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Prescription drug addiction: How the epidemic is shaking up the policy world

Last week, the New York Times' Sabrina Tavernese published a moving account of how prescription painkiller addiction is destroying the lives of people in Scioto County, Ohio. The county is a microcosm of the national epidemic of prescription drug addiction and overdose, which has spurred Congress to introduce legislation to crack down on “pill mills” and led the White House to unveil a new policy initiative comprising prescriber education, addiction treatment and law enforcement. What is less well known is how the surge in prescription drug addiction is overturning three prevalent beliefs in the drug policy field:

  1. It is generally accepted among addiction specialists and drug policy analysts that drugs with similar effect can substitute for each other. For example, if you provide methadone (a synthetic opiate) to someone addicted to heroin (another opiate), their heroin use will usually decline. Likewise, some drug policy analysts believe that if marijuana were legal, alcohol use would decline because some people could get some of the alcohol consumption effects they enjoy by smoking marijuana instead. But throughout the wave of prescription opioid addiction, heroin addiction in the United States hasn’t dropped a bit. A number of smart people have been speculating about this mystery, but no one has an empirically based explanation of why the complementarity hypothesis isn’t panning out.
  2. The fact that pharmaceutical drugs are now the leading causes of drug overdose in the U.S. challenges the common assumption that overdoses result primarily from the variable content of drugs in the black market (i.e., you can’t assess the purity of what you are buying from transaction to transaction). Pharmaceuticals are consistently pure and their dose is standardized, such that everyone knows what they are taking in a way they can’t with illegal drugs such as heroin and cocaine. Yet overdoses on those illegal drugs are flat while overdoses on prescription drugs such as Oxycontin and Vicodin are soaring. It may be that the rationality of addicted people has been overestimated in regards to overdose, i.e., even when they know the exact content of the drug and that it may produce overdose, their desire to use trumps that risk in their minds. The extra information about purity and dose is therefore of little consequence.
  3. Finally, the epidemic throws cold water on the theory that if we legalized all the illegal drugs and let physicians dispense them as they would any other drugs, our national drug problem would abate. People who buy this theory generally point to Britain before World War II, during which any physician could prescribe heroin and cocaine as they saw fit. Physicians are overwhelmingly trustworthy and responsible, but it only takes a few bad apples to feed a drug epidemic. Several hundred dishonest prescribers in South Florida for example managed to cause overdose deaths all over the Southeastern United States. No profession can ensure that not even one tenth of one percent of its members will break professional codes and standards. Turning the currently illegal drugs over to doctors for dispensing is therefore an extraordinarily risky proposition. In Britain, it took years for the addicted community to spread the word about which physicians were reckless prescribers, leading to a drug epidemic. In the era of Internet communication, it now happens within days, and cheap air travel does the rest to spread the epidemic. See the award-winning film Oxycontin Express, available for free viewing on Hulu, for a glimpse of this frightening reality.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

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