Heroin overdose rates doubled in 28 states between 2010 and 2012,according to the Centers for Disease Control and Prevention. A record-breaking 28,000 Americansdied of opioid overdoses in 2014. In 2000, the age-adjusted drug overdose death rate was 6.2 per 100,000 persons. By 2014, it had more than doubled, to 14.7, according to the CDC.
By: Cathy Reisenwitz
This article first appeared at FEE.org
The truth is that many of those deaths are completely preventable and result not from painkillers, but from the Drug Enforcement Administration’s war on painkillers.
This week, the Senate is likely to pass the 21st Century Cures Act. Among other things, it allocates $1 billion to help states “combat heroin and painkiller addiction and recovery.” Policymakers would be wise to make sure that states don’t use that $1 billion to make the problem worse.
Who’s Taking Opioids?
Marine corporal Craig Schroeder served in Iraq. In the so-called “Triangle of Death” region, south of Baghdad, a makeshift-bomb explosion left him with traumatic brain injury. Schroeder returned home with a broken foot and ankle and a herniated disc in his back. He suffers from chronic pain in addition to hearing and memory loss.
A study in the Journal of the American Medical Association showed that half of all troops who return from Iraq and Afghanistan suffer from chronic pain.
This isn’t a new phenomenon. During maneuvers in Germany in 1979, retired Army corporal Mike Davis shattered his left arm from the elbow to the fingertips when he fell from a Pershing missile. He’s needed painkillers ever since.
Accidents, failed surgery, degenerative conditions, or all of the above can cause chronic pain. It can hit anyone at any time. In an unpublished paper, Dr. Harvey L. Rose told the story of a 28-year-old man with persistent leg pain caused by a work accident that lumbar disc surgery couldn’t fix. Rose also treated a 78-year-old woman left with chronic back pain after surgery for degenerative cervical disk disease didn’t work.
Forcing Users into the Black Market
The Drug Enforcement Administration actively prevents patients from getting the prescription painkillers they need. It started in the 1970s, when the DEA’s reporting requirements made many doctors decide to stop prescribing painkillers altogether. Why go through the hassle of ordering triplicate forms and turning them over to the government? Many others stopped out of fear. The DEA sent armed men to arrest Ronald Blum, associate director of New York University’s Kaplan Comprehensive Cancer Center. It turned out he’d done nothing wrong, other than accidentally filling out his forms incorrectly. That mistake cost him $10,000 in legal fees.
Even in 1973, pain undertreatment was endemic, according to Psychiatrists Richard M. Marks and Edward J. Sachar, writing in the February Annals of Internal Medicine.
And the regulations keep coming. In 2015, the DEA decided to require patients to see their doctor, in person, every month in order to get refills for hydrocodone-based medicine. Earlier this year the CDC released guidelines that discourage clinicians from prescribing opioids. The agency recommended doctors prescribe the “lowest effective dose” and “no greater quantity than needed.”
The Black Market Solution
Opioids work by mimicking chemicals our brains produce naturally. The problem for long-term users is that the brain stops producing them if it doesn’t have to. Stopping medication leaves sufferers “constantly sore, sensitive to pain, depressed, fatigued but unable to sleep,” according to Siegel.
Chronic pain sufferers who can’t get their medication experience withdrawal symptoms that “feel like a panic attack and the flu at the same time,” according tothe Washington Post.
Going without painkillers isn’t an option for many people who need them. Dr. Rose’s 28-year-old patient turned to alcohol and street drugs after his doctor prescribed an antidepressant instead of a painkiller.
He later hanged himself in his garage.
The 78-year-old woman Rose got into her bathtub with an electric mixer after a series of physicians refused to prescribe an effective dose of painkillers. In all she tried to kill herself four times, slashing her wrists and overdosing on Valium and heart medication.
Thanks to the DEA, men and women who lost limbs serving in Iraq and Afghanistan are needlessly entering withdrawal. After the DEA rules change, Schroeder’s VA doctor couldn’t see him for nearly five months. This isn’t unusual. Schroeder spent those months bedridden in crippling pain and opioid withdrawal. Another Iraq vet can’t drive due to shrapnel in his femur and pelvis. Getting his medications requires a monthly two-hour bus ride for “a one-minute consult.”
