America’s current prescription drug epidemic is now killing more Americans each year than did the cocaine epidemic of the 1980s and the heroin epidemic of the 1970s combined. But this epidemic differs from those of prior eras in that it could not have started without the aid of physicians. Yes, Florida pill mills typically employ as security guards marginally educated thugs with jailhouse tatts on their biceps, but every one of them has a licensed physician involved as an employee or owner; else they could not write and have filled all the thousands of prescriptions that they churn out every day.
It is instructive to compare the current U.S. epidemic with the British experience over the 20th century. As laid out in the Rolleston report between the wars, all British physicians were allowed to dispense cocaine and heroin with minimal oversight. This policy reflected the very high level of trust Britons had in medical professionals, and in general their faith seemed well-placed. No doubt there were some medics who were dishonest and/or careless, but the British system survived for decades without starting a drug epidemic.
By the 1960s however, word had got round that a small group of British physicians were dispensing drugs very freely. The most famous, Lady Isabella Frankau, was apparently not venal. Rather, she was a true believer in the idea of unrestricted access to drugs (Then, as now, this idea exerted a strong pull on the most privileged and wealthy segment of society). Others may have been in it for the money or a drug kickback, but in any case this small group of errant medics brought the British system down by generating an epidemic of addiction that led to much tighter regulation of prescriptions. (As a side note, it was great fun to hear this story from Dr. John Strang, who now oversees two heroin-prescription clinics in the U.K., while we stood out front of the 24-hour Boots next to Piccadilly Circus. At that spot, hundreds of drug-addicted patients used to line up at midnight to get cocaine and heroin because their prescription date became valid at 12:01).
The most remarkable feature in my mind of the British experience is how long it took the old system to break down. Part of this was a reflection of British national character prior to the 1960s, which put some cultural constraints on recreational drug use. But lack of information and difficulty of travel also played some role. If you were living in Stoke-Upon-Trent in 1930, and heard a rumor that there was a particular physician in Harley Street who was loose with the cocaine or heroin, would you have believed the rumor? Would you have troubled to go investigate, given the cost of the journey? In both cases, probably not.
In contrast, today, anyone who wants to know where the pill mills are need only log onto the Internet. It is public information that 50 of the top pain pill prescribing doctors in the United States are working in a single county in Florida. From my home state of West Virginia, you can catch the “O.C. Express” flight down to Florida for some pills and back for less than a hundred dollars. Almost any American who decided today that they would like a handful of Oxycontin in the next 24 hours could get it.
These changes in technology mean that even if only one tenths of one percent of U.S. physicians is a dishonest or sloppy prescriber, it’s enough to start a drug epidemic, and it will take hold much faster than it would have in prior eras. Because no profession can guarantee perfect compliance with professional standards across 100% of its members, this implies that the prescribing of physicians is going to have be monitored externally more than in prior eras, which isn’t fair to most of them nor needed for most of them. But the damage the few bad apples can cause has grown exponentially, such that there really is no other alternative.
It doesn’t help that physicians are reluctant to prescribe the amount of pain killers that their patients need because they are scared to death of the DEA.
Pill Mills! Epidemic! Please forgive me if I’m not swayed by the current scare words in this latest salvo in the War on Drugs.
I’m unwilling to impose even more of a burden on people who suffer from chronic pain and need these medications to live a semi-normal life in order to save the lives of people who willingly take them for recreational purposes and OD>
Chuchundra: All of these drugs are legal. If the “War on Drugs” now means not only making some drugs illegal but also having any regulation at all even of legal drugs (i.e. a drinking age, taxes on cigarettes, a prescription required before dispensing opioids) then the term has become even more devoid of meaning than before, which truly is a high bar to get over. Transform UK, for example, may be disappointed to know that they now support the War on Drugs, since they favor regulation coupled with legalization of drugs.
I do sincerely respect your taking an explicit position regarding the relative value of different people’s lives. But I don’t share your values for two reasons. First, I think it is worth trying to save the lives of people who use drugs recreationally (p.s. How do you square in your own mind that you are anti-drug war when you come right out and assign zero value to the lives of drug users?). Second, a number of people who die of overdoses were originally prescribed the drugs for pain, so the dichotomy you imply between two populations doesn’t hold.
