The Government's Top Minds Are Working Hard to Make Painkillers 'Tightly Regulated Yet Easily Available'

Yesterday I noted a New York Times profile of Nora Volkow, director of the National Institute on Drug Abuse, focusing on her simplistic, reductionist view of addiction. I should have mentioned that she and her amanuensis at the Times, Abigail Zuger, also had some woefully misguided things to say about the conflict between drug control and pain control:

Prescription drugs, she continued, have a double life: They are lifesaving yet every bit as dangerous as banned substances. "The challenges we face are much more complex," Dr. Volkow said, "because we need to address the needs of patients in pain, while protecting those at risk for substance use disorders."

In other words, these drugs must be somehow legal and illegal, encouraged yet discouraged, tightly regulated yet easily available.

How is that possible? It isn't. Because pain cannot be objectively verified, there is an unavoidable tradeoff between providing adequate treatment and preventing people from getting high. Even if you think the latter goal is a legitimate function of government, protecting one group of people from their own bad choices simply cannot justify forcing another group of people to live (or die) with horrible pain. Morally, this is a no-brainer: It is better to let 10 addicts trick doctors into prescribing them narcotics than to let one legitimate patient suffer needlessly.

That is not how the government, as channeled by Zuger, sees it:

Treating people with the prescription drug problems is particularly challenging, because, of course, for these particular drugs, physicians are the nation's pushers.

The number of prescriptions written for potentially addictive pain medications has soared in the last decade, reaching more than 200 million in 2010, Dr. Volkow said. Surveys asking teenagers where they get pills find that relatively few buy from strangers. Many have their own prescriptions, often from dental work. Even more are given pills by friends and relatives, presumably out of other legitimate prescriptions.

Doctors may be flooding the country with narcotics, but most have never learned much about pain control. Dr. Volkow said that some data suggests that medical schools devote considerably less time to the subject than veterinary schools do. The Obama administration addressed exactly this deficiency in April with a call for doctors to undergo special training before being allowed to prescribe some of the most addictive painkillers.

"Students and residents have gotten the message that pain is undertreated," said Dr. Mitchell H. Katz, an internist who directs the Los Angeles County Department of Health Services. "So they just prescribe higher and higher doses." 

The official narrative that emerges from the Times article goes like this: Doctors used to be unnecessarily reluctant to prescribe opioids, but now they are erring in the other direction. Therefore we need to crack down on prescriptions, because too many people are using these drugs for nonmedical reasons. But such a crackdown inevitably hurts people in pain, because it encourages doctors to distrust their patients.

In an April column, I argued that the Obama administration's anti-diversion recommendations would limit access to pain treatment. More on pain treatment here.