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Thursday, March 27, 2014


Treating Doctors as Drug Dealers: The Drug Enforcement Administration’s War on Prescription Painkillers

Since 2001, the federal government has accelerated its pursuit of physicians it alleges are contributing to an increase of prescription-drug addiction. These highly publicized indictments and prosecutions have frightened many physicians out of the field of pain management, exacerbating an already serious health crisis—the widespread undertreatment of severe chronic pain.

In 2010, a dentist extracted my wisdom teeth, told me to gargle with salt water, and sent me home with a prescription for a Costco-sized bottle of hydrocodone pills. During the procedure, she knocked me out with propofol—the same drug that killed Michael Jackson—and afterward I felt no pain. After a few hours, I popped one hydrocodone, more out of politeness than need. Weeks later, I still felt fine, but I popped two more, just to see what it was like. Hydrocodone’s dreamy, pain-dulling effect was impressive: I bit my cheek hard enough to draw blood, and it didn’t hurt at all. But the pills made me woozy. I then put the remaining 57 or so of them into my medicine cabinet, and I have no idea what happened to them after that. Lost in a move, I guess.
Heroin epidemics don’t come and go randomly, like the McRib. They have clearly identifiable causes—and in this case, by far the largest cause is doctor-prescribed pills. Every year since 2007, doctors have written more than 200 million prescriptions for opioid painkillers. (Consider that there are 240 million adults in the country.) And about four in five new heroin addicts report that they got addicted to prescription pills before they ever took heroin.
My experience was typical: Most people who try opiates don’t get addicted. But enough do. Since 2002, the total number of monthly heroin abusers has doubled to 335,000 nationwide. Some of the addicts get the pills through a well-meaning doctor or dentist, and many others swipe leftover pills from their friends or family members. The result for an addict is the same: Once the pills or money run out, heroin is still available—and cheap. At about $10 per hit, it can be half the street cost of pills.
“We seeded the population with opiates,” says Robert DuPont, an addiction doctor who served as drug czar under Presidents Nixon and Ford and who is now a harsh critic of opiate over-prescription. The supply shock from easy access to prescription drugs has pushed heroin use out of cities and into rural and suburban and middle-class areas. Massachusetts reported a staggering 185 heroin deaths outside its major cities since November, and Peter Shumlin, the governor of Vermont, spent his entire “state-of-the-state” address talking about the nearly eightfold increase in people seeking opiate treatment there since 2000. “What started as an OxyContin and prescription-drug addiction problem in Vermont has now grown into a full-blown heroin crisis,” he said.
Just 30 years ago, the pills were barely available in the United States, and the only way to get addicted to opiates was to shoot or snort heroin, probably bought on a street corner from a man carrying a weapon. DuPont observed a heroin boom in the late ’60s in Washington, D.C., when users consisted primarily of young black men with criminal backgrounds. Dupont says these users chose heroin as their first drug, skipping more benign highs like marijuana. That wave gained energy when American servicemen began returning from Vietnam, where pure Golden Triangle heroin—the granddaddy of all smack—could be bought cheap. “Through 1992, if you went to a methadone program, that’s who you’d see,” DuPont says. “It was an aging population of people who began their addiction in the 1970s.”

Illustration by Jonny Ashcroft
It took the intervention of doctors to bring heroin back, with the demographic switcheroo we see coming to fruition today. In 2000, the Joint Commission on Hospital Accreditation released a report concluding that doctors were undertreating chronic pain and that thousands of patients were suffering needlessly. Pharmaceutical companies welcomed the medical profession’s decision to supply those patients with previously unobtainable prescription opiates. Companies zealously promoted these drugs and underplayed their potential to turn patients—and any bored friend or relative who decided to play prescription roulette with the contents of their medicine cabinets—into junkies.
Over the last two decades, pain doctors have been competing with each other to win the business of addicts. At one point, 25 of the top 50 prescribers of opiates in the United States practiced in Broward County, Florida. Some of them boasted that they didn’t even require patients to show ID—a frank admission that the clinics welcomed doctor-shopping addicts and their money. In many cases, they advertised a “No Pill, No Pay” policy. Some doctors still dispense opioids like Pez, and patients know exactly where to find them. “Physicians get their practices reviewed on Yelp, and people who don’t get their opiates give bad reviews,” says Michael Ostacher, an addiction psychiatrist at Stanford.
Until recently, the system was rigged to encourage doctors and dentists to give out opioids with reckless abandon. “Most things in health care that seem crazy become explicable if you look at the incentive structure,” says Keith Humphreys, a psychologist who worked in the Office of Drug Control Policy from 2009 to 2010. “If you are a dentist and you give someone thirty Vicodins, they won’t bother you again. And if they develop a problem, no one blames you.” A physician in California told me he could easily end up with a long line of paying patients out his door, if he just let word out to addicts that OxyContin flowed freely from his prescription pad. Better medical education and tighter regulation have at least begun to slow down the pill flow.
“The result of this is that you probably have opioids in your medicine cabinet right now,” says Humphreys. “And who knows that? People who are addicted to opioids.” Realtors now advise people selling their homes to clear out their medicine cabinets before an open house, because of the high risk that addicts will attend the showing solely to swipe pills. “You don’t have to go to a drug dealer anymore,” says DuPont. “You just have to know some college friend who had his wisdom teeth pulled.”
For the addict and his or her family, the addiction can of course be hellish, no matter how it started. But there are two silver linings to this epidemic, relative to the previous ones. First, there is a movement to increase public access to Naloxone (brand name: Narcan), an “anti-O.D.” drug that first responders can stick up a victim’s nose. Naloxone strips opioids off the receptors in the addict’s nervous system, and if used in time can keep the addict breathing long enough to survive. Some worry that the availability of Naloxone will lead addicts to take more risks—opiate enthusiasts have been known to wear “Got Narcan?” t-shirts, using the “Got Milk?” logo—but already the drug has saved lives, and there’s no evidence yet that it makes people inject heroin more than they already are.
Second, we can take slight comfort in knowing that the origins of this epidemic at least aren’t directly tied up in gang violence, or in a psychologically and morally scarring war in Indochina. If you can choose which addict to have in your life, the one who starts by furtively gobbling pills, or the one who is surrounded by violence and one day decides to drive a spike into his vein and inject a substance sold to him by a street-corner pusher, you definitely want the former. Docility and passivity are virtues in an addict, and in previous heroin booms, the gateways to addiction opened more readily for criminals and killers than for suburban kids poking through their grandparents’ bathrooms.
So while the addicts are more numerous than a decade ago (still only 0.14 percent of Americans), they are also significantly less scary and perhaps more likely to survive long enough to be helped. Unfortunately, modern medicine hasn’t yet figured out a universally effective way to wean abusers off long-term addiction; some will be sidling up to a methadone-clinic window every morning for the rest of their lives. And their addictions will continue the way they began, just as the doctor ordered.

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