As ever, we face two questions:
1)”What results will follow if legislators enact policy X?” and
2) “Do we want those results?”
We also have to consider the distribution of costs and benefits over time. Let users remove themselves from the gene pool and the problem will solve itself over time (my advice to abortion opponents, also).
“Addiction” by itself is not a reason to control anything. I’m addicted to food. That is, I will experience withdrawal (hunger) and death without. Some people abuse food; obesity is epidemic. Certainly, some people will OD if legislators repeal laws against sale and ownership of heroin. So? Some people will crash hang gliding or drown surfing.
Stricter regulation of the dispensing of pain medication will invariably lead to less pain relief and more difficulty in getting that relief for people who legitimately need it. As it is now, it can be very difficult for those with serious pain conditions to get enough medication so that they can live a normal life. Pain patients have to be careful not to display “drug-seeking” behaviors, which often means living with more pain, because Doctors who do not monitor these behaviors can find themselves in trouble with the DEA.
Maybe it seems cavalier to you that I’m willing to let more addicts die from the consequences of their own actions than deny millions of people the pain relief they need to live and enjoy their life. I can tell you that it looks quite the opposite to me.
Mr. H, is it really necessary to invent the fiction that Chuchundra assigned “zero value to the lives of drug users”? His statement was that he was unwilling to increase the burdens on those dealing with chronic pain to save the lives of recreational abusers who OD. It says something interesting about you that you convert that to the apocalyptic “zero value” canard.
JMG: Here is Chuchundra’s statement “I’m unwilling to impose even more of a burden on people who suffer from chronic pain and need these medications to live a semi-normal life in order to save the lives of people who willingly take them for recreational purposes and OD”.
Where do you see a valuation of the lives of drug users in that statement?
Here is Malcolm: Let users remove themselves from the gene pool and the problem will solve itself over time
Same question. I have spent more than two decades taking care of people who are addicted to drugs, and I can’t help but be offended at hearing them so degraded. If that’s an over-reaction, I do apologize (I mean that).
All: You are making the usual arguments for legalization…but these drugs are legal already! Drugs get black box warnings or required trainings or get pulled from the market when we find they have dangerous side effects…this is basic public health and regulation of a legal product.
If your view really is that all regulation of legal drugs is wrong, then you should defend that position instead of invoking arguments for legalization, which are simply not germane here. Most people I have met who advocate legalization accept and indeed support the idea of regulation, rather than a free-for-all, but if you don’t fine….but prove your case rather than simply repeating the arguments to legalize what is already legal.
The fact that the drugs are legal is a bit moot when doctors and their patients have to choose between managing severe chronic pain and the risk of going to prison if the “medical experts” at the DEA and various DA offices disagree on the amount of pain killers needed to do so.
Keith, by confronting Malcolm, you make the same mistake I did yesterday confronting some LaRouche supporters. Your words are wasted.
If we are trying to raise the cost to careless or venal prescribing physicians and dispensing pharmacists, one idea might be red tape. Every time someone dies of a prescription drug overdose, not clearly by suicide, require lengthy reports from the doctor and pharmacist, with follow-up interviews. This would be bearable and even helpful for honest practitioners who make occasional mistakes; but it would mount up for pill shops. Rather like nailing Al Capone for income tax violations.
The scheme would have to be designed carefully not to discourage proper palliative care, in which morphine may quite properly accelerate death.
Keith Humphreys: All of these drugs are legal.
No wonder Gil Kerlikowske doesn’t have the word legalization in his vocabulary. It’s moot.
On a serious note, by your implied logic, no drug is illegal, including marijuana, since there exist some provisions under which the drug is legally manufactured and administered to humans (say, a clinical study). But that’s just an example of the semantic slipperiness of the word ‘controlled’ in controlled substances.
The basic aim of the WoD* is to stop people from consuming psychoactive substances on their own initiative for non-medical purposes, or in lay terms, to stop people getting high. Ergo, legalization thus means to introduce a regime which, even encumbered by regulations, accommodates the desire of a generic adult to get high. The current regime is structured to prevent that happening, even if the drug can be manufactured and traded and used for other purposes.
