US and WHO were at loggerheads during opioid and HIV crises too, Trump isn't first president to slam the agency
US President Donald Trump recently halted funding to World Health Organization (WHO), stating that the agency had "failed in its basic duty" in its response to the coronavirus pandemic. However, the US's long-troubled history with the WHO goes back to the country’s opioid crisis.
In 2017, several members of Congress sent a letter to the WHO warning that Purdue Pharma was attempting to expand its drug sales to international markets using "fraudulent marketing tactics that instigated the opioid crisis" in the US.
"We expressed our concern that Purdue’s expansion could trigger an opioid crisis on a global scale. When the WHO failed to respond to the letter, we began to question why they would remain silent about such a significant and devastating public health epidemic. The answers we found were deeply disturbing,” said a May 2019 report by two US lawmakers titled ‘Corrupting Influence: Purdue and the WHO'. It said a review of the guidelines makes it clear the 'problem' that the WHO seems to be addressing is “not how to limit the use of these highly addictive drugs, but rather how to eliminate barriers to their use".
Lawmakers Congresswomen Katherine Clark and Hal Rogers alleged that Purdue Pharma helped shape the WHO’s recommendations for prescribing opioids. According to the report, two WHO guidelines on treating severe pain — one for adults and one for children — "alarmingly" copy Purdue’s marketing strategies for increasing prescriptions and expanding sales. They contain dangerously misleading and, in some instances, outright false claims about the safety and efficacy of prescription opioids, the US lawmakers said. "We are disturbed that the WHO, a trusted international agency, appears to be lending the opioid industry its voice and credibility," they said.
The report elaborates that in the 1990s, Purdue and the company’s owners developed an aggressive marketing strategy to increase its sales of OxyContin. “According to Purdue’s own internal planning documents, the company sought to influence the WHO’s recommendations on how healthcare providers and policymakers should administer prescription opioids. Almost a decade later, multiple aspects of Purdue’s marketing strategy were included in two WHO guidelines on opioid prescribing," the report said.
In 2011, the WHO published a document — Ensuring Balance in National Policies on Controlled Substances, Guidance for Availability and Accessibility of Controlled Medicines — which said that opioid analgesics such as codeine and morphine, and antiepileptics such as lorazepam and phenobarbital, are considered as essential medicines by the WHO. It was written as an update to the previous WHO guideline that solely focused on cancer pain. There is a broad consensus that opioid analgesics are indispensable for the treatment of moderate to severe pain and some, like methadone and buprenorphine, are increasingly used for the treatment of drug dependence, said the guidance.
“Opioid analgesics, if prescribed in accordance with established dosage regimens, are known to be safe and there is no need to fear accidental death or dependence. A systematic review of research papers concludes that only 0.43% of patients with no previous history of substance abuse treated with opioid analgesics to relieve pain abused their medication and only 0.05% developed dependence syndrome,” said the WHO report.
Following the publication of the 2011 report, the WHO published another document in 2012 — Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses — which was also an update to a previous advisory that focused exclusively on using opioids to treat cancer pain in children.
“The guideline uses the marketing term coined by the opioid industry and often utilized by Purdie, ‘opiophobia', which is how the opioid industry defines a physician’s “unreasonable fear” of prescribing opioids. Persisting Pain in Children tries to overcome opiophobia by emphasizing the safety of opioids. The WHO claims that there is no maximum dosage of strong opioids like OxyContin, for children," the 2019 report said.
It further said that the WHO published this claim even though US public health agencies had already found that fatal overdoses skyrocket in adult patients who are prescribed above 90 morphine milligram equivalents (MME) per day.
"The web of influence we uncovered paints a picture of a public health organization that has been manipulated by the opioid industry. The WHO appears to be lending the opioid industry its voice and credibility, and as a result, a trusted public health organization is trafficking dangerous misinformation that could lead to a global opioid epidemic," the lawmakers said.
The lawmakers wrote that what is most striking about the 2012 document is that it eliminates the second step on the WHO’s model of treating pain: a three-step pain treatment ladder. The report explains that under the initial guideline, the WHO recommended that physicians start pain patients on non-opioids like Tylenol before moving them “up the ladder” to a combination of non-opioids with low-strength opioids. If the first two failed in treating a patient’s pain, then the WHO recommended moving up to stronger opioids like OxyContin.
