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The Lethal Success of Pain Pill Restrictions

A new study provides more evidence that the opioid crackdown is driving people toward deadlier drugs.

In a speech on Monday, Attorney General Jeff Sessions said the Justice Department is striving to "bring down" both "opioid prescriptions" and "overdose deaths." A study published the following day suggests those two goals may be at odds with each other, highlighting the potentially perverse consequences of trying to stop people from getting the drugs they want.

Columbia University epidemiologist David Fink and his colleagues systematically reviewed research on the impact of prescription drug monitoring programs (PDMPs), which all 50 states have established in an effort to prevent nonmedical use of opioid analgesics and other psychoactive pharmaceuticals. Reporting their results in the Annals of Internal Medicine, Fink et al. say the evidence that PDMPs reduce deaths involving prescription opioids is "largely insufficient," adding that "implementation of PDMPs may have unintended negative outcomes—namely, increased rates of heroin-related overdose."

The review covers 17 studies, 10 of which looked at the relationship between PDMPs and deaths involving narcotic pain relievers. Three studies "reported a decrease," six "reported no change," and one "reported an increase in overdose deaths."

The picture looks worse when you take into account deaths involving illegally produced drugs, which now account for a large majority of opioid-related fatalities. Fink et al. found six studies that included heroin overdoses, half of which reported a statistically significant association between adoption of PDMPs and increases in such incidents.

To the extent that PDMPs succeed in making pain pills harder to obtain, they encourage nonmedical users to seek black-market substitutes. "Changes to either the supply or cost of prescription opioids after a PDMP is instituted," Fink et al. observe, "might reasonably drive opioid-dependent persons to substitute their preferred prescription opioid with heroin or nonpharmaceutical fentanyl."

Restricting access to pain pills also seems to be increasing the percentage of opioid users who begin with heroin. A 2015 survey of people entering treatment for opioid use disorder found 33 percent had started with heroin, up from 9 percent in 2005.

If the aim is preventing drug-related deaths, this shift is counterproductive, to say the least. Because their purity and potency are inconsistent and unpredictable, illegally produced opioids are much more dangerous than pain pills.

Comparing deaths counted by the federal government to its estimates of users suggests that heroin is more than 10 times as lethal as prescription opioids. Policies that drive people toward more dangerous drugs help explain why deaths involving heroin and illicit fentanyl have skyrocketed in recent years, even as opioid prescriptions have declined.

A report published last month by the health care consulting firm IQVIA shows that the total volume of opioids prescribed in the United States fell by 29 percent between 2011 and 2017, from 240 billion to 171 billion morphine milligram equivalents. According to data from the U.S. Centers for Disease Control and Prevention (CDC), deaths involving pain pills nevertheless rose by 24 percent from 2011 to 2016, while total deaths involving opioids rose by 85 percent.

That trend includes a 252 percent increase in heroin-related deaths and an astonishing 628 percent increase in deaths involving the opioid category that consists mainly of fentanyl and its analogues. Final CDC figures for 2017 are not available yet, but the provisional numbers indicate there will be more increases.

In addition to magnifying the risks that nonmedical users face, the crackdown on pain pills is hurting patients. Many people who have successfully used opioids to treat severe chronic pain for years now find it difficult or impossible to obtain the medication they need to maintain a decent quality of life.

Since the current strategy is manifestly not working, drug warriors are, as usual, redoubling their efforts. The Drug Enforcement Administration, which sets annual quotas for opioid production, reduced the limit by 25 percent in 2017 and 20 percent this year.

Sessions plans to squeeze the supply even more, because "we are facing the deadliest drug crisis in American history." He seems determined to make it deadlier.

© Copyright 2018 by Creators Syndicate Inc.

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  • Nardz||

    I'm all for removing prohibitions and letting people get what they want over the counter, but Reasons constant bitching is annoying. What are we talking about here? Part of the non-prohibition stance is that with freedom comes responsibility.
    Forgive me for not crying over crackheads who can't get the pills they want and OD. Really don't give a shit if someone who decides to do heroin dies. It's a consequence of choice, not a tragedy.
    Are some people suffering legitimate pain because they can't get a prescription? Im skeptical of the frequency that this happens. Oh no, only 170 billion milligrams of morphine are being prescribed! Yea, seems super unavailable.
    Sure, it's dumb that we need prescriptions- But why does Reason care only about opioid? Why not amphetamines or anything else?
    Could Reason be getting some of that sweet, sweet pharma cash? It's literally the same article every damn day. "Banning opioid is bad because people do heroin and die and others suffer needlessly." Cool - This is the 864th article you've said that and nothing else.
    He'll, not even a single experiment to see if it really is hard to get that prescription. Kinda minimal effort

  • JoeBlow123||

    "Really don't give a shit if someone who decides to do heroin dies. It's a consequence of choice, not a tragedy."