*substances that have escaped the umbrella of the WoD are either culturally embedded - alcohol - or those popular drugs showing fairly modest psychoactive effects viz. caffeine, nicotine
“*substances that have escaped the umbrella of the WoD are either culturally embedded – alcohol – or those popular drugs showing fairly modest psychoactive effects viz. caffeine, nicotine”
This is completely wrong. All the drugs mentioned are regulated in the US, even caffeine.
(Malcolm): “…consider the distribution of costs and benefits over time. Let users remove themselves from the gene pool and the problem will solve itself over time (my advice to abortion opponents, also).”
(Keith): “I have spent more than two decades taking care of people who are addicted to drugs, and I can’t help but be offended at hearing them so degraded. If that’s an over-reaction, I do apologize (I mean that).”
Thanks for the apology. I mean that. Friends of mine died of OD. Others lost touch with the world of work and family. I had to move to get away from cheap cocaine. I lost a good job offer (Foreign Service) through honesty about my experience with drugs. The Mormons are right; you will get the best, longest lasting high from exercise, sleep, a healthy diet, and a supportive family. Some of us lack some of these ingredients and resort to supplements like heroin and meth.
(Keith): “If your view really is that all regulation of legal drugs is wrong, then you should defend that position instead of invoking arguments for legalization, which are simply not germane here. Most people I have met who advocate legalization accept and indeed support the idea of regulation, rather than a free-for-all, but if you don’t fine….but prove your case rather than simply repeating the arguments to legalize what is already legal.”
I don’t know the answer, but then I’m not the one threatening peaceable dopers with forcible innoculation with HIV (prison). You imagine that prison isn’t degrading? Federalism. “What works?” is an empirical question which only an experiment (numerous local policy regimes) can answer. I agree that cross-border traffic introduces a complication.
(Mobius): “Keith, by confronting Malcolm, you make the same mistake I did yesterday confronting some LaRouche supporters. Your words are wasted.”
I continue to hold outo the hope that Mobius will make a positive contribution to our ongoing discussion.
Just curious and too lazy to google, Keith, but what percent of overdoses on pharmaceutical opiate overdoses are due to the opiates alone as opposed to synergistic effects with other drugs (including liver toxicity from acetominophen)?
James: This is completely wrong. All the drugs mentioned are regulated in the US, even caffeine.
My parenthetical referred to the WoD i.e. War on Drugs, of which caffeine is not a part, Four Loko notwithstanding.
As usual, understanding this situation requires holding two somewhat dissonant ideas in mind at once: that pain is badly under-treated by U.S. physicians, partly out of fear of law enforcement, and that a few crooked docs act more or less as dope dealers. Surely external scrutiny is needed, and it’s a reproach to the medical profession that medical boards have decided to turn the problem over to the DEA - meaning that judgments are made by non-physician agents, prosecutors, and juries - rather than doing the job themselves.
Surely external scrutiny is needed, and it’s a reproach to the medical profession that medical boards have decided to turn the problem over to the DEA – meaning that judgments are made by non-physician agents, prosecutors, and juries – rather than doing the job themselves.
It’s my understanding that the DEA has not been willing to defer to the medical boards on this, rather than that the medical boards have not tried. The medical profession has been trying to get best practices in prescribing to be a safe haven, but the DEA has to decide that-the AAPM can’t.
This is another area, btw, where lack of universal access to care plays a role in facilitating abuse. If everyone had decent local access to pain-management specialists and coverage for pain-reducing drugs, then people going out-of-network to a few high-volume practitioners would stand out even more than it does now.
There are primarily two kinds of addicts: the ones who became addicted to the pills that they got when they were in pain and the ones who use the pills purposefully for some reason other than to treat physical pain. And there are the in betweens as well: those who might be in pain but otherwise not have access to medical care (think, someone injures their back but can’t imagine stepping back from their physically demanding job as a waitress — or maybe it’s two jobs).
chuchundra assumes his wife (I think) is the virtuous user, the one who NEEDS these specific drugs — the kind of person society should support to the point of writing off others whose misery is even a tiny bit self-inflicted.
