Lessons Learned From The War On Drugs
The responses to earlier drug crises are well known. After President Richard Nixon declared that Americas public enemy number one in the United States is drug abuse, the federal government, states, and localities dramatically ramped up law enforcement and punishment for the next three decades, while allocating limited resources to prevention and treatment.136)Mauer, M. . Race to Incarcerate. New York, NY: The New Press. Years after working as one of Nixons top aides, John Ehrlichman revealed that the administration was specifically using the drug war to target African Americans and the anti-war left: We knew we couldnt make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities.137)Baum, D. . Legalize it All.Harpers Magazine.
Figure 4. State prison population with drug convictions
Figure 5. Federal prison population with drug convictions
The Drug Enforcement Administration Is Fighting To Make Vicodin
The Drug Enforcement Administration is fighting to make Vicodin-type drugs harder to get, in order to reduce the abuse potential. We have a national crisis on our hands when it comes to addiction to prescription painkillers the majority of vicadin-type drugs are indeed consumed in the U.S. At the same time, the legal use of prescription painkillers does helps millions of Americans in pain so we need to balance that usage against the abuse that occurs every day.
ABC News, 1/24/2013
The Dangerous Opioid From India
This piece was originally published in The Diplomat.
The opioid crisis continues to claim thousands of lives every month across the United States, driven in part by use of fentanyl, a powerful opioid primarily manufactured in China. But it is another opioid, tramadol, that threatens to wreak global havoc, and another Asian giant that is pouring it into the world.
In 2015 , 12.5 million people in the United States abused opioids, and it is estimated that 24,861 people died from overdoses of prescription and synthetic opioids.1 Some expect these numbers to have tripled for 2016,2 and six U.S. states have now declared public health emergencies to combat the opioid crisis.3 In October, President Trump declared the opioid crisis a public health emergency.
Fentanyl is at the center of the opioid crisis in the United States. It is used as a direct substitute for heroin, but it is 50 times more powerful than heroin. Fentanyl is a synthetic opioid, meaning it requires precursor chemicals to manufacture, and it is prescribed as a pain medication. In the past two years, however, illicit manufacturing and importing of fentanyl has skyrocketed. The death rate from synthetic drug use reflects this trend.
In the Middle East and Africa, the less potent opioid tramadol, not fentanyl, is responsible for the opioid crisis. India is the biggest supplier.
Natalie Tecimer is a program manager and research associate with the Wadhwani Chair in U.S.-India Policy Studies at CSIS.
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What Are The Demographics Of The Opioid Crisis
The vast majority of those who overdose on opioids are non-Hispanic white Americans, who made up close to 70 percent of the annual total in 2020. Black Americans and Hispanic Americans accounted for about 17 and 12 percent of cases, respectively. Economists Anne Case and Angus Deaton have argued that the rise in what they call deaths of despairwhich include drug overdoses, particularly among white Americans without college degreesis primarily the result of wages stagnating over the last four decades and a decline in available jobs.
U.S. military veterans, many of whom suffer from chronic pain as a result of their service, account for a disproportionately high number of opioid-related deaths. Veterans are twice as likely as the general population to die from an opioid overdose, according to a study commissioned by the National Institutes of Health.
What Can Policymakers Do To Combat The Opioid Epidemic
Addressinga public health crisis of this magnitude is a complex undertaking. Policymakerscan work to prevent people from becoming addicted to opioids and to help peoplewho are already misusing opioids to treat their addiction and minimize the riskof death or other harm. In general, there are four kinds of strategies:
Limiting prescription opioids
Forthe last 15 years, physicians have been prescribing opioids at high rates. In ahandful of states, there is morethan one opioid prescription per person each year. Some overprescribingis the result of pill millsunethical providers who write prescriptions with indifferenceto clinical need. Other times, patients may be visiting multiple prescribers toseek prescription opioids. And in still other cases, providers may be using prescriptionopioids to combat pain when other treatments, smaller quantities, or less potentdrugs may suffice.