    With choice comes responsibility. Dudes overdosing on fentanyl or heroin are pretty low on my care list.

  • ThomasD||

    Whether someone dies because they got their heroin dose wrong, or packed their parachutes badly doesn't really change things much in my eyes.

  • ThomasD||

    Let's be very clear about one thing.

    This study does not differentiate who is choosing to use the deadlier street drugs.

    Any inference that it is "chronic pain patients" is simply NOT supported by the available data.

    The headline could just as easily read "Prescription Drug Monitoring Plans Not Proven to Save Drug Abusers From Themselves."

    But, then again, nobody ever said they would.

  • Cynical Asshole||

    Sure, it's dumb

    Yes, you are.

  • Rossami||

    re: "Are some people suffering legitimate pain because they can't get a prescription? Im skeptical..."

    Then you a) are not paying attention and b) clearly have no loved ones who suffer from long-term pain or terminal illnesses. Congratulations that you and your family are currently so blessed. For the rest of us who watch our loved ones suffer every day due to inadequate pain management, your comment comes across as clueless and naive.

    My wife, an emergency room nurse, was once forbidden from administering morphine to a patient who was going to die within a matter of days. The reason given was "to prevent the patient from becoming addicted." The utter cluelessness of government bureaucrats is hard to overestimate.

  • LarryWilson||

    People with terminal illnesses are not a part of the opioid epidemic or the ones allegedly turning to street drugs for relief.

    Your anecdote about your wife is nothing more than an anecdote and hearsay until we get the other side of the story. 30 years of emergency medicine experience and I've never once observed the scenario you speak of.

    There is no denial that there is an epidemic that people want to pretend does not exist which is an epidemic of people throttling the health care system to get drugs for no therapeutic intent.

  • JFree||

    Exactly what govt agency forbade her from administering morphine to a terminal patient? Morphine has always been a Schedule 2 drug - which means it is legal for a doctor to prescribe. It has ALWAYS been the 'standard' against which other pain medications have been measured. It has always been legal for the various mfrs to produce and sell. Before the mid 1990's, it was uncommonly prescribed merely for pain (400% increase in prescriptions since then) - but terminal patients were always the patient group who received it.

    I call BS on this. Maybe a doctor or the hospital rules forbade it. But that ain't govt.

  • marshaul||

    According to my conversations with pain management practitioners, they are under intense scrutiny and extreme pressure to cut back on opioid prescriptions. This pressure is applied via the mechanism of licensure: essentially, doctors who are deemed to "overprescribe" or to have exercised insufficient discretion are liable to have their licenses suspended or revoked. A trivial Google search can confirm that this is, indeed, a thing which occurs.

    This, by the way, is how you can tell that the hyper-insecure closet Republicans who have infested the Reason commentariat of late are entirely ignorant of libertarian thought, despite their constant (and transparent) attempts card-check the Reason staff over their putative lack of bonafides. Anyone who has spent years thinking as a libertarian doesn't need to have this sort of indirect pressure explained as to a child; we are all aware of the mechanism used by the Federal government to extend its hegemony past its Constitutional limits.

    Meanwhile, the closet Republican are, like children, effortlessly mislead by not-even-Orwellian doublespeak, e.g. "it's hospital policy". Sure, yeah, it's hospital policy, but you never stopped to consider why that might be the case.

    Go crawl back under your rock, JFree. You're just a crappy human being, morally and intellectually.

  • Ogre||

    Speaking as someone who lives with debilitating, chronic pain, to the point when there are some days where I cannot walk, and I have to use a fucking bedpan, because the blood pressure spike from the pain of moving myself to a toilet could literally give me a stroke....

    I'm a disabled vet. The VA used to issue me vicodin, and about 30mg/day gave me decent quality of life. I could walk, I could even take a shit all by myself, and bend enough to wipe my own ass.

    Then the DOJ/DEA/Fucking retards at the VA decided that I needed a pain management contract, because 'reasons'. I had to take a piss test every 60 days. Immediately after that, they shut me off entirely, because actually giving me a piss test ever two months was 'too much trouble'.

    Now? I get nothing. I have good days, and bad. Some days, my wife has to wipe my ass, because I can't reach.

    Shit, -hospitals- are having a hard time getting enough opiates.

    If you don't understand why Session's treatment of opiates is a huge freaking problem, you live a charmed live. Treasure it, because some day, you're gonna hurt. And you're gonna need drugs. And you won't get them.

  • swampwiz||

    I was once given vicodin for a nasty cough. Yes, the cough went away stat, but the withdrawal was really bad (I had only taken like 2 doses); I could see why junkies are always looking for the nest hit.

  • Ogre||

    eh, I didn't have any withdrawel. And frankly the side effects sucked. But being able to go take a piss whenever I wanted was kinda nice. Instead of having to ask someone to help me. Oh, and the not being in blinding pain was nice, too.

