You can’t pick up a newspaper, turn on the TV or radio, or access any online news source without encountering headlines screaming “opioid epidemic.”
There is the alarming rise in the number of chronic pain patients who have become addicted to opioids. And the explosion, in recent years, of opioid prescriptions by health care providers now under government pressure to curtail their prescribing.
This pressure has driven many opioid addicts to the illicit drug market to avoid the pains of withdrawal. There, according to the Centers for Disease Control and Prevention (CDC), they often find opioid heroin cheaper and sometimes more readily available despite a 50‐year “War on Drugs.” Thus they become heroin addicts.
Media hysteria begets calls to action. Politicians and the administrative state devise new laws to control this “evil plague.” As a surgeon who regularly prescribes painkillers for patients suffering from postoperative pain or painful conditions, I see a painful cognitive dissonance.
Begin with US policy towards heroin. Originally developed in the 1870s, diacetyl‐morphine was marketed under the brand name Heroin, by the Bayer pharmaceutical company. Despite pleas by the Surgeon General and the American Medical Association to keep it legal, Heroin was banned in the US in 1924 because political leaders believed it the drug corrupted an individual’s moral character.
Meanwhile, dilaudid, 3 to 4 times more potent than morphine, is legal and is routinely administered for pain both as an oral and an injectable agent. Fentanyl, or Duragesic, is legal, too, although it is more than 50 times the potency of morphine.
There is even greater cognitive dissonance with methadone, the powerful opioid approved for use in the US in 1947 and commonly used in this country to treat addiction to heroin and other opioids.
Chronic users of opioids develop a tolerance, requiring ever‐increasing doses to achieve the desired effect. A low, oral dose of methadone binds with enough of a person’s opioid receptors to prevent withdrawal symptoms yet not produce the euphoric effects.
The idea behind “methadone maintenance” programs is to transfer the addiction from heroin or another opioid. Because they do not experience the euphoria and “escape” of their chosen opioid, methadone addicts can resume a normal, productive — even conventional — life. Some can be tapered off from methadone and “detoxified.” But many remain on methadone, sometimes for their entire lives.
To put things in proper perspective, chronic alcohol use is much more dangerous. Chronic use can cause cirrhosis of the liver, cardiomyopathy (heart failure from damaged heart muscle), encephalopathy and dementia, chronic pancreatic inflammation, and has been linked to cancer of the stomach and the esophagus. In addition, one can overdose on alcohol as well — which may cause a person to stop breathing, become hypoxic, and die.
And here’s where the cognitive dissonance comes in: it is perfectly acceptable and permissible — even public policy — to allow people to be chronically addicted to the opioid methadone. The side‐effects of prolonged use are considered serious yet tolerable. But it is unacceptable and counter to public policy for a person to be chronically addicted to any other opioid, even if that person self‐doses to prevent withdrawal while avoiding the “high” in order to lead a peaceful and productive life.
The concept of “harm reduction” as an approach to substance abuse has gained increased acceptance by health care practitioners as well public health and government authorities. Harm reduction approaches chemical dependency in a non‐judgmental and realistic way, leaving drug prohibition in place.
The strategy seeks to ameliorate the most destructive effects of prohibition on the individual drug user and addict. The health care practitioner focuses on minimizing the addict’s self‐inflicted harm. Clean needle‐exchange programs to prevent the spread HIV and hepatitis are a part of harm reduction.
Methadone maintenance is in its way a form of harm reduction, substituting an illegal opioid addiction with the legal and safe administration of a drug of pure and controlled quality.
Medical professionals in 1914 expressed concern that the Harrison Narcotics Act, making opioids available only by prescription from a physician, would lead to government intrusion on the patient‐doctor relationship and, eventually, the micromanagement of doctors prescribing narcotics.
The surgeon general at the time assured doctors and patients that the new prescription requirement was “intended simply to gather information.” Yet fine print in the law said that a doctor might prescribe these drugs “in the course of his professional practice only.” The interpretation of that phrase was left up to Treasury department officials, and they later interpreted the prescribing of narcotics to an addict as not “professional practice,” but rather feeding a bad habit.
Six weeks after the law took effect the New York Medical Journal editorialized against it, predicting a rise in the “…commission of crimes which will never be traced to their real cause, and the influx into hospitals for the mentally disordered of many who would otherwise lead socially competent lives.”
Federal and state governments today closely watch and strictly control the prescription of opioids and seem poised to insert themselves even deeper into the patient doctor relationship.
Set aside the unintentional harm caused by an ineffective War on Drugs. Think about how many people with chronic pain conditions are either under‐medicated for their pain out of a fear of opioid addiction or are driven to the streets, where they engage in much more risky behavior because state authorities pressure health care providers to cut back — or cut them off entirely — from opioids.
As a health care provider, I think current public policy should more comprehensively adopt harm reduction when it comes to America’s opioid addiction problem. I think current drug policy should stop interfering with what should be an inviolable relationship between the health care practitioner and the patient.
Let doctors exercise their best professional judgment and prescribe opioids accordingly — free from the chilling effects created by monitoring government agencies. It is the responsibility of a health care provider to make certain a patient is aware of the proper use and the potential for abuse of any pain medication prescribed.
Should a doctor suspect a patient is developing a potential addiction, a frank discussion should ensue. The practitioner should offer help to the patient wanting to end the addiction. If the patient has no interest in curbing or ending use of the substance, then the prescriber should be allowed to choose to continue to prescribe it to the patient, while frequently monitoring and communicating with the patient (as professional conduct demands).
Many practitioners will, and should be able to decide that it is better for the patient to continue a controlled addiction to an opioid while maintaining an otherwise productive life than to be driven to the street and the black market. There should be no sanctioning of health care providers for using their best professional judgment in advising and treating their patients in this regard.
To facilitate this harm reduction — and to offer providers more options for treating their patients’ pain — diamorphine should be reclassified by the FDA under the Controlled Substances Act from Schedule 1 (no accepted medical use — which is obviously not true), to Schedule 2 (has a medicinal use but a high potential for abuse and physical dependence), like morphine, dilaudid, methadone, and fentanyl.
Instead, politicians and bureaucrats seem bent on pressuring medical professionals to limit the opioids they prescribe, punishing them for issuing too many prescriptions, and referring patients into chemical dependency rehab programs with high recidivism rates.
And so we continue with incongruous and irrational policy. It’s perfectly acceptable for a surgeon like myself to prescribe morphine for my patient’s post‐op pain. Or dilaudid, which is 3 – 4 times more potent, or fentanyl, which is at least 50 times more potent. But I cannot prescribe medical heroin. It’s OK for a person to remain addicted just as long as the opioid is methadone.
There is a word to describe such an opioid policy: incoherent.