Theoveruse of prescription opioids fuels the epidemic in two ways. First, it introducespatients to an addictive substance,which creates the risk of subsequently developing opioid use disorder. Second, itcreates a flow of opioids that can be diverted from their intended purpose.
Therefore,policymakers can take actions that reduce opportunities for misuse of prescriptionopioids. These include:
- Law enforcement. Cracking down on pill millsand other unethical and illegal overprescribing behavior by health care providerscan have a major impact on the volume of prescription opioids.
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Strategies For Restricting Supply
As discussed previously, the responsible clinical use of prescription opioids can be a powerful tool for pain management under some circumstances. The primary area of continuing concern relates to long-term use of opioids to alleviate chronic noncancer pain. A constellation of policies related to lawful access and judicious clinical decision making can help ensure that opioid-related harms are minimized while providing access to these drugs for patients with appropriate clinical indications. This section reviews such supply-side strategies, including regulation of legal access to opioids for legally approved uses. The next section addresses legal regulations and professional policies aimed at reducing lawful access by discouraging unnecessary opioid prescribing or promoting safe prescribing practices. Although both types of strategies aim to control access to opioids, the former focuses on legal restrictions on distribution, while the latter focuses on efforts to influence the decisions of health care providers as the gatekeepers to lawful access by patients.
How The Opioid Crackdown Is Backfiring
President Donald Trump has set a goal of cutting opioid prescriptions by one-third over the next three years. He has also boasted of stepped-up prosecutions of doctors who prescribe them inappropriately and sought tougher sentences for those who sell drugs illegally. | Elise Amendola/AP Photo
Last August, Jon Fowlkes told his wife he planned to kill himself.
The former law enforcement officer was in constant pain after his doctor had abruptly cut off the twice-a-day OxyContin that had helped him endure excruciating back pain from a motorcycle crash almost two decades ago that had left him nearly paralyzed despite multiple surgeries.
I came into the office one day and he said, You have to find another doctor. You cant come here anymore, Fowlkes, 58, recalled. The doctor gave him one last prescription and sent him away.
Like many Americans with chronic, disabling pain, Fowlkes felt angry and betrayed as state and federal regulators, starting in the Obama years and intensifying under President Donald Trump, cracked down on opioid prescribing to reduce the toll of overdose deaths.Hundreds of patients responding to a POLITICO reader survey told similar stories of being suddenly refused prescriptions for medications theyd relied on for years sometimes just to get out of bed in the morning and left to suffer untreated pain on top of withdrawal symptoms like vomiting and insomnia.
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Strategies For Influencing Prescribing Practices
Reducing prescribing of opioids is at once a tool both for reducing lawful supply and for reducing demand, or aggregate desire for using or misusing the drugs. Reduced prescribing can affect demand in two ways: first, by reducing patients’ reliance on opioids to manage pain by satisfying their needs through other forms of pain management and second, by reducing the number of patients or others who develop OUD and increasing the incentive for treatment among patients with OUD. This section describes a range of formal and informal policies, interventions, and tools designed to shape, guide, and regulate the prescribing practices of physicians and other health care professionals authorized to prescribe these drugs.
Summary Of Findings For Contextual Areas
Full narrative reviews and tables that summarize key findings from the contextual evidence review are provided in the Contextual Evidence Review .
Effectiveness of Nonpharmacologic and Nonopioid Pharmacologic Treatments
Benefits and Harms of Opioid Therapy
Balance between benefits and harms is a critical factor influencing the strength of clinical recommendations. In particular, CDC considered what is known from the epidemiology research about benefits and harms related to specific opioids and formulations, high dose therapy, co-prescription with other controlled substances, duration of use, special populations, and risk stratification and mitigation approaches. Additional information on benefits and harms of long-term opioid therapy from studies meeting rigorous selection criteria is provided in the clinical evidence review . CDC also considered the number of persons experiencing chronic pain, numbers potentially benefiting from opioids, and numbers affected by opioid-related harms. A review of these data is presented in the background section of this document, with detailed information provided in the Contextual Evidence Review . Finally, CDC considered the effectiveness of treatments that addressed potential harms of opioid therapy .
