We know from a century of prohibition that cutting down the supply of a desired drug tends to encourage stronger, shadier alternatives.
A pharmacist and his tech in Neosho, Missouri. Laurie Sisk /The Joplin Globe via AP
In an unprecedented move intended to help ease America's opioid overdose epidemic, Surgeon General Vivek Murthy sent a letter to every physician in the United States last month, urging them to follow Center for Disease Control (CDC) guidelines by avoiding prescribing opioids for pain whenever possible and treating addiction like a disease. The problem on Murthy's radar isn't exactly a new one, but over the course of a single week in August, some 225 people overdosed on opioids in four counties across four states.
It's increasingly clear, however, that the federal government's emphasis on cutting the opioid supply is failing to stem the tide of opioid overdose—and might even be making the problem deadlier.
Since 2012, opioid prescriptions have fallen by 12 percent, according to data from IMS Health, which tracks pharmaceutical sales; another, similar database operated by Symphony Health Solutions puts the drop at 18 percent. But overdose rates are still climbing. Meanwhile, many pain patients are losing access to the only treatment that works for them, with doctors fearing loss of their license—or worse—if they don't follow the newest guidelines, released in March. One online survey of more than 2,000 chronic pain patients taking opioids found that since then, two thirds had either had their dose reduced or their medications cut off entirely. At the same time, key steps that could be taken that require little in the way of new government funds continue to be ignored.
The most important of these measures consists of expanding access to maintenance treatment with methadone or buprenorphine, the only medications proven to cut the death rate from opioid addiction by 50 percent or more. Further reductions in prescribing opioids risk simply raising the death toll by shifting users from legal meds with standardized content and dosing to far more dangerous illegally manufactured ones, like super potent fentanyl and its derivatives. But in a testament to the toxic legacy of the war on drugs—and despite a kinder, gentler rhetorical approach—supply-side battles are still engrained in American health policy.
"I have deep respect for the surgeon general and his efforts," Dr. Stephen Martin, associate professor at the University of Massachusetts Medical School, told VICE. "We have been hearing for years about safer prescribing practices. My state of Massachusetts, where opioid overdoses are still increasing, is in the lowest quintile of opioid prescribing. [But these] recommendations as the basis for policy in 2016 can be seen as an example of generals fighting the last war."
Martin treats both addiction and chronic pain and told me that what has happened to pain patients and their doctors since the new CDC guidelines dropped has been "chilling." Basically, doctors know that if they are targeted by prosecutors for overprescribing, failing to follow the CDC's voluntary rules could put them in legal jeopardy. In fact, the DEA once set guidelines to help physicians understand what practices would keep them safe from arrest—before withdrawing the guidelines when it seemed like they might be used as a legal defense.
When the goal is cutting supply, keeping docs scared of prescribing at all is the best way to drive it down fast.
"We've been fielding desperate, predictable calls from people who have been abruptly cut off or sharply tapered down on opioids that were successfully working for their chronic pain in the wake of the CDC guidelines and accompanying rhetoric," Martin told me.
Meanwhile, the Obama administration has kept in place (while slightly relaxing) a hard limit on the number of patients a doctor can treat with buprenorphine—a cap not backed by any research at all. (One independent research group, the Pew Charitable Trusts, recently wrote Congress and labeled the limits "arbitrary.") But since the patient cap is enforced by the DEA, doctors who ignore it risk not only their licenses but their freedom.
To be sure, at least when it comes to how they talk about the problem, the feds have adopted a modernized approach to addiction—a sign of progress in the national dialogue, if nothing else.
"Having the surgeon general ask physicians to step up to the plate... is hugely significant," said Dr. Sarah Wakeman, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital. "His call to arms explicitly acknowledges that this is a disease, and it is unacceptable for doctors to simply opt out."
Unfortunately, according to Dr. Martin, only 4 percent of all doctors have completed the required training to allow them to treat addiction with buprenorphine, and there's that pesky patient cap for those who do. The Obama administration has also done little to cut regulatory barriers to access to the other key lifesaving drug, methadone—and in fact, US officials have traditionally stressed that both medications should only be provided in the context of counseling and monitoring of urine tests for other drug use. This is at odds with the science.
"There are many paths to recovery and counseling can be very helpful to people with opioid addiction," said Dr. Robert Schwartz, medical director of the Friends Research Institute in Baltimore. "But the balance of research data does not support making counseling a requirement to receive potentially life-saving treatment with methadone or buprenorphine."
What's perhaps most frustrating is that the current crisis might have been averted with more recognition earlier on that cutting supply doesn't end existing addictions. Far from being an unpredictable result of the crackdown on use of medical opioids that started in the early 2000s, the rise of street heroin markets where they had never previously existed and the subsequent use of fentanyl to boost potency are classic examples of two widely recognized phenomena in drug-policy history.
The first is known as the "iron law of prohibition," which I've written about previously. Basically, the idea is that because illegal drugs need to be kept hidden, harsher laws will tend to promote the spread of more potent and dangerous drugs, simply because smaller quantities are easier to conceal and smuggle. Alcohol prohibition, for example, favored whisky over beer. The rise of illegally produced fentanyl and its derivatives— overdoses of which increased 79 percent between 2013 and 2014 alone—seems an apt illustration of this principle.
The second phenomenon is called the "balloon effect," which occurs whenever supply is interrupted in one location or via one major route. Like pressing on a balloon, cutting the supply simply makes the air bubble pop up somewhere else, rather than eliminating it. So the shutdown of pill mills and increasing pressure on doctors not to prescribe legal opioids has almost certainly been a key driver of America's heroin problem. (The trend toward marijuana legalization, as some have bizarrely suggested, almost certainly has not.)
What's saddest about the situation is the bevy of missed opportunities to help: Medical records at those mills tend to include names of everyone who receives a prescription. (Given that these prescriptions are for controlled substances, real ID is needed to fill them.) Though some clients certainly resell the drugs, a large share are likely themselves addicted. And every time a "doctor shopper" gets caught and arrested or dismissed as a patient, another treatment opportunity is missed.
If the government had offered immediate access to maintenance meds to every patient at every pill mil, and referred people with chronic pain to other doctors immediately, the market gap opened by the supply cut might have been dramatically reduced. Left in withdrawal, it's unsurprising that people are turning to street supplies. But research shows that providing buprenorphine access to patients in medical crisis like overdose dramatically increases the odds that they will enter treatment and also reduces relapse.
In commemoration of International Overdose Awareness Day on August 31, the Obama administration reported adding $53 million in funds towards dealing with the crisis. Just $11 million of that, however, will go to maintenance treatment. If America really wants to reduce the death toll from its opioid crisis, we need to focus on reducing demand, not supply.
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