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Let’s Fight a Different ‘War on Drugs’
To put the magnitude of the issue in perspective, the death wave from drug abuse is now as big, in terms of annual deaths, as the one caused by HIV-AIDS in the late 1980s. That resulted in a national public-health response. And yet policy makers have been largely silent about prescription drugs.
Though there are many who use prescription drugs responsibly, the data suggest a medical system widely complicit in their abuse. They also suggest opportunities to curtail that abuse without jeopardizing the proper use of medication.
In 1980, about 2.7 people died per 100,000 from drug poisoning, both from prescription and illicit substances, according to data from the Centers for Disease Control and Prevention. As of 2008, about 12 people died per 100,000. Roughly half of drug overdose deaths result from prescription painkillers. And for every person who dies from prescription painkillers, there are about 32 more emergency department visits.
The soaring increase in sales of prescription painkillers explains most of the deaths. In 1999, a total of 2 kilograms of such drugs were sold for every 10,000 people; as of 2010, about 7 kilograms were. According to the CDC, opioid analgesics such as methadone, hydrocodone and oxycodone are the most common cause of drug poisoning.
The war on drugs, launched by President Richard M. Nixon in the 1970s, has focused public policy on the use of illicit drugs, marijuana in particular. Prescription-drug abuse now presents a much larger problem but receives a fraction of the resources invested in criminal justice and law enforcement against illegal drugs.
Simple changes in public policy can probably achieve significant reductions in prescription-drug mortality. Let's take a look at some of the data:
- Almost all of the prescription drugs are obtained legally, rather than from pharmacy theft, though thefts are growing. Almost all of the drugs, moreover, come from friends and relatives for whom the prescriptions were originally written.
- The prescriptions originate from a tiny number of medical professionals who work in primary care, internal medicine, and dentistry -- not specialists. About 20 percent of prescribers write 80 percent of painkiller prescriptions.
- Drug-overdose rates are highly correlated with painkiller sales, both of which vary widely from state to state. For every additional 10 kilograms of prescription painkillers sold, one person will die from an overdose. (See the accompanying graph.)
Together, these facts suggest that policy efforts to restrict illegitimate prescriptions of painkillers could achieve reductions in poisoning mortality -- and without compromising access for those who use drugs appropriately.
Limiting the supply of prescription drugs, it appears, does not generate significant substitution behaviors. Abuse of illicit drugs, alcohol or other substances is not systematically higher in states with lower painkiller sales and prescription-drug abuse. And the state-level data imply that tighter controls on prescriptions will lead to significantly less abuse.
Policy makers should focus on prescribers because once the drugs reach patients’ hands, the distribution network becomes informal. Since the problem stems from a relatively small fraction of doctors, the enablers will be easy to catch. A doctor who prescribes 10 times the number of painkillers as that of comparable doctors, for example, will have no plausible story. By shutting down the “pill mill” doctors, the larger distribution network will dry up.
What, specifically, can be done? New York State took a good first step last year when it enacted a law to increase the monitoring on prescription painkillers through mandatory electronic health records. More than 40 states have implemented similar systems, though they tend to be voluntary.
There is more room for state governments to take action against the doctors themselves. A coordinated national wave of high-profile prosecution and de-licensing of doctors who enable prescription-drug abuse, for instance, could go a long way. Doctors currently face perverse incentives to cooperate with patients who want prescription drugs, according to a piece published last year in the New England Journal of Medicine.
This war on drugs is increasingly important for the lives of Americans. And we might just be able to win it.
(Evan Soltas is a contributor to the Ticker. Follow him on Twitter.)