Forty people die each day from what Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention (CDC), calls an “epidemic” of prescription drug overdose. Frieden largely attributes the rise in overdose deaths, which have tripled since 1999, to overprescribing by doctors. But the reality is much more complicated.
At Tuesday’s teleconference announcing the release of new CDC data on the problem, Frieden said, “In fact, now the burden of dangerous drugs is being created more by a few irresponsible doctors than by drug pushers on the street corners.”
Such hyperbole is unlikely to lead to effective solutions for an extremely complex problem. Panics over addiction have always tended to focus relentlessly on supply, while failing to understand demand. In this case, unnecessary hysteria may also serve to reduce legitimate patients’ access to needed pain treatment.
Let’s start with the facts: the vast majority of people who misuse prescription painkillers — 7 out of 10, according to drug czar Gil Kerlikowske — get them from family or friends, not directly from doctors. Secondly, most people addicted to these medications have used illegal drugs previously; they do not become addicted while being treated for pain.
A 2007 study of nearly 1,400 people addicted to OxyContin, who were treated at rehabs across the country, found that 78% had never been prescribed the drug themselves; the same percentage had been in rehab for a previous drug problem. Earlier data found that 80% of those addicted to OxyContin had previously used cocaine, a rate many times that seen in the general population.
That overlap is not likely to be attributed to pain patients who suddenly decide to try cocaine. The more probable explanation is that painkiller addiction is primarily affecting people with current or previous drug problems, not innocent patients being treated by pill-happy doctors.
Indeed, it is impossible for a doctor to “make someone” into an addict. Even if the doctor tied the person down and injected him or her daily with heroin or other strong opioids, only physical dependence could be created. That means the person would suffer withdrawal symptoms when the doctor stopped, but whether such victims genuinely became addicted would be determined by their own actions after that point.
If the research data is anything to go by, most people who use opiate drugs don’t subsequently go looking for dealers or rob their grandmothers to get money to buy more. Of those who try heroin, more than 80% do not become junkies. Likewise, among adults who are legitimately prescribed opioid painkillers and who do not have past histories of drug problems, more than 97% don’t develop new addictions.
Normal, healthy people given these drugs tend to find them unpleasantly numbing, not overwhelmingly attractive. Even among soldiers who served in Vietnam — 45% of whom tried opium or heroin while serving — just 1% developed ongoing heroin addictions that persisted after they came home.
Addiction doesn’t just “happen”: it requires people to choose repeatedly to use drugs to get high or to escape. By definition, this behavior must occur despite ongoing negative consequences; otherwise, it is not classified as addiction.
Moreover, although people with addiction often have genetic predispositions or exposures to traumatic experience that make drugs especially attractive to them, and although continued use itself can impair decision-making, they are not automatons with no free will. Their ability to choose not to take drugs may be reduced as they get hooked, but it’s not eliminated: after all, no one shoots up in front of the cops.
The fact that addiction is not just about access to drugs is why talk of drug “epidemics” rarely changes their course. Supply-side efforts have had little effect on addiction rates. The exponential growth on such spending since Ronald Reagan declared war on drugs in the 1980s has no correlation whatsoever with rates of drug problems. The recent crackdown on prescription opioids began in the mid-2000s, with intense concern over OxyContin misuse — and yet overdose deaths continue to rise.
If we want to reduce opioid addiction, it might help to try to figure out why so many people feel the need to escape. And if we want to reduce opioid overdose, it might make sense to distribute the antidote, naloxone (Narcan), with prescriptions and make it available over the counter. Unlike efforts to restrict prescribing, this won’t hamper appropriate pain care, and unlike rhetoric about epidemics and associated crackdowns on supply, there’s actually a growing body of literature suggesting that Narcan saves lives.