Clinician and Patient Values and Preferences
The recommendations are grouped into three areas for consideration:
In summary, the categorization of recommendations was based on the following assessment:
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Ii Sources Of The Crisis
The dramatic increase in opioid overdose deaths in the United States has paralleled the booming legal market in prescription opioids such as hydrocodone and oxycodone, known by brand names including Vicodin, OxyContin, and Percocet.16)Katz, J. . Short Answers to Hard Questions About the Opioid Crisis.The New York Times. The CDC reports that legal sales of opioid pain relievers in 2010 were four times those in 1999.17)Centers for Disease Control and Prevention. . Vital Signs: Overdoses of Prescription Opioid Pain Relievers United States, 19992008.Morbidity and Mortality Weekly Report Prescribing Data.Centers for Disease Control and Prevention, 30 August 2017. In 2015, 97.5 million people aged 12 or older used, or misused, pain prescription relievers in the previous year, representing 36% of the population.18)These figures pertain to the population aged 12 or older in the civilian, noninstitutionalized population . Hughes, A., William, M. R., Lipari, R. N., Bose, J., Copello, E.A.P., & Kroutil, L.A. . See note 4. As the Associated Press observes, Most U.S. drug epidemics over the past two centuries were sparked by pharmaceutical companies and physicians pushing products that gradually proved to be addictive and dangerous.19)Stobbe, M. . Opioid Epidemic Shares Chilling Similarities with the Past. AP News. Understanding how this statement applies to the current opioid crisis can help to expedite its end.
New Addictions Every Day
But the rise of heroin does not mean the prescription opioid crisis is going away.
In years past we had a cocaine baby once in a while. All of a sudden our unit is full of these babies. Were all like, whats going on? We had no idea why there were so many. Screaming. It was bad. You couldnt feed them. Theyre in withdrawal, she said.
Well never control the heroin if we dont control the opiates because there are new addictions every day
If there is a heroin epidemic, nine out of 10 heroin users start with prescription opiates. Well never control the heroin if we dont control the opiates because there are new addictions every day.
Colbert points the finger at the drug manufacturers led by Purdue Pharma, the maker of OxyContin and a medical establishment she said that puts too much emphasis on prescribing powerful drugs to deal with pain.
In 2007, Purdue paid a $634m penalty for misrepresenting the drugs addictiveness. In December it reached a $24m settlement with Kentucky after the state claimed Purdue cost it an entire generation to OxyContin.
Colbert accuses the pharmaceutical companies and doctors of attempting to shift blame for the epidemic by accusing those hooked on prescription opioids of abusing the drugs.
That was the experience of Eaton, who calmly recalls the trauma of his years of addiction but becomes visibly angry when talking about drug manufacturers and doctors.
The Florida Medical Association did not respond to a request for comment.
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What Is The United States Doing To Reduce Demand
Previous federal antidrug campaigns relied on incarceration to deter drug use and trafficking. This approach has been widely criticized for failing to keep people from cycling in and out of prison and for disproportionately targeting Black Americans. In recent years, federal and state officials have shifted toward prevention and treatment. Some city and local governments have launched what are known as harm-reduction programs, which focus on limiting virus transmission and overdoses through the promotion of safer drug use. Critics of such programs argue that decriminalization would lead to higher rates of drug use.
President Barack Obama reduced prison sentences for hundreds of nonviolent drug offenders during his tenure. However, he failed to secure legislation that would have eliminated mandatory minimum sentences for federal drug crimes. His administration also established hundreds of new drug courts, which proponents say are an effective alternative to incarceration. Drug courts, the first of which was launched in 1989, under the George H.W. Bush administration, provide nonviolent offenders an alternative to the criminal justice system that involves monitoring and rehabilitation services rather than prison time. In 2016, Obama signed legislation authorizing more than $1 billion in funding, largely in the form of state grants, to expand opioid treatment and prevention programs.