On the other hand, if we are going to see the issue in such stark terms, there may be some of us who don’t really care about the chuchundras and their suffering spouses of the world — we just don’t want our teenaged children exposed to oxycontin.
In reality, there are definitely solutions at hand to protect both sides — the accutane solution, for instance, whereby additional documentation has to be submitted to a national registry in order for a drug to be dispensed as written.
But I find the continued willingness to “write off” addicts as deserving of their misery to be offensive, and it certainly doesn’t increase my sympathy for those who are in pain. Your pain isn’t sacred and as a society we don’t have to tolerate every possible breakdown in order to make it easier to ameliorate it.
Just want to point out that — while I don’t hold this stance myself — it’s completely possible to be logically consistent in both opposing the drug war and not caring if drug users OD. For instance, in the strong case, one could be perfectly indifferent about a drug user ODing, dying of hepatitis or being tortured to death by the DEA, but also hold that the costs of the drug war on non drug users is far too high. Alternatively, one could take essentially the (small ‘l’) libertarian position that it is an individual’s right to choose to ruin their life with drugs; such a person could truly value the life of a drug user and deplore ruining such a life, but value even more the person’s ability to choose for themselves. Finally, as a subset of the first option, one could distinguish between a drug abuser who might OD and a drug user who maintains a good relationship with the drug and therefore will not OD; such a person could value a drug abuser at nothing, while still valuing the (non abusing) drug user, and opposing the WOD for the harm it inflicts on such a person (in the pill-mill situation, someone with a chronic pain condition might be one example of a non-abusing drug user).
For the medical profession vs. the DEA, I’d be interested in some evidence. Frankly, I’m willing to believe almost anything about DEA arrogance and unwillingness to consider any drug use acceptable, but on the other hand, the medical profession has an extremely well-deserved reputation for being very reluctant to police themselves.
Seriously, you just can’t get this issue right unless you start out by accepting the premise that people have the right to do somewhat dangerous things for pleasure. Some people climb mountains, some people skydive, and some people take drugs. The government doesn’t have the right to “save” any of them by depriving them of something they enjoy.
That said, for the reasons Mark Kleiman says, prescription drug policy is a thorny issue. We should err, however, on the side of making sure people can get their medicines.
Dilan, I am not going to defend every drug law or FDA policy — but I haven’t noticed, for instance, that people can sky dive wherever they want to — or that they fly unregistered planes when they do it. Misuse (use for pleasure) inevitably makes legitimate use much more difficult to assure no matter how much we are willing to write off abusers. The two are not disconnected — it’s not like erring on the side of providing drugs to the legitimate users even if a few more people OD will ever be a successful strategy.
It doesn’t take much perspective to see that there are an awful lot of externalities to the use of prescription pain relievers for “pleasure” (certainly) and even when they are ostensibly being given for pain (e.g., the many people who sell or share their legitimate prescriptions). A lot of people will do what they can to avoid these externalities.
Some pharmacies, for instance, have stopped stocking these drugs because they don’t like being held up at gun point. That makes it harder for people to get the drugs whether they need them or not. Should our zeal to protect access to those in pain make us indifferent to the safety of pharmacy employees? (Some people think it should.) Likewise, many doctors refuse to prescribe Oxycontin because they don’t care to try to differentiate a drug seeker from a person in desperate pain. This does almost nothing to reduce the use of illegitimate users but is a terrible burden to those with intractable pain, who don’t have quite the wherewithal to drive around to find willing doctors. Even if I were willing to write drug abusers off, a lot of people are not willing to write off their own safety or their own professional prerogative not to treat pain.
Dr. Humphreys -
Let’s follow your logic where it leads. You say that misbehavior in the 1960s “brought the British system down by generating an epidemic of addiction”. Based on a quick Googling, that 1960s “epidemic” amounted to two thousand prescription heroin users, equivalent to ten thousand users in the USA today. But in reality, there are well over one hundred thousand heroin users in the USA today … a prevalence over ten times as great.