  • Sedona Vortex Hunter||

    loi, what horseshit. You had no withdrawal from 5mg Vicodin for a couple days idiot. You may have had some other issue you decided to blame drugs for, but it was not withdrawal.

  • Eman||

    No, what reason is constantly bitching about, I assume, is that we have figured out ways to prevent at least the most preventable overdose deaths, but we make them unavailable to the people who need them the most. J That's what's stupid.

  • Sedona Vortex Hunter||

    it does something else too though, and this is impossible to actually measure, but it is prevalent in every single case where a patient (especially ER) presents with pain. The doctor is suspicious of nearly every pain complaint. The damage this does to the trust between patient and doctor is immense and causes endless anxiety and even misdiagnosis. If doctor knew opiates could be bought legally without a script they would never again suspect patients of lying about their pain.

    I can't overstate how much damage this causes. Pain is an extremely common reason to see the doctor. That some ER's and doctors now claim to not treat pain is a complete joke. I am not even sure how a person could be a proper doctor in this manner. You don't go t o the doctor or ER because you feel fine. That you have to worry about saying you are in pain is a fucking insane. Personally I fucking resent it and it makes me distrust and not like the doctor.

    This is all created by the drug war and opiate panic. A friend of my sisters had a string of bad headaches and was labeled a 'drug seeker' by the ER. They sent her home and she died from bleeding in the brain. This would have never happened if doctors were not paranoid about pain as a symptom. I cant even believe it has come to this when I type it....patients have to fucking worry about presenting with pain...lol WTF

  • MikeP2||

    "A new study provides more evidence that the opioid crackdown is driving people toward deadlier drugs."

    No...it doesn't.

    This is the study's conclusion taken verbatim:

    "Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences."

    Don't misuse science to push an agenda. Don't misquote studies and cherry-pick what you want to hear.

  • Jerryskids||

    Three of 6 studies found an increase in heroin overdoses after PDMP implementation.

    That's from the abstract, which I would suggest is, in fact, "evidence". What you're quoting says there isn't sufficient evidence to draw a conclusion, i.e. "proof". Which claim the writer didn't make.

  • Echospinner||

    I agree, the meta analysis, I did not go past the abstract, does not support any conclusion.

    Since each state or reporting district has major differences in the population and regulations it is difficult to make any conclusions as the report indicates. They included few studies in the final analysis.

    Answer? We do not know.

  • Jerryskids||

    Pain is God's way of punishing you for being a sinner. Prescribing or using pain-killers is thwarting the will of God. Therefore, Jeff Sessions is doing the Lord's work in denying these sinners surcease from God's wrath. He is the head of the Department of Justice, after all, and Man's justice must be subordinate to the justice of the Lord.

  • ThomasD||

    You have zero evidence that any death counted by this study involved anyone who was using drugs to treat pain.

    Staistically speaking it is likely some of them did have pain, but it is also statiscally likely that the vast majority of the dead were using for reasons other than pain control.

    I'm not arguing in favor of drug laws. I'm arguing against basing arguments over government policy on any sorts of efforts to "save" people. That's is how we got into this mess in the first place. Sullum's approach is never going to lead us out.

  • ThomasD||

    One of these days I'll spell statistically correctly...

  • DajjaI||

    This is all very true, but nothing will change until pain patients get angry enough to infiltrate their local 12 Step meetings and see the losers and malcontents for whose 'sins' they are suffering. Otherwise the fact is, everyone has a deep seated need to believe the addiction narrative: "I just wanted to get high and oops I took one too many." The truth is, most overdoses are suicide attempts in which they took every pill in the house (and bottle of booze). Yes this includes fentanyl overdoses, which are mostly polydrug as well. But like I said, nothing will change until pain patients stop blaming their inaction on pain. Also things will be no better under the progtards. They need the addiction narrative ("my brain made me do it") even more than the conservatives. In part this will be to punish the Trumpkin "oxy electorate", not that they don't deserve it.

  • Inigo Montoya||

    "The truth is, most overdoses are suicide attempts"

    That may well be, but so what? I feel bad for those so lost and hopeless they want to kill themselves, but that is their prerogative so long as no one else is pressuring them into it.

    I love how these nanny statists want to ban all drugs and all guns in part to prevent suicides. Are they also going to ban all sharp objects, Windows that open? How about eliminating all tall bridges? If you're that determined to end your life, you will find a way to do it.

  • UnrepentantCurmudgeon||

    I believe it was Trotsky who once pointed out that if an adult decides to commit suicide there really is nothing you can do to prevent it. More simply: where there's a will there's a way.

  • Inigo Montoya||

    Portugal legalized ALL drugs and what happened? Drug use in general and ODs in particular went down.