“Purdue’s planning documents from the 1990s identified replacing combination drugs with OxyContin on step two of the WHO’s pain ladder. In 2012, the WHO gave Purdue exactly what they wanted. (In the 2012 guidance) if a child’s pain is assessed as moderate to severe, the WHO recommends skipping step two altogether and moving straight from non-opioid medication to strong opioids like OxyContin,” the report said.
In a statement, Purdue had said that the congressional report “seeks to vilify the company through baseless allegations". Purdue’s relations with third parties are “transparent, and any potential conflicts of interest are fully disclosed", the company said.
Based on their findings, Clark and Rogers also wrote a letter to the WHO, requesting that the organization rescind the two guidelines. “We hope that after ignoring our warnings in 2017, you will immediately rescind these two guidelines, provide us with a comprehensive explanation of why your internal controls failed to prevent this scheme, and issue a warning to the world that your 2011 and 2012 guidelines should not be followed," said the May 22 letter addressed to WHO Director-General Dr Tedros Adhanom Ghebreyesus.
Following these allegations, the WHO withdrew the two guidelines in June 2019, stating that the organization “takes very seriously concerns recently raised” about its 2011 and 2012 guidelines. “WHO is discontinuing these guidelines in light of new scientific evidence that has emerged since the time of their publication. This will also address any issues of conflicts of interest of the experts that have been raised. WHO remains fully committed to ensuring that people suffering severe pain have access to effective pain relief medication, including opioids. WHO is concerned that there is very low access to medication for moderate and severe pain, particularly in low and middle-income countries,” said a June 20 WHO statement.
The WHO said it recognizes that the need for access to pain relief must be balanced with concerns about the harm arising from the misuse of medications prescribed for the management of pain, including opioids. The organization said that scientific evidence indicates there are risks associated with the use of these medications such as the development of dependence, overdose and accidental death. Even when prescribed according to established clinical guidelines and patients’ needs, and used as directed, certain factors may increase these risks, it emphasized.
Overdose deaths involving opioids, including prescription opioids, heroin and synthetic opioids (like fentanyl), have increased almost six times since 1999 in the US, according to the US Centers for Disease Control and Prevention (CDC). In 2018, 67,367 drug overdose deaths occurred in the US and opioids were involved in 46,802 overdose deaths, that is 69.5% of all drug overdose deaths.
US halted WHO funds at the start of AIDS outbreak
Trump's decision to suspend payments to the WHO is not the first time a US president has withheld funds and criticized the organization early in a pandemic. It was done by former US President Ronald Reagan in the 1980s when HIV/AIDS had started emerging as a killer.
"President Reagan did it in the 1980s as HIV/AIDS began to emerge as a global killer. And DA Henderson, then dean of what would become Johns Hopkins Bloomberg School of Public Health, advocated fiercely for the WHO," says a report by the Johns Hopkins Bloomberg School of Public Health.
After Reagan took office in 1981, his administration “assailed the UN and its agencies as an unaccountable, bloated bureaucracy". Congress voted many times to postpone an $86M payment. By the end of 1987, for the first time since the creation of the WHO in 1948, the US had failed to send all of its promised payments for over a year.
“In mid-1987, as top world leaders attended the first special session on AIDS at the G7 summit, WHO faced its worst budget crisis to date, largely because of the withheld US payments. Henderson noted in the Washington Post, America’s 'embarrassing and awkward' position because the US was both the epicenter of the AIDS epidemic and the only country in default to WHO," the blog said.
Calling AIDS "the most serious global epidemic of recent centuries", Henderson asked the president and Congress not to “cripple, perhaps destroy the one organization which can contain this foe". The payments, however, remained on hold for another 18 months.
"In September 1988, as Reagan prepared his final address to the UN, he was warned that he might be booed if the US had still not released the funds when he spoke. At the 11th hour, he relented and ordered the release of the backlog of UN commitments. In return, the UN agreed to a 15% staff cut and a much smaller austerity budget,” the report said.