Prescriptions Are Down, but Overdoses Are Up — Is That Progress?

This article appeared in the The Hill (Online) on May 9, 2019.
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President Trump recently spoke at the annual Prescription Drug Abuse and Heroin Summit in Atlanta, touting “pretty amazing” progress in combating the overdose crisis afflicting the country and expressing pride in government efforts to reduce the total number of opioids prescribed, claiming a 34 percent drop in total opioid prescriptions during his time in office.

The number of opioid prescriptions might be coming down, but overdose deaths continue to mount, with the Centers for Disease Control and Prevention provisional report showing over 46,000 opioid-related deaths in the 12 months ending April 7, 2019, 60 percent of which involved illicit fentanyl. Thirty-two percent involved heroin.

If this rates as “pretty amazing” progress then the president is grading on a steep curve. If he wants to really see progress, the focus of drug policy must move away from the number of pain killers prescribed and over to harm reduction.

Patients in pain grow desperate as doctors are terrorized into under-prescribing pain medication, fearing arrest and prosecution. State regulators, licensing boards and even pharmacies and insurers have misinterpreted and misapplied the already controversial 2016 CDC opioid prescribing guidelines which were meant to be “voluntary [guidelines] rather than prescriptive standards.”

This misapplication has resulted in chronic pain patients being abruptly tapered off of their medication, leading some in desperation to turn to the black market or resort to suicide. It has gotten so bad that during the same week of the drug summit the CDC issued a “clarification,” stating their guidelines were never intended to encourage abrupt tapering.

The government’s own data show no correlation between the prescription rate and non-medical opioid use or opioid use disorder.  That’s why we need harm reduction, which seeks to reduce the physical dangers that come from nonmedical drug use in a dangerous black market fueled by drug prohibition.

In the states where we have seen improvements in mortality rates, it is because those states have begun to employ harm reduction. Ohio and Massachusetts, for instance, have greatly proliferated needle exchange programs and widely distribute the overdose antidote naloxone. They have also expanded the number of licensed methadone treatment clinics. Needle exchange programs are endorsed by the CDC and the Surgeon General and have been proven to reduce the spread of HIV and hepatitis; now many of them hand out naloxone to people along with clean needles. Unfortunately, unlike Ohio and Massachusetts, many states still have anti-paraphernalia laws that prohibit needle exchange programs.

Harm reduction strategies are beginning to reap rewards. Ohio’s Cuyahoga County, for instance, reported 560 overdose deaths in 2018 compared with 727 in 2017. Overdose deaths dropped by four percent during the same year in Massachusetts. But much of harm reduction requires action on the federal level.

President Trump should push reform of regulations on methadone clinics, buprenorphine prescribing and other forms of what is called Medication Assisted Treatment, so that more primary care providers can treat more patients. In the UK, Canada and Australia, primary care physicians are permitted to treat addicts with methadone in their offices, but in the U.S., addicts must seek treatment at heavily regulated clinics approved by the Drug Enforcement Administration and this restricts their availability. And providers are still limited by quotas on how many addicts they can treat at any given time with buprenorphine.

The president should seek a repeal of the federal "Crack House Statute" that doesn't allow our major cities to establish safe consumption/overdose prevention sites, which have saved so many lives in more than 120 cities in Europe, Canada and Australia. He should have the FDA make naloxone available off-the-shelf to increase its availability and legalize cannabis so it can be used to treat pain and can undergo trials as a Medication Assisted Treatment

Drug overdoses and abuse are not confined to the U.S. The problem exists in much of Europe, in Canada and in Australia. But death rates in those countries are dwarfed by those in the U.S. and that’s largely because harm reduction strategies have been widely adopted in most of the rest of the developed world since the 1980s.

President Trump can set a new precedent — and make historic progress — by being the president who shifts the strategy from a war on drugs to a war on drug-related deaths.