The Corner

Politics & Policy

Opioids: Politicians Should Not Play Doctor

Back in January 2013 I put up a post over on Ricochet on moves to cut access to prescription painkillers by then Mayor Bloomberg and the rather better qualified FDA.

As the New York Times reported, the FDA explained (my emphasis added):

Trying to stem the scourge of prescription drug abuse, an advisory panel of experts to the Food and Drug Administration voted on Friday to toughen the restrictions on painkillers like Vicodin that contain hydrocodone, the most widely prescribed drugs in the country. The recommendation, which the drug agency is likely to follow, would limit access to the drugs by making them harder to prescribe, a major policy change that advocates said could help ease the growing problem of addiction to painkillers, which exploded in the late 1990s and continues to strike hard in communities from Appalachia and the Midwest to New England. But at 19 to 10, the vote was far from unanimous, with some opponents expressing skepticism that the change would do much to combat abuse. Oxycodone, another highly abused painkiller and the main ingredient in OxyContin, has been in the more restrictive category since it first came on the market, they pointed out in testimony at a public hearing. They also said the change could create unfair obstacles for patients in chronic pain.

My comment then:

Chronic pain? No matter. Just suffer a little bit.

And, no, this won’t achieve anything. There will just be something else.

There was.

Lessons have not been learned.

Charlotte Gazette-Mail:

States are enacting strict limits on the number of powerful prescription painkillers doctors can prescribe, a move that many believe will help fight the opioid crisis but has raised alarms among some physicians.

At least 17 states have enacted rules to curb the number of painkillers doctors can prescribe. Some, including Arizona, Connecticut, Delaware, Massachusetts, New Jersey and Ohio, have passed laws limiting the duration of initial opioid prescriptions to five or seven days. Others are passing dosage limits. In Kentucky, a law went into effect last month capping opioid prescriptions for severe acute pain to three days…

Writing for the American Council on Science and Health, Josh Bloom notes that Oxycontin in its abusable (pre-2010) format had been “a significant driver of opioid addiction since its introduction in 1996”, but he also notes the “fallacy that is now all but “fact” is that opioid pills are now responsible for the surge in overdose deaths in the US”, but (my emphasis added):

A bit of digging around on the NIH [National Institute of Health] site tells us otherwise. In 2010, the year that OxyContin became abuse-resistant, 20,000 people died from opioid overdoses. During the ensuing five years, OxyContin abuse dropped and the strict restrictions we now see on opioid pills began to take hold. The result? Between 2010-2015 [annual] opioid overdose deaths in the US increased by 65%, roughly 13,000. And even a cursory examination of Figure 2 [You’ll have to follow the link to the whole piece to see the chart] shows that increase was entirely due to injectable drugs like heroin or fentanyl.

There was indeed “just something else”.

From an earlier (November, 2016) piece by Bloom:

Once abuse-resistant OxyContin (pure oxycodone, the opioid medication in Percocet) was approved in 2010, its use immediately declined by 66 percent. But, between that time and 2013, overdose deaths from heroin (more accurately heroin and/or fentanyl) more than doubled, as addicts were forced to turn to these cheaper, more available, and more dangerous drugs. Not only did heroin/fentanyl overdose deaths go through the roof, but outbreaks of HIV (from needle sharing) were subsequently seen in Indiana, Kentucky, and Tennessee.

This same trend was seen in different forms in different areas of the country.

To deny that there is an opioid crisis would be lunacy, and it’s unsurprising to see commenters asking Bloom what he would do.

Here’s his ‘lead’ answer (again my emphasis added):

This is both easy and difficult. The “easy” part is admitting that harsh restrictions on prescription opioids have provided no benefit, only harm, especially to pain patients. The entire 2016 CDC Guideline for Prescribing Opioids for Chronic Pain has to be thrown out. The CDC and PROP premise that limiting prescriptions will prevent pain patients from becoming addicted is clearly wrong. The data that I showed proves that it does nothing of the sort. Addiction to opioid in pain patients – even those who have been treated long term- is rare, and there is plenty of evidence to support this. Addiction arises from *recreational*, not therapeutic use of the drugs.

While pill mills must be shut down, the government must stay out of the doctor’s office. There cannot be arbitrary limits on dose or number of pills. Doctors who act in good faith should not have to worry about getting on a DEA list (they do). Patients with real needs should NOT have their doses involuntarily tapered down. This is barbaric. The care of patients is none of the government’s damn business. Loosening the tight restrictions on prescribing meds for pain patients and the physicians who treat them is essential.

These new laws and policies punish the innocent to protect the guilty.

For those already addicted, there is no easy answer. With fentanyl replacing heroin, addicts will die sooner or later. It is inevitable. If this takes wider use of methadone to stem this tide, so be it. The Puritanical objection to “replacing one drug for another” may sound appealing, but this is real life. Harm reduction, not philosophy is what is crucial.

The war on drugs has never been won. Carrying it out on the backs of the sick and injured is inhumane.


And making things worse is, well…

As to what should be done, that is an enormously difficult question, and it is a question that is likely to become even more acute. As automation creates ever higher levels of structural unemployment and—don’t forget it— underemployment, more and more people will try to devise more pleasant alternative realities for themselves, perhaps by losing themselves in video games, or maybe by turning to whatever Soma they can find.

I don’t have an answer to this, but I do know that politicians who pretend that they do are making matters very much worse.