Politicians and journalists often tell a story about greedy pharmaceutical companies that turned doctors into dealers and patients into addicts. And now, we're told, tens of thousands of Americans are dying of overdoses every year because of government inaction.
If this is truly an epidemic, the diagnosis is wrong in a few major ways. And the cure prescribed by the government is making the disease worse.
Pain and Suffering
Dr. Forest Tennant is one of the last doctors in America willing to treat pain patients using high doses of opioid painkillers. He operates out of a strip mall in West Covina, California. And he's contacted by patients from all over the country on a daily basis, pleading with him to treat them because nobody else will.
But in a matter of months, thanks in part to increased pressure in the government's war on opioids, he may be closing his clinic's doors, which have been open since 1975.
When Reason did a story on Tennant's clinic in 2017, his patients spoke of how government restrictions on opioid use were causing legitimate pain patients to suffer needlessly. Four months after we ran that story, the DEA raided Tennant's clinic and home. The search warrant accused him of overprescribing medication and accepting payoffs from the pharmaceutical company INSYS. Tennant has earned speaking fees from the company as recently as 2015, which he says is standard practice. And his nonprofit clinic regularly operates at a loss, according to financial statements submitted to the Department of Justice.
"I think the government is trying to kill me and every one of [Tennant's] patients," said Gary Snook, a resident of Montana, when asked about the raid on Tennant's clinic. Snook, who suffers from chronic pain resulting from back surgery complications, turned to Tennant when he couldn't find adequate pain treatment from a local physician.
"We have no place to run," says Snook.
Last year, the Centers for Disease Control recommended new opioid prescription guidelines, with a maximum dosage of 90 morphine-milligram equivalents (MME) a day. Although the guidelines were supposed to be voluntary, Tennant says most physicians have begun to treat them as mandatory. Several states have adopted legislation that mirrors the federal recommendations.
"I do not know of physicians who will be willing to prescribe high-dose opioids anymore," says Tennant.
This situation has put a target on the back of doctors who don't follow the guidelines, and Tennant says the pressure that the guidelines have put on him are a major reason that he's decided to wind down his practice and focus on tapering his patients down below 90 MME so that they can find other doctors to treat them once he retires.
But he maintains that some patients exhibit genetic variations that require them to take unusually high doses of opioids to achieve pain relief.
"I don't know how those people are going to get down to 90," says Tennant. "There has been propaganda—and it's pure propaganda—that you can just stop opioids. No need to taper them. Just stop. And we're going to have some patients commit suicide."
Prohibition, Then and Now
Government officials like Attorney General Jeff Sessions and former New Jersey governor Chris Christie, who heads the President's Commission on Combating Drug Addiction and the Opioid Crisis, have repeatedly blamed the problem on doctors overprescribing opioids to their patients and turning them into addicts.
"It's not starting on our street corners. It's starting in our doctors' offices and hospitals," Christie told CNN's Jake Tapper in July 2017.
But the story isn't quite so straightforward. Several studies, including a recent one out of Harvard, pegs opioid abuse among postsurgical patients at less than one percent. Estimates about abuse among chronic pain patients vary, with the high end being a little less than eight percent.
"Most policy makers have bought into this idea that we doctors prescribe opioids to our patients, who then rapidly become drug addicts," says Jeffrey Singer, a Phoenix-based general surgeon and policy analyst (and a donor to Reason Foundation, the nonprofit that publishes this website). "All of the evidence suggests that this is not the case."
Singer says it's a myth that most nonmedical users start on pills prescribed to them by a doctor. Instead, they more often borrow, buy, or take them from a friend or family member with leftover pills. The DEA calls it "diversion." A 2014 analysis of data from the National Survey on Drug Use and Health (NSDUH) confirms that most nonmedical pain pill users obtain their pills via diversion, not directly from a physician.
In many ways, the story of the opioid overdose crisis begins with the introduction of OxyContin to the US market in 1995. It promptly became the pill of choice for nonmedical street users of opioids.
Purdue Pharma, the manufacturer of OxyContin, was aware of its popularity as a street drug, which it allegedly worked to conceal. Yet the company also created abuse-resistant formulations (ADFs), which are uncrushable and can't be liquefied. By doing so, the company was able to extend the drug's patent. With encouragement from the Food and Drug Administration, Purdue soon made all OxyContin pills uncrushable. Singer says policies of this sort have profound unintended consequences.
"The only thing [ADFs] have done is to make nonmedical users switch over to something other than [pain pills], and most of the time it's been heroin," says Singer.
