Drug Wars Abroad, Prescription Pain Killers at Home

Prescription opioids perform a vital role in pain management, but their overproduction lax regulation has had the inevitable result of mass diversion to illicit channels.
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Masked by our continuing drug war in Mexico, and the administration's recent expansion of U.S. drug enforcement into Central America and the Caribbean, is the more serious problem of prescription drug abuse, especially opioids, the class of psychoactive drugs used for pain management which includes codeine, hydrocodone, and oxycodone, among others. By all measures, the illicit consumption of prescription opioids today exceeds any of our previous drug crises, including heroin in the 1960s and 1970s, and crack cocaine in the 1980s and 1990s. Because those addicted to prescription opioids often take far in excess of safe doses or ingest them in a dangerous manner (chewing, smoking, injecting, or mixing with other drugs), rates of overdose also have exceeded anything we saw with heroin or cocaine. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), reports a 100 percent increase in emergency room visits associated with prescription drug misuse since 2007. After marijuana, prescription drugs comprise the majority of illicit drug abuse among 12th-graders in the United States, according to a National Institute on Drug Abuse (NIDA) study.

Eight percent of high school seniors reported non-medical use of Vicodin; 5 percent of Oxy-Contin. In a report released in April 2011, the Obama administration noted that "Prescription drug abuse is the Nation's fastest-growing drug problem," labeling the problem an "epidemic." The problem is not as simple as it seems, and certainly not as much as we would like it to be. NIDA broadly defines prescription drug abuse as "the intentional use of a medication without a prescription; in a way other than as prescribed; or for the experience or feeling it causes."

This, however, includes a broad range of users, including recreational and experimental users, but also people whose addiction began therapeutically in pain management. It also includes individuals who, lacking health care coverage, have borrowed or illicitly purchased medication for legitimate pain management. And then there are those who will develop a problem relationship with these drugs for some of the same reasons as people do with alcohol or illicit drugs: as a "self-prescribed" treatment for common mental health conditions such as anxiety or depression. Certainly, the absolute criminalization of illicit prescription drug use -- historically a favored but generally ineffective policy in the United States -- will be even less appropriate here. The solution should focus on production and distribution oversight and treatment interventions for those with addictions.

We need, however, to take an honest look at the role of overproduction and the aggressive marketing of opioids. Given the ramped-up production, sale, and consumption of opioid painkillers, it should not be surprising that this form of substance abuse stands to surpass all others. A 2010 study showed that the period between 1997 and 2007 in the U.S. saw a 402 percent increase in the average per-person purchase of prescription opioids, from 74 milligrams to 369 milligrams. In 2000, retail pharmacies filled 174 million opioid prescriptions; by 2009, that number had reached 257 million.

In some areas, the current administration -- acting largely through its Office of National Drug Control Policy (ONDCP), the Department of Justice, NIDA, and the FDA -- and the federal government have moved in productive directions. To prevention and treatment the White House has added a third application, recovery, to its approach to demand reduction. This emphasizes access to post-treatment services, especially for veterans and military families. In April 2011, it announced a coordinated effort to address the prescription drug addiction issue, including patient and physician education, and encouragement of state-run prescription drug monitoring programs (PDMPs). Taking a lead from the White House, the U.S. Senate Caucus on International Narcotics Control last month released a report on "Reducing the U.S. Demand For Illegal Drugs," in which it raised the question of how the nation's medical and public health systems might be improved to deal with drug addiction. The Caucus's recommendations included more public awareness of the issue; increased support for drug treatment, and improved data collection on treatment; and passage of legislation more tightly regulating online sales of prescription drugs.

Yet current proposals skirt the issue. The PDMP program, for example, is active in nearly all of the states. For having been left largely to the states, cities, and counties, however, the program has received criticism for not being as uniformly effective as a federally-led initiative would be.

Similarly, the tighter regulation of online transactions will not affect a large proportion of opioid sales. Despite these rather weak measures, the Senate Caucus on International Narcotics Control seems willing to cede influence to private industry in public discussion, recommending that the White House raise non-public funding for the ONDCP's National Youth
Anti-Drug Media Campaign. To do so, it should "work to leverage greater private resources for this program," which should be transformed into "an eventual public-private partnership."

There is something counterintuitive, however, in looking to private partnerships to fund and therefore structure -- public discourse regarding problem partially rooted in private industry. Imagine inviting the tobacco industry to be partners in the national discussion on youthful smoking and lung cancer.

There are no simple answers, and we need to focus our attention on the domestic dimensions of our biggest drug problem. Prescription opioids perform a vital role in pain management, but their overproduction lax regulation has had the inevitable result of mass diversion to illicit

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