Over 16,000 people per year die from overdoses of prescription painkillers (Opioid analgesics)—more than triple the number of deaths two decades ago.(2,4,5,6,12) This vast increase has led to a major public health initiative to reduce the misuse and abuse of these drugs. Will it work? There are reasons for optimism, but there are also important questions to raise about whether these campaigns need to be recast to have greater impact on the behavior of people at high risk and of doctors who over-prescribe as well as to be sure that people who need pain relief get it.
- Prescription painkillers include Oxycodone (OxyContin), Hydrocodone (Vicodin), Oxymorphone (Opana), and Methadone, which has been used to treat heroin addiction for over four decades but now is increasingly prescribed as a painkiller.(3,7)
- There are now more overdose deaths from prescription painkillers than from heroin and cocaine combined.(2)
- The increase in the number of deaths from prescription painkillers over the past two decades parallels the increase in the number of opiod analgesics prescribed, which has also more than tripled.(1)
- About 20% of doctors prescribe 80% of painkillers.(4) This may reflect the fact that some doctors are more likely to treat patients with severe pain. But in some cases doctors knowingly write prescriptions for drugs that will be resold illegally.
- Most people who die from overdoses of prescription painkillers did not have prescriptions. The drugs they use have usually been “diverted”, either purposely or inadvertently, from the people for whom they were intended.(4) (There is some indication that in the case of methadone as many people with prescriptions die from overdoses as those using diverted drugs.(7))
- 30-40% of deaths from prescription painkillers involve the use of methadone. (3,7,12)
- About half of all deaths involve the use of more than one drug—frequently an anti-anxiety drug (a benzodiazepine) and/or alcohol.(4)
- Over 100 million Americans suffer from chronic pain.(8) Most can manage pain without recourse to opiod analgesics. But for some, opiods are the only painkillers that are effective.
The Pubic Health Initiative
The public health initiative to reduce the number of overdose deaths from prescription painkillers focuses on (1) changing the prescribing practices of physicians who overprescribe opiod analgesics, (2) encouraging those who need and use prescription painkillers to use and store them cautiously, (3) persuading people who use opiod analgesics to get high not to do so and to get treatment if they are addicted, and (4) making an antidote to opiate overdoses available for emergency, lifesaving intervention.
Specifically, The Centers for Disease Control (CDC) recommends(4) that:
- States should develop “prescription drug monitoring programs” (which 36 already have in place) to identify high risk patients and physicians who prescribe large quantities of opiod analgesics. (High risk patients include those who get prescriptions for both painkillers and benzodiazepines and who get prescriptions from multiple doctors.)
- States should also develop “patient review and restriction programs” and restrict some high risk patients to one doctor and one pharmacy for their drugs. It might also be possible to provide education to them about the risks of their drugs and/or to engage them in treatment.
- States should also develop “health care provider accountability” mechanisms, including education of doctors who are high prescribers of opiod analgesics, as well as removing licenses of some physicians for irresponsible practice and/or initiating criminal investigations for purposeful diversion of drugs for non-medical purposes.
- States should develop laws to reduce diversion of drugs from those who need them to those who use them to get high.
- There should be better access to drug treatment.
Notably missing from these CDC recommendations are efforts to reduce the demand for prescription painkillers and promote their safe use and storage through public education, including advertising. It appears, however, that a number of state and local health departments, NYC for example, have adopted this approach.
Also notably missing from the CDC recommendations is any concern about improving pain management. There are alternatives to opiod analgesics that are effective for some people with chronic severe pain. Many doctors need education about them. In addition, The National Institute of Drug Abuse (NIDA) notes a need for research to develop less dangerous treatments for people for whom opiod analgesics are currently the only effective form of pain treatment.(11)
Cautions About the Current Public Health Campaign
It is clear that misuse and abuse of prescription painkillers is a major public health problem in the United States and that there needs to be a major effort to reduce overdose deaths. And, the efforts now underway mostly fit the facts and may ultimately be as effective as anti-smoking campaigns have been.
