Heroin and Painkiller Deaths Require Public Health Policies

Drug policies that unilaterally curb access to prescription opioids can have unintended consequences, exacerbating the very problems, such as overdose, that they purport to solve.
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The death of Philip Seymour Hoffman has brought public attention not only to rising heroin overdose rates, but also to the unprecedented use of opioid painkillers such as Oxycontin and Opana in mainstream America: in suburbs, rural towns, and affluent urban neighborhoods like Hoffman's. Prescription opioids are the most common cause of overdose deaths in the U.S. And now, according to data published in the New England Journal of Medicine, opioid pill users are transitioning to heroin following the manufacturers' replacement of abusable pills with tamper-resistant formulations. Prescription Drug Monitoring Programs, that mandate doctors to check patients' existing prescriptions before prescribing opioids, have been followed by an increase in heroin use. Drug policies that unilaterally curb access to prescription opioids can have unintended consequences, exacerbating the very problems, such as overdose, that they purport to solve. It is time for us to adopt harm reduction approaches to drug policy that put public health above the fear and stigma of addiction.

In Western Europe, heroin overdose deaths have been dramatically reduced by making an opioid -- buprenorphine, commercially known as Suboxone -- readily available. In France, for example, the rate of opiate overdose fell by 80% in the first seven years after primary care doctors routinely prescribed Suboxone for opiate dependent patients. Suboxone is less likely to cause people to stop breathing, and therefore has a lower risk of overdose death, than heroin and synthetic opiates (opioids). In the U.S., Suboxone was FDA approved for office-based treatment of opiate dependence by general physicians in 2002, based on its safety profile and its combination of buprenorphine with naloxone, which causes withdrawal symptoms when injected rather than taken orally as prescribed.

Ironically, in the U.S., doctors who want to prescribe Suboxone must complete an 8-hour certification course and use a special identity number for DEA surveillance of their prescriptions, yet prescribing more lethal opioid painkillers requires no special training or identity number. The number of Suboxone certified prescribers is small relative to the growing number of opioid dependent patients, particularly in public clinics. This has led to disparities in access to Suboxone treatment by income, ethnicity and race. And the DEA has begun auditing Suboxone prescribers' records, which may further discourage physicians from prescribing it.

Another widespread policy response to the prescription opioid epidemic are prescription drug monitoring programs (PDMPs), now operational in almost every state. These programs are designed to identify and stop "doctor shopping" and "pill mills" by flagging multiple prescribers, excessive doses, and dangerous combinations of medications. In almost every state with a PMDP, prescribers face serious sanctions or criminal penalties for failing to use the PMDP. This is intended to reduce prescribing, and research suggests it does just that, but there is no evidence that they help people access the harm reduction and treatment services they need. Our interviews with prescribers and patients in New York City indicate that doctors are turning away opioid seeking patients without offering the opiate antidote naloxone for emergency overdose reversal, Suboxone, or referrals to drug treatment. This isn't surprising. Most doctors have not been given the training, tools, and resources needed to effectively manage or refer patients struggling with addiction. Yet their refusal to see such patients may well drive them from pills to heroin.

To redress the opioid overdose crisis rather than compounding it, we need to equip doctors and our health care system to respond more effectively to addiction. The DEA licenses that permit doctors to prescribe narcotics should require them to train in the safe use of opioids for pain, in the distribution of naloxone overdose reversal kits to opioid treated or dependent patients, in the use of Suboxone, and in skillful assessment and referral of patients to addiction treatment. We must also use the opening provided by the Affordable Care Act and the Mental Health Parity Law to create effective linkages between health care, harm reduction, and drug treatment programs, by making the provision of a wide range of substance abuse treatments and services, as well as patient retention and satisfaction, key quality indicators in evaluation and reimbursement protocols. This will also require investment in harm reduction programs, such as community based naloxone, Suboxone, and methadone, and investments in the underfunded addiction treatment system. These steps would re-tool our drug policies to prioritize public health over punitive responses.

We now have the opportunity to respond to a public health crisis with a public health approach, by offering safe alternatives to people at risk for overdose, infection and incarceration, along with health care and other essential services.

Helena Hansen, MD, PhD, is an addiction specialist and researcher, and is assistant professor of Psychiatry and Anthropology at New York University.

Julie Netherland, PhD is the New York deputy state director at the Drug Policy Alliance

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