Patients who can’t find legal opioids because of the DEA turn to heroin and other black market opioids. With legal prescription opioid medication, chronic pain sufferers know their dose. Without accurate labeling, they must estimate their drugs’ purity, which varies according to source. When they guess wrong, they overdose. Even worse, heroin has a smaller margin of error than prescription opioids. Meaning if you guess wrong with heroin, you’re more likely to die.
The CDC suspects that many, if not most, of the people who died of opioid overdoses in 2014 were taking black-market fentanyl. Many drug dealers add fentanyl to heroin without letting users know.
When the CDC reports on opioid deaths, that includes street drugs like heroin and synthetic opioids. Toxicology tests used by coroners and medical examiners can’t distinguish black-market fentanyl and prescription fentanyl. But we do know that there was more of the illegally-manufactured, synthetic opioid-derived fentanyl available in 2014 than in previous years, according to law enforcement reports. This coincided with the 2014 jump in deaths from opioid overdoses.
In addition, we know that patients combine drugs when they can’t get enough painkiller. Combinations of opioids and drugs like alcohol make up 60% of deaths ruled opioid overdoses by the CDC. New York City government datashows that more than 90% of opioid overdose deaths involve mixtures of opioids with other drugs.
The toxicology tests did reveal that almost none of the opioid deaths involved methadone. Methadone and buprenorphine are synthetic and semi-synthetic opioids that are proven to divert patients away from the black market. Whether a person is no longer in chronic pain, doesn’t like the side effects of opioids, or is caught in a lifestyle they don’t enjoy, these drugs safely keep withdrawal symptoms at bay.
The key, again, is dosing. Under close medical supervision, methadone activates your brain’s opioid receptors just enough to prevent withdrawal, but not enough to get the user high.
Zachary Siegel is a MA candidate at the University of Southern California’s Annenberg School for Communication and Journalism and has been treated for opioid addiction.
“This gives the brain, and most importantly, one’s connection with the world, a chance to rebuild,” Siegel wrote of his experience with the drugs. “Simply put, these medications hydrate a thirsty system. Synthetic and semi-synthetic opioids help stabilize users and stanch these side effects while giving the brain a chance to heal. On these drugs we can work, drive, and behave virtually indistinguishably from ordinary Janes and Joes.”
Yet the DEA keeps patients from getting methadone and buprenorphine treatment. The DEA forbids doctors outside of highly regulated clinics to prescribe these drugs. The DEA meddles in buprenorphine prescriptions to an unprecedented degree. Even in those clinics, only doctors who’ve completed an eight-hour course and applied for a special license from the DEA are legally allowed to prescribe buprenorphine. And even those doctors can only prescribe it to 275 patients. This is all part of why three-quarters of U.S. opioid-use disorder patients don’t get these medicines.
Dependence Isn’t Addiction
Jacob Sullum pointed out that bureaucrats accept “dependence” on heart or cholesterol medicine. Nobody talks about being addicted to Lipitor. But the government is willing to make criminals of people who depend on certain types of painkillers.
This is nothing new. In 1973, Drs. Marks and Sachar looked at why patients were complaining about pain after doctors gave them medication. They found that, in “virtually every case.” doctors and nurses were under-prescribing pain medication. Further surveys of patients and doctors found “a general pattern of undertreatment of pain with narcotic analgesics, leading to widespread and significant distress.” The problem was, and is, that doctors don’t understand the difference between tolerance and physical dependence, causing “excessive and unrealistic concern about the danger of addiction.”
An article in a 1993 National Institute on Drug Abuse newsletter said narcotics “are rarely abused when used for medical purposes” and lamented that “thousands of patients suffer needlessly.”
“It’s just insulting to the veteran to assume they are abusing these drugs,” Linda Davis said of her husband Mike Davis. “I’m fully aware that people doctor-shop, some docs overprescribe. But I think they need to realize that there’s a real difference between addiction and dependence.” VA patients suffer nearly double the overdoses of the national average, according to a 2011 American Public Health Association study.
This moralizing and dearth of empathy fuels policies that spend tax dollars to “make our lives more difficult and painful,” Sullum wrote.