But it seems to me that there is a moralistic tone to this public health campaign similar to the moralistic cast of most of American drug policy and quite dissimilar from the tone of anti-smoking campaigns. The CDC and others recommend monitoring doctors and their patients, putting patients on restrictions if they take multiple drugs or doctor shop, threatening the licenses of doctors who are high prescribers, and passing laws to stop the diversion of drugs (as if the failure of the effort to curb illegal drugs hasn’t already raised enough questions about the use of that sort of approach).
It makes sense, of course, to identify high risk patients and reach out to them. And it makes sense to lift the licenses of doctors who violate professional ethics and to put them in prison if they are really drug dealers hiding behind a license. But to get people to say no to drugs takes a lot more than moralizing.
In addition, policies being put in place show a distinct lack of sympathy for those who suffer from severe chronic pain. Yes, NIDA has called for some additional research to find less dangerous treatments for pain management, but it is a minor part of its agenda. Most statements on the need to address addiction to, and deaths from, prescription drugs barely mention the suffering of people who have to live with severe, chronic pain.
So, it seems reasonable to ask whether the campaign against misuse of opiod analgesics will result in their becoming less available to people who desperately need them.
A recent article in The Washington Post highlights this concern.(13) “New federal rules that make it harder to get narcotic painkillers are taking an unexpected toll on thousands of veterans who depend on these prescription drugs to treat a wide variety of ailments, such as missing limbs and post-traumatic stress,” the article begins. It focuses on bureaucratic obstacles emerging in the VA in an effort to avoid inappropriate prescribing practices. The VA, of course, is notorious for its bureaucracy. But isn’t there reason to worry that physicians elsewhere will also become excessively cautious about prescribing painkillers as they come under greater scrutiny?
Government regulations and protective practices in health care organizations tend to be overly broad and to throw out at least some of the baby with the bathwater. Hopefully, the campaign to reduce the inordinate number of deaths from overdoses of prescription painkillers will be refined over time, dampening the possibly excessive enthusiasm for restricting access to these drugs and protecting those who need prescription painkillers so that they can have tolerable lives.
Michael Friedman is retired but continues to teach at Columbia University and to write about behavioral health and about aging. He is the founder and former director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City. He can be reached at firstname.lastname@example.org.
- Bohnert, Amy, et al. “Association Between Opioid Prescribing Patterns and Opiod-Related Deaths.” Journal of the American Medical Association. April 6, 2011.
- Centers for Disease Control and Prevention. “Prescription Painkiller Overdoses in the US.” CDC Vital Signs. November 2011.
- Centers for Disease Control and Prevention. “Prescription Painkiller Overdoses: Use and Abuse of Methadone As A Painkiller.” CDC Vital Signs. July 2012
- Centers for Disease Control and Prevention. “Policy Impact: Prescription Painkiller Overdoses”. July 2, 2013
- Centers for Disease Control and Prevention. “Prescription Painkiller Overdoses: A Growing Epidemic, Especially Among Women”. CDC Vital Signs. July 2013
- Centers for Disease Control and Prevention. “Prescription Drug Overdose in the United States: Fact Sheet”. March 2, 2015.
- Government Accounting Office. “Methadone-Associated Overdose Deaths: Factors Contributing to Increased Deaths and Efforts to Prevent Them.” March 2009.
- Institute of Medicine. “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research”. June 2011.
- Substance Abuse and Mental Health Services Administration. Opioid Overdose TOOLKIT. HHS Publication No. (SMA) 14-4742. 2014.
- Substance Abuse and Mental Health Services Administration. NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings. September 4, 2014.
- Volkow, Nora. “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse: National Institute of Drug Abuse (NIDA) Presentation to the Senate Caucus on International Narcotics Control”. May 14, 2014.
- Warner, Margaret, et al. “Increase in Fatal Poisonings Involving Opioid Analgesics in the United States, 1999-2006”. National Center for Health Statistics of the Centers for Disease Control. September 2009.
13. Wax-Thibodeaux, Emily. “New Rules on Narcotic Painkillers Cause Grief for Veterans and VA”. The Washington Post. February 18, 2015.