

The United States Preventive Serv-

ices Task Force has just recommended

that physicians screen all adults for

substance use disorders — and settle-

ment funds could also be used to sup-

port this effort, which will require im-

proved training for doctors in dealing

with pain and addiction.

The pharmaceutical industry, doctors

and regulators all deserve blame for

overselling and overprescribing pain

medications. But now, as they reverse

course, they are abandoning people in

pain as well as people with addiction. If

the Johnson & Johnson settlement and

any future ones are to provide some

measure of justice, they must help both

groups.

MAIA SZALAVITZis the author of “Unbro-

ken Brain: A Revolutionary New Way of

Understanding Addiction.”

Punish pharma, not patients

Prosecutions

of opioid

makers like

Johnson

&Johnson

shouldn’t

leave people

suffering

unspeakable

pain.

Oklahoma’s attorney general, Mike Hunt-

er, who took Johnson & Johnson to court.

SUE OGROCKI/ASSOCIATED PRESS

Maia Szalavitz

HONG KONG Across the street that was

about to become a battlefield, forces

massed on each side tensely adjusted

their gas masks, nervously fiddled

with their weapons.

The riot police, with pistols at their

hips, were ready with tear-gas grenade

launchers and guns loaded with rubber

bullets. Down the street, young pro-

democracy protesters set up barriers

to slow the police, and stretched fish-

ing line across the road to trip them.

Both sides wore helmets and gas

masks, and both clutched sticks or

truncheons. Then the police charged

and a sedate neighborhood erupted

into a fury of tear gas, flying rocks and

Molotov cocktails.

The Hong Kong and Chinese govern-

ments have mishandled these protests

from the beginning, and both sides are

now escalating and becoming increas-

ingly violent. That face-off on the

street was a microcosm of a larger

standoff between China’s president, Xi

Jinping, determined to impose his kind

of order, and countless Hong Kongers,

equally determined to breathe freely.

My heart is with the protesters.

Hong Kongers are highly educated and

of course they deserve the right to

choose their leaders.

China under Xi has been nibbling

away at Hong Kong’s autonomy, just as

he has been ratcheting up repression

at home — so it’s impossible not to be

inspired by up to two million brave

Hong Kongers marching to gain rights

that are taken for granted in so much

of the world.

When a small, skinny man in shorts

and a tank top stood with his arms

outstretched to try to protect pro-

testers from a police officer pointing a

gun at them — the scene of an unfor-

gettable photo — how could we not be

moved?

But I also feel a sense of foreboding.

It’s probably only a matter of time

before someone is killed, and that will

unleash a new cycle of recrimination,

escalation and violence. There are so

many parallels to the Tiananmen

student democracy movement that I

covered in China 30 years ago — and I

wonder if Beijing may ultimately de-

ploy troops, perhaps from the paramili-

tary People’s Armed Police, to crush

these protests as well.

As with the 1989 Tiananmen pro-

tests, these in Hong Kong are partly

about democracy

but also about

economic frustra-

tions. The average

Hong Konger en-

joys housing space

of only 160 square

feet, just a hair

bigger than the

average New York

City parking space.

As in 1989, these

protests snowballed

because of govern-

ment mishandling and arrogance.

China’s hard line has also deeply an-

tagonized Hong Kongers. Graffiti

everywhere denounce “ChiNazi” influ-

ence, and people scold me when I refer

to the population here with the old,

familiar term of “Hong Kong Chinese.”

No, people object: We’re not Chinese.

Say “Hong Konger.”

Thus one of Xi’s legacies: He has

tarnished the word “Chinese.”

Hong Kong’s police have sometimes

been restrained, other times heavy

handed, firing tear-gas grenades in

ways that experts say are excessive.

The authorities are also accused of

using more than 100 Chinese gang-

sters, known as triads, to do their dirty

work and club and disperse protesters.

The Hong Kong chief executive,

Carrie Lam, is generally regarded as

having bungled the affair from the

beginning. Her next step may be to

invoke emergency powers — akin to

martial law — and crack down further

on dissent; this may just backfire and

inflame the protests.

On the other side, protesters have

also escalated their tactics and become

increasingly violent. More and more

people — although still a tiny minority

of the overall pool of protesters — hurl

rocks or Molotov cocktails at the po-

lice. Hong Kongers say they have

absorbed the lesson that the govern-

ment pays no attention to purely

peaceful demonstrations. I believe the

violence is a mistake that increases the

risk of a crackdown, but the public

frustration is so great that I found few

people ready to condemn it.

