According to the best evidence we have, prescribing opioid pain killers for chronic pain patients has played only a minor role (if any) in yearly increases of overdose-related deaths.
As I wrote recently in the The Crime Report, “The US is now chasing the wrong epidemic in its efforts to reduce the death toll from narcotic drugs. Both pain patients and addicts are paying the ultimate price for this misdirection.”
The opioid crisis was not caused by medical exposure.
The root causes of addiction are primarily social. They include family trauma, and stress from economic hardship and family disintegration, sometimes mental health issues.
Although many young people first begin abusing prescription drugs (and alcohol), these drugs are not given to them by doctors. They are initially diverted by theft, provided by family members, or bought on the street. As drug involvement increases, it is almost entirely fed by street drugs—most often heroin and fentanyl, both of which are cheap and plentiful.
Although there were serious errors in the report of the President’s Commission on Combating Addiction and the Opioid Crisis, the Commission got one thing pretty much right. Processing non-violent drug offenders through the prison system is counter-productive.
Having a criminal record raises major barriers to community reintegration and employment after release. Diversion into community-based drug treatment programs offers at least marginally better chances for harm reduction, even if a road to assured abstinence and recovery presently escapes us.
If 40 years of the so-called “War on Drugs” have shown us anything, it should be that counter-drug law enforcement policy and prisons do nothing to reduce addiction or promote recovery. A June 2017 report by the Pew Charitable Trusts confirms these outcomes.
If law enforcement is not an effective policy instrument in combating addiction, then it is fair to ask what might be better.
The broad outlines of the necessary ways forward are known and some of them are represented among recommendations of the President’s Commission. However, none of those steps outlined in the Commission involves reducing the availability of pain management to millions of people in agony.
Recommendation #4, for example, suggested aggressively adding addiction prevention to the education curriculum, staring as early as middle school. “Just say no” was a miserable failure, but other programs have better track records.
The commission also suggested improving access to drug overdose intervention (Naloxone) delivered by first responders. A key element in making this possible might turn out to be cost control as manufacturers repeatedly raise prices.
The program needs appear to be much larger than those contemplated in the Commission’s report:
- Improved addiction recognition and intervention training for community-based physicians and counselors;
- Providing access to Medication Assisted Therapy programs, allowing for methadone or buprenorphine to be administered in accessible community settings.
- Developing community reintegration programs that providing safe / sober housing to addicts who will otherwise become homeless, if they are not already.
- Establishing job development and training programs in economically depressed regions. Jobless addicts become pushers out of dire economic necessity, not moral failure.
- Funding long-term community-based counseling and support programs for addicts in recovery─many of whom will relapse repeatedly.
We also know what doesn’t work:
- 28-day detox centers don’t work when patients are discharged without ongoing community support, back into the conditions which made them vulnerable to drug abuse in the first place (See comments by Dr. Kelly Clark of the American Society of Addiction Medicine during the June 2017 meeting of the President’s Commission);
- Narcotics Anonymous and other abstinence-based programs also have very high relapse rates when used alone;
- Restriction or withdrawal of opioid prescribing to otherwise well-managed chronic pain patients have no positive effect on risk of addiction. (On the contrary, coerced tapering off medication is a known health and mortality risk.)
Arguably, there is no objective evidence that drug contracts or short-notice urine testing of chronic pain patients have saved a single life. But there is ample evidence that false positives in urine tests can lead to patient discharge by doctors afraid of losing their licenses—followed by decline of the patient into agony and disability.
The Real Barriers to Effective Prevention
Given the complexity of human behavior and biology, we might never have a “cure” for addiction. However, present barriers to effective prevention in youth and harm reduction among addicted adults are not conceptual.
They are political and financial.
Serious programs of community reintegration, job development and safe housing will cost billions of dollars per year for the foreseeable future.
We have already seen an example in the 1960s, when governments refused to embrace similar issues. Americans decided that it was no longer acceptable to incarcerate mentally disorganized people who were merely strange rather than dangerous. Mental health assistance was supposed to come from community outpatient programs. But programs failed to materialize and thousands of patients became homeless on our streets as a result.
In the political climate of 2018, political conservatives are determined to reduce the size and scope of government programs. This goal seems incompatible with harm reduction for hundreds of thousands of addicts. The majority of programs around which treatment would be expanded are administered under US Medicare.
There is yet one more unacknowledged elephant in this room of hard choices. Why not decriminalize possession of small amounts of presently illicit opioids, even if possession for sale remains a criminal offense?
Portugal has already done this experiment with promising results. Since 2001, the number of opioid-related overdose deaths in Portugal has dropped to near zero, and rates of heroin addiction are significantly down.
A Post Script from the author to regular readers of The Crime Report. January 10, 2017
In the 24 hours following publication of this article, 16 people in pain have commented — some of them at great length. While their thoughts might seem off-topic to the concerns of regular readers, I encourage law enforcement professionals to at least sample from the ideas expressed here. You will rarely hear these views in the forums where you commonly circulate. But the commentators know things that you do not.
This disconnect in personal realities is in a serious sense, “the problem” on which I’ve written. To use a meme common among chronic pain communities, “patients are not addicts”. In an even broader sense, addicts are not “junkies” either — nor is either stigmatized group often seriously engaged by people who write national policy. When given an opportunity to speak, these folks are desperate to be heard. They are too often the dispossessed, the disregarded, the scapegoats, the silent walking-wounded of a generations-long and horridly unsuccessful “war on drugs” that has lately become a regulatory war against doctors and people in agony as well. It is time for both wars to stop.
What we’ve been doing about addiction as a nation and in law enforcement isn’t working. To get to better places, we have to recognize that addiction is not a disorder of medical exposure. It is largely a disorder of social disintegration and the failure of traditional communities. Laws or regulations alone cannot correct this failure. But laws written without subtlety or enforced without compassion can add to the problem. And this is occurring widely.
Thus I implore readers: sample some of what follows. Take it in. Let your hearts be moved or torn. Then “let change begin with me”. Advocate to include patients and addicts in forums where policy and laws are debated and made for either group. And please add your thoughts to the comments below.
Richard A. Lawhern, PhD, is Co-Founder and Corresponding Secretary of the Alliance for the Treatment of Intractable Pain. A non-physician patient advocate and writer with 20 years of volunteer public service, he has written for The Journal of Medicine, National Pain Report, Pain News Network, and other online media. His wife and daughter are pain patients. Comments from law enforcement professionals are invited and welcome.