In recent years, federal and state officials have shifted toward prevention and treatment.
The Treatment Gap In The Criminal Justice System
The treatment gap persists among people who are entangled in the criminal justice system, with few receiving structured and professional treatment services. The Bureau of Justice Statistics reports that 58% of people in state prisons and 63% of those serving jail sentences between 2007 and 2009 reported having a drug use disorder in the year prior to their admission.72)The Bureau of Justice Statistics examined rates of drug dependence or abuse as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition . Bronson, J., Stroop, J., Zimmer, S., & Berzofsky, M. . Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. US Department of Justice. These levels were 10 times higher than among the general population, after statistically standardizing to match these populations by sex, race/ethnicity, and age.73)Bronson, J., Stroop, J., Zimmer, S., & Berzofsky, M. . See note 72. But only about one-quarter of incarcerated people who had a drug use disorder reported participating in any drug treatment program while serving a sentence in prison or jail.74)Bronson, J., Stroop, J., Zimmer, S., & Berzofsky, M. . See note 72 Mumola, C.J. & Karberg, J.C. . Drug Use and Dependence, State and Federal Prisoners, 2004. US Department of Justice.
Table 1. Rate of drug treatment since prison or jail admission among incarcerated people with drug use disorder
|Criminal justice environment|
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Strategies For Reducing Demand
This section reviews strategies aimed at reducing aggregate desire and need for opioids, including both reducing patients’ reliance on opioids for pain management and reducing the occurrence and prevalence of untreated OUD. Accordingly, the discussion encompasses two main strategies: education programs focusing on alternatives to opioids for pain management and prudent and limited use of opioids if they are prescribed and health policies bolstering and improving access to and utilization of evidence-based treatment for OUD.
A Growing Number Of Insurers And Health Care Organizations Are Moving To Regulate Opioid Prescription Strength
Last spring, the CDC published a first-of-its-kind guideline on prescribing opioids for chronic pain that has reverberated throughout the health care system. The recommendations questioned the effectiveness of opioids in managing chronic pain and raised serious concerns about long-term use.
And individual insurers, state and federal agencies, and national health care accreditation organizations have either proposed or put into effect policies ranging from limiting the number of days an initial opioid prescription can last to restricting the strength of the actual doses doctors can prescribe.
In the state of Maine, for instance, the health department is requiring all long-term opioid users to reduce their daily doses to 100 MME by July 1. The National Committee for Quality Assurance , a leading accreditation organization of health insurers and physicians, is moving to enact opioid dosage limits too.
What NCQA has proposed would be far-reaching it would penalize health care providers who prescribe patients more than 120 MME daily over a three-month period.
The NCQA cautioned Vox that the specifics of how the measure would work are still being discussed, and a final version wont be released until July. Whats more, if the measure is implemented, the first year will be a test period to collect data and determine whether it merits being included in the accreditation program.
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Primary Areas Of Focus
Contextual evidence is complementary information that assists in translating the clinical research findings into recommendations. CDC conducted contextual evidence reviews on four topics to supplement the clinical evidence review findings:
- Effectiveness of nonpharmacologic and nonopioid pharmacologic treatments , including studies of any duration.
- Benefits and harms of opioid therapy related to specific opioids, high-dose therapy, co-prescription with other controlled substances, duration of use, special populations, and potential usefulness of risk stratification/mitigation approaches, in addition to effectiveness of treatments associated with addressing potential harms of opioid therapy .
- Clinician and patient values and preferences related to opioids and medication risks, benefits, and use.
- Resource allocation including costs and economic efficiency of opioid therapy and risk mitigation strategies.
CDC also reviewed clinical guidelines that were relevant to opioid prescribing and could inform or complement the CDC recommendations under development .