Singer compares ADFs to attempts by the federal government to control alcohol consumption during Prohibition. The government ordered the "denaturing" of industrial alcohol through the addition of unpalatable chemicals. But it's hard to stop determined consumers from getting what they want, and people kept drinking the denatured alcohol. So the government went a step further by adding poison to the alcohol, a move that likely resulted in thousands of deaths.
Seymour Lowman, the assistant U.S. treasury secretary partially responsible for overseeing alcohol prohibition, even said that if drunks were "dying off fast from poison 'hooch'" then "a good job will have been done" if it meant a more sober America. Singer doesn't think that modern government officials have the same attitude but argues that the effects are quite similar.
"If [policy makers] step back and think about what they're doing by promoting abuse-deterrent formulations of opioids, they're in effect doing to same thing that alcohol prohibition people did. They're driving people to much more deadly, dangerous substances," says Singer.
A June 2017 National Bureau of Economic Research paper found that "there appears to have been one-for-one substitution of heroin deaths for opioid deaths. Thus it appears that the intent behind the abuse-deterrent reformulation of OxyContin was completely undone by changes in consumer behavior."
The Nature of Addiction
"The focus on prescription pain killers is especially misguided now that the vast majority of opioid-related deaths actually involve illegally produced drugs," says Reason's Jacob Sullum.
Sullum been writing about the suffering caused by restricting access to pain medication for 21 years. His April cover feature for Reason magazine examines the myths underlying the government's response to the opioid overdose problem. He says the misguided focus on the supply of opioids is a proven failure but that politicians continue to do it because it's much simpler than dealing with the complicated nature of addiction.
Jillian Monda is an Ohio-based bartender and photographer who struggled with and overcame an addiction to heroin several years ago. She says her boyfriend introduced her to heroin and that she took to it because it allowed her to turn off her mind and forget about a recent sexual assault she experienced and keep her obsessive-compulsive disorder under control.
"Heroin is really good at making you not feel anything at all," says Monda. "The big unifying factor [among users I knew] was that everyone had some kind of mental problem or thing they were trying to avoid…and rather than getting proper psychiatric care for that, they were doing heroin."
Victims of trauma like Monda, or people with mental illnesses who are self-medicating, are far more likely to develop an opioid addiction than are pain patients. To deal with these complex psychological and social problems, Sullum says a more nuanced approach than supply-side prohibition is needed.
Cities like San Francisco and Oakland, California are at the forefront of what's called the "harm reduction" movement in America.
"Harm reduction is, at its core, a pragmatic way of looking at all risk-taking behavior," says Eliza Wheeler of the Harm Reduction Coalition, a policy organization that advocates for harm reduction measures such as needle exchanges, many of which operate in the Bay Area. These exchanges allow heroin users to turn in dirty needles and obtain clean ones to prevent the spread of diseases. They also offer medications like naloxone, which can save lives by reversing the effects of an opioid overdose.
And now San Francisco's Department of Public Health is preparing to convert some needle exchanges into "safe consumption sites," where drug users can shoot up, snort, or smoke their drugs under supervision.
San Francisco would be the first American city to allow safe consumption sites, but Vancouver has already allowed the practice for years and the U.S. Surgeon General recently announced support for the idea in the United States.
"The problem with implementation [of harm reduction measures] is not lack of evidence that it works," says Wheeler. "What we're battling is a moral discomfort."
There's an even more radical approach than harm reduction. In response to its own overdose crisis, Portugal decriminalized all drugs in 2001. The country saw rates of overdose deaths, disease transmission, and overall use fall. Portugal's drug overdose rates are now approximately six deaths per million people. In the U.S., it's 312 per million.
Meanwhile, the DEA investigation of Dr. Tennant is still ongoing. He hopes to find another doctor to take over his clinic. If not, he'll close its doors by the end of June, and his patients—already turned away by their hometown doctors—will need to find someone else to care for them.
"When people get hopeless is when they think about suicide," says Tennant. "And so we need to give people some hope. If nothing else, let them know that somebody cares."
Sullum says that if the government doesn't change its approach to opioids soon, we can expect more of the same results.
"The strategy the government seems to be pursuing is one of harm maximization," says Sullum. "If it continues to do that, at the expense of harm reduction policies, you're not going to see a decrease in opioid-related deaths—and in fact, they may continue to go up."
CORRECTION: This story originally stated that the Harm Reduction Coalition "funds and oversees" needle exchanges. Though the Harm Reduction Coalition does provide support in the form of coordinating the distribution of naloxone, it is a policy organization and doesn't directly fund or oversee the operation of exchanges. The text has been edited to correct the error.
Produced by Zach Weissmueller. Shot by Alex Manning, Jim Epstein, Lexy Garcia, and Weissmueller. Additional graphics by Brett Raney. Additional color correction by Todd Krainin.
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