That strongly suggests one of two conclusions:
* Either the idea of a heroin “epidemic” in 1960s Britain was rubbish, used by political entrpreneurs to rev up socially-conservative voters already disposed to believe that drugs were rotting the nation’s fiber
* Or the USA faces a far worse “epidemic” today, requiring the same wholesale abandonment of failed policies (i.e., abolish the DEA and start over).
Which is it?
Dilan, I am not going to defend every drug law or FDA policy — but I haven’t noticed, for instance, that people can sky dive wherever they want to — or that they fly unregistered planes when they do it. Misuse (use for pleasure) inevitably makes legitimate use much more difficult to assure no matter how much we are willing to write off abusers. The two are not disconnected — it’s not like erring on the side of providing drugs to the legitimate users even if a few more people OD will ever be a successful strategy.
Well, there’s a big difference between telling people where they can skydive and telling people they can’t do it at all because the government has determined that you can’t run the risk.
The second is a society that doesn’t respect the freedom of people to trade risk for pleasure. It’s a society that says that one person’s moral disapproval is a more important interest to protect than another person’s pleasure.
As for the other arguments you make, the way you decrease the risk to pharmacists and doctors is to admit that getting high is a personal freedom and is just as legitimate a reason to take drugs as pain relief is. Then you allow the people who use drugs for pleasure to obtain them and you don’t have the problems you cite.
Ingesting a substance that another person thinks is immoral is just as much a human freedom as using your genitals in a manner that other people find immoral is.
Dilan, it’s not the morality of the substance. I never said it was immoral to take it. It’s the fact that people who take it “for pleasure” (addicts don’t get much pleasure from it in my view, but whatever) end up creating enormous havoc for other members of society. I don’t care if people use marijuana — it doesn’t screw them up like methamphetamine or oxycodone abuse. Oxycodone is a difficult proposition precisely because most people don’t abuse it and have legitimate needs for it.
And society doesn’t tell people they can’t trade risk for pleasure. Or else smoking would be illegal.
I am all for re-examining drug laws along the lines of tying them more closely to the probable externalities of their medical and non-medical use. I am all for foregoing prison sentences for those who use drugs outside of legal norms so long as they are not violent offenders, as well as providing rehab for anyone who wants and needs it. I am not pro-interdiction because this is the way we have always done it. But your analysis (beginning with the idea that addicts are exercising the freedom to trade risk for pleasure) is looped.
Interesting discussion, thanks all. Two general remarks and one specific one:
Some of the comments seem to assume that the drug using population is made up entirely of pleasure seeking, autonomous, non-addicted people. There are definitely such people at any given moment. But there are also people who are addicted. Two important aspects of addiction deserve consideration here. First, severely addicted people are typically not driven by pleasure, but by negative reinforcement. They feel awful without their drug and okay with it, but the rush of pleasure they got early in their use career is diminished or gone. Second, addicted people often want desperately to stop, indeed they ask other people to help them do so. It is not as simple as “they are expressing their freedom and some outsider is interfering”. I have had people addicted to drugs (legal or illegal, it doesn’t matter) literally beg me for help, they can see they are destroying their lives and their families and they want outside intervention…people voluntarily check themselves into inpatient units where they have little freedom because they want to give over some control to others in the hopes of getting control of themselves.
Another point is that regulation of medicine is not a choice between no regulation and federal agents busting down doors and shooting people. The new Florida law that says that the doctor has to actually examine the patient before prescribing an opiate is regulation, so is the new proposal to require training so that doctors do not precipitate overdose with oxycodone. If you want health oriented drug policy, then I think you should support health regulations here such as apply to all other parts of medicine.
In response to Warren’s query on what exactly causes overdose, I would point you to research by Shane Darke, a well-respected Australian researcher. His work shows that polypharmaceutical overdose is extremely common, especially an opiate + a tranquilizer or both of those plus alcohol. That is part of what makes management complicated…you give the person naloxone which knocks the opiate out of their mu receptor and saves their life, and then they get into a car and crash because they still have a large amount of benzos and alcohol on board that the naloxone didn’t affect.
I agree completely with Mark Kleiman.