Patients are becoming collateral damage in US war on drugs

Tighter restrictions on pain medications would only contribute to needless suffering

November 26, 2013 6:00AM ET
Hydrocodone pills, also known as Vicodin, at a pharmacy in Montpelier, Vt.
Toby Talbot/AP

In October the U.S. Food and Drug Administration proposed tightening restrictions on access to certain low-potency narcotic pain medicines in an effort to stem the rising tide of prescription-drug abuse in the United States. The new rules would require patients to visit their doctors more often to refill their prescriptions and prohibit pharmacists from filling prescriptions over the phone.

The recommended changes may seem innocuous to many Americans, who are accustomed to getting just one side of the story on prescription-drug use. In fact, they are part of a disturbing trend that threatens to disrupt access to life-sustaining medication for millions of law-abiding citizens while having minimal impact on levels of drug abuse and addiction.  

The move by the FDA to reclassify low-level hydrocodone preparations like Vicodin as Schedule II narcotics — the same category currently assigned to stronger pain medications, including fentanyl and morphine — follows several years of unilateral action by the states to erect new roadblocks to pain management. Advanced under the guise of protecting the health of Americans, these restrictions represent a heedless expansion of the war on drugs at the expense of the privacy and well-being of innocent patients.

In Pennsylvania, Republicans in the State Assembly are pushing legislation that would inappropriately expand access to the commonwealth's prescription-drug-monitoring database and automatically notify the state attorney general and local prosecutors of "irregular" dispensing patterns. If this effort were about proper government monitoring, then the very same coalition would not simultaneously be working to dismantle the state's firearms-transfer database. The American Civil Liberties Union and the Pennsylvania Medical Society have filed briefs in opposition to the bill.

In Indiana, the legislature passed a bill last spring requiring the state's Medical Licensing Board to adopt a set of emergency protocols governing the prescription of opioid pain medication that include mandatory drug screening of people prescribed opioids to ensure they are taking the drugs as prescribed. The new standards went into effect in October.

Two years ago Washington state adopted new restrictions on dispensing opioid painkillers that are among the strictest in the nation. The law holds doctors accountable for tracking patient behavior and administering random urine tests, and it set a first-of-its-kind dosage threshold of 120 milligrams of morphine or its equivalent per day before a prescribing doctor must get a special evaluation from a pain specialist. Only cancer patients and those in hospice care are exempted.

Blowback from the law was swift and widespread. Within months of its taking effect, hundreds if not thousands of patients had been denied life-enabling medications "by doctors leery of the burdens and expense imposed by lawmakers," The Seattle Times reported.

A number of other states — including New Jersey, Oklahoma, Tennessee and Ohio, which recently introduced its own dosage thresholds — are considering or have passed similar measures as part of their efforts to address the growing epidemic of painkiller addiction.

"We are trying to prepare our state for what we hope is the inevitable curbing of the use of opiates in chronic pain," Orman Hall, director of Ohio's Department of Alcohol and Drug Addiction Services, told The New York Times last year.

Burdensome restrictions on pain management have a ripple effect that leads doctors to withhold medication out of fear of prosecution or censure.

Not only is such a goal medically unsound — for most cases, science has yet to develop a more effective means of granting people in unremitting pain a semblance of a normal life — but it also runs counter to internationally accepted human-rights standards.

Since 1972, the U.S. has been a signatory to the United Nations' Single Convention on Narcotic Drugs, which not only addresses the control of illicit narcotics but also obligates countries to work toward universal access to medications necessary to alleviate pain and suffering. In spite of that mandate, tens of millions of people around the world continue to suffer from moderate to severe pain each year without treatment, according to the World Health Organization.

A massive international metastudy of pain management in cancer patients conducted last year by more than 20 oncology and palliative-care organizations concluded that untreated pain is "a major international public-health crisis." In the U.S., researchers have found that roughly a third of cancer patients are undertreated for pain. Many of them are unwitting casualties of America's war on drugs.

The WHO has long held that restrictions on the legal use and availability of opioid analgesics like morphine and OxyContin are an impediment to adequate pain care. According to a 2011 report (PDF) by Human Rights Watch — which has called access to pain meds a "fundamental human right" — burdensome restrictions on pain management have a ripple effect that leads doctors to withhold medication out of fear of prosecution or censure, even when that fear is unfounded.

No one denies that prescription-drug abuse is a serious problem that demands the attention of policymakers. Each year, hundreds of thousands of people are rushed to emergency rooms in the U.S. after overdosing on pharmaceutical drugs, and statistics show that misuse of pain medication kills more Americans than heroin and cocaine combined.

While proponents of new prescribing regimens claim to balance patient health with the desire to mitigate abuse, too often their noble ambitions are clouded by an entrenched misunderstanding of the nature of long-term pain management and the effect of opioid analgesics on the patients for whom they are prescribed. Among the most pernicious myths is the claim that prescribing extremely high doses of narcotics amounts to medical malpractice. In fact, since tolerance increases over time, one man's overdose is another man's aspirin.

What's more, the effectiveness of restrictions on legitimate access to narcotic pain medication in combating abuse and overdose is questionable at best. For one thing, the disease of addiction is stronger than any one particular substance. One study, published in The New England Journal of Medicine in 2012, to gauge the effects of changes to high-potency OxyContin tablets that made them harder to abuse, found that two-thirds of users had simply switched to other drugs — primarily heroin.

There are, fortunately, better ways to address the legitimate problem of prescription-drug abuse. These include increasing penalties for diversion, educating patients on the need to properly secure and dispose of medication, passing laws requiring the reporting of lost and stolen meds and, above all, tackling the problem of addiction by alleviating barriers to treatment.

On Nov. 8 the Department of Health and Human Services took an important step in that direction when it announced new guidelines requiring insurers to provide the same level of coverage for behavioral and mental-health disorders as they do for medical claims. The administration has said as many as 23 million Americans who meet the criteria for a substance-abuse disorder could benefit from the new rules.

Given time, the policy change is likely to prove that by establishing sensible policies to steer addicts into recovery, the U.S. can get a handle on drug abuse without adding needlessly to the suffering of the sick.

Christopher Moraff is a freelance writer who covers policing, criminal justice policy and civil liberties for Al Jazeera America and other media outlets. He was recognized in 2014 with an H.F. Guggenheim reporting fellowship at John Jay College

The views expressed in this article are the author's own and do not necessarily reflect Al Jazeera America's editorial policy.

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