We Know How to Cure Addiction and Save Lives
If the goal is to prevent overdoses, we already know how to do that.
A 2015 U.K.-based studyfound that opioid-dependent patients treated with medication like methadone and buprenorphine were half as likely to die of an overdose within four years as counseling-only patients. Australia found similar results in their 2014 study of opioid-dependent patients leaving prison. Methadone or buprenorphine treatment reduced their risk of overdose death by 75 percent.
The World Health Organization calls methadone or buprenorphine “essential” for keeping people out of the black market for opioids, which besides saving lives, also reduces crime and the spread of infectious diseases. France allowed doctors to prescribe methadone and buprenorphine when they deemed it necessary during the 1995 HIV outbreak. In the years since, France reduced their overdose deaths by 80 percent. Baltimore cut overdose deaths by 66% by 2008 after making methadone or buprenorphine move available in 1995.
The data is clear. By making methadone or buprenorphine harder to get, the DEA has caused death, disease, and crime.
Will this Money Fund More of the Same?
The DEA wants you to think that overprescribing opioids leads to addiction. Even Huffington Post reporters are buying the story, reporting that the pharmaceutical industry has spent billions of dollars over the last decade encouraging doctors to prescribe OxyContin and other opioids. True as that may be, that’s not the reason opioid pain reliever deaths are up.
The irony of blaming prescriptions of OxyContin for opioid deaths is twofold. First, opioids are still underprescribed. Jacob Sullum reports that prescription painkiller has declined recently.
Second, opioids are actually safer than most other pharmaceuticals. The most serious common side effect of long-term opioid use? Constipation.
Aggressive DEA enforcement causes opioid underprescribing. This means patients can’t access safe pain medicine. Facing chronic pain and withdrawal, patients take black-market opioids. The reduction in prescription painkiller use has been accompanied by an increase in heroin use.
A 2014 JAMA Psychiatry study found that most young heroin addicts entering treatment had previously been on prescription painkillers, and more than 90% of them switched to heroin because it was cheaper and easier to get.
This causes overdoses. Not only is it intuitively obvious to anyone who bothers to think about it, it’s even backed up by CDC data.
People simply don’t overdose on prescription painkillers under medical supervision. They overdose when they can’t get the medicine they need and turn to the black market for help. The DEA’s efforts to keep chronic pain sufferers from accessing prescription painkillers and methadone is literally killing them.
And yet lawmakers and reporters keep buying the DEA’s lies that prescription opioids cause overdose deaths. New Hampshire Senator Jeanne Shaheen said of the 21st Century Cures Act, “My goal has been trying to get funding to address the heroin and opioid epidemic. And there is significant funding in this bill.” She alsosupports increasing federal funding “for all aspects of Drug War.”
The 21st Century Cures Act looks likely to pass, with bipartisan support and the Obama administration’s blessing. But if we want to end the opioid overdose epidemic, we don’t actually need to spend $1 billion. We could just abolish the DEA, which would also free up$28 billion.
Think that sounds crazy? Portugal decriminalized heroin, along with every other drug, in 2001.
Check out what happened to their overdose deaths:
In Portugal, three out of a million people die each year by overdosing on any drug. Just as a reminder, each year in America 14.7 out of every 10,000 people die of an opioid overdose. Sure, decriminalization demonstrably and unambiguously saves lives. But won’t it lead to more drug use?
The other key to preventing overdose deaths is legalizing over-the-counter sales of naloxone nationwide. In the same way that you use an EpiPen to reverse anaphylactic shock, naloxone reverses opioid overdoses. It still requires a prescription in most states and is outright banned in three. We should also make sure people who call the ambulance when their friend overdoses won’t face criminal charges.
Since most opioid-related deaths involve alcohol or other drugs, awareness campaigns about the dangers of combining opioids could help. But more important than teaching people not to combine is giving them access to enough safe drugs that they aren’t tempted to.
The best thing the Trump administration could do to end the overdose epidemic is to stop the war on painkillers. Psychiatrist Jerome H. Jaffe, Richard Nixon’s drug czar, himself said, “No patient should ever wish for death because of his physician’s reluctance to use adequate amounts of potent narcotics.”