One more eerie parallel with Tianan-

men: Many protesters scoff at the

possibility of amilitary crackdown.

“Western pressure will prevent a

Tiananmen from happening here,” a

29-year-old man told me during a

march the other day.

A young couple, Charles and Cindy,

came out in matching helmets, gas

masks and goggles to stand up for

democracy, but they told me that Bei-

jing would never use force to crush the

protests.

“The free world will support Hong

Kong,” Charles told me. And Cindy

pointed to Hong Kong’s economic

importance to China, adding, “We are

still very valuable to them.”

True enough, and people often say

that China will never kill the goose that

lays golden eggs. But as Chris Patten,

the last British governor of Hong

Kong, once dryly noted, that phrase

came into existence only because

“history is littered with the carcasses

of decapitated geese.”

In the run-up to the massacres of

1989, idealistic protesters often told me

that their cause was invincible. And

then I watched tanks roll over right-

eousness.

A police officer raised a pistol at a protester during demonstrations in Hong Kong on Sunday.

LAM YIK FEI FOR THE NEW YORK TIMES

Straining through the tear gas

In Hong Kong,

flinching at

echoes of

China’s

ill-fated

Tiananmen

democracy

movement

of 1989.

Nicholas Kristof

opinion

quently ruled out this possibility. Mr.

Johnson himself said a few months ago

that the odds of no deal were “a million

to one against.” Forecasters predict

crashing out will do the country great

harm.

Yet this is the strange place in which

Britain finds itself. Here’s the problem.

As with “Mornington Crescent,” the

rules on which its politics are based

are unwritten — in contrast to its

French, American or German counter-

parts — and its smooth workings are

held together by convention, good

manners and a sense of whether or not

something is fair play. There are also

few correctives, it is finding out, should

someone decide to break with all this.

As Mr. Johnson and the Brexiteers

plow on, M.P.s and commenters have

tried manfully to keep up with the

game. “Ah yes,” they say, at every

astonishing break with tradition. “Mat-

ters will soon return to normal. If you

turn to Appendix VIII, Featherington

edition... ” (Even on Wednesday,

there was debate on whether the

Queen herself could or would intervene

to end this breach of protocol. She

could or would not.) The main players,

though, have suddenly realized that

they can win much faster by ignoring

the rules altogether: “Mornington

Crescent!” they chorus, immediately,

and the game is over.

The rules are easy to ignore. Brit-

ain’s jumbled Constitution is set up

that way, easily changed by a vote in

Parliament or at a decision of the

Speaker of the House of Commons. For

years, British lawmakers were wary of

tampering with it. But they have

grown reckless.

Some cite the carelessness of Tony

Blair, who rather brazenly devolved

power to assemblies in Scotland, Wales

and Northern Ireland, and to the peo-

ple through referendums. Other coun-

tries are more careful. Ireland holds

referendums, but the rules of its Con-

stitution mean people can hold a refer-

endum only after a bill laying out

exactly what it means, in detail, has

been passed. Britain held the referen-

dum first, and thought it could sort out

the details later.

All of this tampering might not

necessarily have led to this, however,

had the shame mechanism not broken

down. But little by little, the years

since 2016 have witnessed a slow wear-

ing away of the willingness to play by

the rules that once held this brittle

system together.

There was the lying by the Leave

campaign; the sudden tendency of

party leaders to cling to their posts in

circumstances in which their predeces-

sors would have felt that the only

recourse was to step down. There was

the odd new convention that politicians

messing up badly no longer mattered.

Two weeks of bad headlines were once

enough to finish a career; now shamed

ministers are expected to merely

weather the storm.

Where does all this leave British

democracy? Our current prime min-

ister has learned from his predeces-

sor’s mistakes: She was hamstrung by

the rules. But the country is now

presented with a prime minister

elected by a tiny percentage of the

population — his mandate is from

Conservative Party M.P.s and mem-

bers — not the country — deliberately

skirting Parliamentary scrutiny to

push through a policy that was never

voted on. Upholding democracy is the

rallying cry of those who wish to see

Brexit done. But Brits must start to

question whether their island is float-

ing away from the concept altogether.

Did Boris just break Parliament?

G ILL, FROM PAGE 1

MARTHA GILLis a political journalist

living in London.

DANIEL LEAL-OLIVAS/AGENCE FRANCE-PRESSE — GETTY IMAGES

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