    Is Reason pushing an agenda? I certainly hope so. But statists are gonna state, and they make up 97% of the population, and probably 87% of the commentariat.

    If course freedom comes with responsibility. But that rests on each of us as individuals — the same way I'm perfectly free to drink drain cleaner if I want to, but I'm smart enough not to, without any outside pressure from the likes of Jeff Sessions.

    So basically fuck off, slavers.

  • Echospinner||

    Portugal did not legalize all drugs. It is decriminalized on the user level. You bring a kilo of heroin into Portugal and get caught you will go to prison.

    For individual users caught with a small supply the government expanded treatment programs. It is a good approach.

  • Unicorn Abattoir||

    *looks in mirror.*

    Is this my shocked face? I don't look shocked.

  • Sebastian Cremmington||

    Very important column. Opioids work and trying to restrict access harms people in pain that need medication. Germany and America have the most restrictive drug policies and those two countries have the most opioid deaths by far. Restricting access doesn't work and a big part of the movement is Progressives on a new anti-tobacco kick because apparently someone made a lot of money from the OxyContin patent.

  • JFree||

    Neither Germany nor America has anywhere near the most restrictive drug polices (among wealthier countries - Singapore, France, Sweden, etc are stricter than both of them). And Germany doesn't have a bigger opioid death problem than anywhere else. They merely have a big population.

    The country that is unique re the problem is the US. Not because it restricts access to opioids - but because it is responsible for close to 90% of the worlds opioid prescriptions. And our addiction rates are higher (like double at least) than any other countries except the poppy producing countries (who smoke plant opium not pharma/processed anything) and former USSR countries.

    Everywhere else, doctors limit their prescriptions of those to seven days at a time max. So patients don't have much to sell - or much to steal from - or give away. And every seven days, they have to return to the doctor so the doctor can determine the medical basis for a new prescription (if necessary). And doctors WILL transition chronic patients to NSAID's. IOW - they never got the lying sales pitch from the drug mfrs that denied addiction was ever an issue.

  • UnrepentantCurmudgeon||

    As I have related before, I have gone over 10 years without a pain-free day and have undergone the gamut of pain-relieving prescription drugs including opioids. I never risked addiction because my doctor regularly switched my meds, and because I was never prescribed more than a 30-day supply at a time. It really is not that hard to accomplish. And most of the pain patients I know would love to get off the junk; they don't enjoy the side effects and hate that they could become addicted (habituation is actually more of a problem).

  • swampwiz||

    I'm not a pain pill junkie, but I do have problems sleeping (caused in part by me posting comments late at night), so I take Schedule IV zolpidem. A few years back I went through a spell of moving around, and I noticed that a lot of physicians did not like prescribing this for new patients, and I'd often wondered what the big deal was, until I read about some hillbillies in Trump Country who would pop half a month's supply to zonk out. Any pressure to decrease Schedule II opioids will probably have an effect on folks like me getting out Schedule IV Rx.

  • ThomasD||

    While you may still have some sort of underlying problem sleeping it is also quite possible that what you have is dependence on zolpidem. From the standpoint of the doctors sorting that out is difficult, since it involves you not taking zolipidem for a few weeks(first week is withdrawal, next few weeks is to see if you can re-establish a more normal/drug free sleep pattern.)

    The general growing consensus within the professions is that chronic hypnotic (sleep inducing agents) use is better avoided.

  • ThomasD||

    And the common response when this course of treatment is proposed is something along the lines of "I'm fine, I just want the pill. Give it to me or I'll get it from someone else."

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  • W H||

    Reason's is correct.
    The media hair-on-fire over "addiction" and the "opioid epidemic" is hysteria for the sake of readership.

    -Cochrane analysis of over 88,000 cases, demonstrated that addiction arising from a valid prescription has an incidence of 0.5%. This leaves 99.5% of addiction arising from something else. Stupid behavior.
    -Prescription numbers have been dropping since 2010. Doctors knew a long time ago. Yet, all we hear is the yammering about prescription opioids. Why?
    -Illegal opioids: Cheap, super potent fentanyl analogs from China, are the real root cause of the epidemic. Even as prescriptions are falling, illegal drugs are rising at a startling rate. Recreational drugs is a real problem. Why won't the DEA focus on this? Why won't the media and the politicians focus on this? Money and control.
    - The DEA's budget is upwards of $50 (maybe 80+) billion a year. That exceeds the current entire military spending of every country in the world except two - USA and China. And their effectiveness is worse than zero.
    - Solution: Drop the DEA. Get off doctors' backs. Educate the medical profession. Educate the populace about addiction dangers. Educate and treat addicts, especially about synthetics that are so potent that you can't even see a fatal overdose with the naked eye. Stop the billions of tax dollars wasted on coercive, totalitarian policies.

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