By J. Westly McGaughey, MBA/MPP candidate 2016
On 3 November 2015, Ireland’s National Drug Strategy Chief announced that the country will decriminalize small amounts of illicit drugs for personal use[1]. The move is intended to help addicts rather than jail them. This is a prudent policy. In contrast, the U.S. supports policies that go against the evidence. While recent years have seen progress in terms of decriminalizing marijuana—and there is considerable momentum there—the majority of drug policies run counter to productivity. One of the biggest drug policy concerns to hit the daily news is prescription drug abuse. The policies that are enacted in this area tend to make things harder for patients who legitimately need the drugs while doing very little to prevent abuse of the drugs. The 2014 election saw the defeat of California Proposition 46, a package of three initiatives to address prescription drug abuse. Only one of them was compelling: adjusting the cap on pain and suffering damages to victims of medical malpractice for inflation. The other two initiatives would have been inconsequential, but they are of a problematic ethos: drug testing for doctors and requiring doctors to check an existing database of patients with narcotics prescriptions before prescribing any more to them. The latter was ostensibly to prevent drug addicts from “doctor shopping;” another misguided attempt at addressing substance abuse. Yet, it would have been ineffective, doing little more than making it harder for legitimately sick people to obtain relief.
In 2010, my partner underwent surgery to remove a tumor in the center of his spinal cord, leaving him with nerve damage and chronic pain in his neck, chest and arms. He must take two narcotics and several other medications to participate in activities of daily living. Opioids are the most effective treatment available, and getting them requires an onerous process. He is required to visit his doctor, a billable consultation, to get the prescriptions. Narcotics prescriptions require triplicate serialized security hard copies that are not refillable and only for a 30-day supply. The prescriptions for his two opioids must not be written on the same form. If the pharmacy is out of one drug but has the other, and if they are on the same form, they cannot fill it. They cannot “split” the prescription like other medications. If they are out of one or have less than the exact amount, he must wait until they order more, often 48 hours or longer.
While he waits, pain breaks through the protection of the other medications. Then withdrawal kicks in. He hurts unbearably and gets sick from withdrawals. He is physically dependent on the narcotics—and appropriately so. Physical dependence is different from addiction. Policies like Prop 46 hurt the physically dependent and do nothing to curb addiction. Legal scholar Ben Rich describes physical dependence as a natural response of the body to medications like opioids.[2] Addiction, however, is compulsive use of a drug, a craving, and continued use despite self-harm. Policy makers, the general public, and many doctors get this wrong.
If a patient begins to withdrawal because they are physically dependent on a medication, they may get irritable and push for their medication. Providers then often label the patient “drug seeking.” If one is labeled as such, the provider becomes reluctant to dispense the medication, passing judgment on the patient, even documenting it in their medical records; once something goes in a medical record—paper or electronic—it’s almost impossible to get it removed.
Our prescription drug policy has fomented an epidemic of untreated pain. According to the IOM, there are four times as many people in the U.S. suffering from chronic pain than diabetes.[3] Yet, substance abuse rates continue to rise, as does chronic pain. Doctors fear treating chronic pain as the DEA monitors their prescriptions and can face punitive actions and unbearable red tape, de-incentivizing treatment. All the while the risk of a patient becoming addicted to opioids is the same as the risk of becoming addicted to anything else—and even addicts may still have legitimate pain that should be treated. The World Health Organization calls the failure to treat pain poor medicine, unethical practice, and an abrogation of a fundamental human right. Moreover, the majority of prescription drugs on the street come from theft from pharmacies and pharmaceutical companies, not patients. Prescription drugs are diverted to the street before they ever reach a patient with a prescription. Yes, there are some patients who “doctor shop” and receive multiple prescriptions. Those folks are a minority, yet we focus on them as if they are the only ones who get medication like this. We need drug policy focused around addiction treatment and harm reduction that does not further harm sick people.
[1] Rose Troup Buchanan. (2015, November 3). Ireland to decriminalise drugs including heroin and cocaine. Retrieved November 5, 2015, from http://www.independent.co.uk/news/world/europe/ireland-to-decriminalise-small-amounts-of-drugs-including-heroin-cocaine-and-cannabis-for-personal-a6719136.html
[2] Kushner, T. (Ed.). (2010). Your Guide to Pain Management. In Surviving Health Care; A Manual for Patients and Their Families. New York, NY: Cambridge University Press. Retrieved from http://www.cambridge.org/us/academic/subjects/philosophy/ethics/surviving-health-care-manual-patients-and-their-families
[3] Institute of Medicine. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Retrieved from http://books.nap.edu/openbook.php?record_id=13172&page=1