America’s current prescription drug epidemic is now killing more Americans each year than did the cocaine epidemic of the 1980s and the heroin epidemic of the 1970s combined. But this epidemic differs from those of prior eras in that it could not have started without the aid of physicians. Yes, Florida pill mills typically employ as security guards marginally educated thugs with jailhouse tatts on their biceps, but every one of them has a licensed physician involved as an employee or owner; else they could not write and have filled all the thousands of prescriptions that they churn out every day.
It is instructive to compare the current U.S. epidemic with the British experience over the 20th century. As laid out in the Rolleston report between the wars, all British physicians were allowed to dispense cocaine and heroin with minimal oversight. This policy reflected the very high level of trust Britons had in medical professionals, and in general their faith seemed well-placed. No doubt there were some medics who were dishonest and/or careless, but the British system survived for decades without starting a drug epidemic.
By the 1960s however, word had got round that a small group of British physicians were dispensing drugs very freely. The most famous, Lady Isabella Frankau, was apparently not venal. Rather, she was a true believer in the idea of unrestricted access to drugs (Then, as now, this idea exerted a strong pull on the most privileged and wealthy segment of society). Others may have been in it for the money or a drug kickback, but in any case this small group of errant medics brought the British system down by generating an epidemic of addiction that led to much tighter regulation of prescriptions. (As a side note, it was great fun to hear this story from Dr. John Strang, who now oversees two heroin-prescription clinics in the U.K., while we stood out front of the 24-hour Boots next to Piccadilly Circus. At that spot, hundreds of drug-addicted patients used to line up at midnight to get cocaine and heroin because their prescription date became valid at 12:01).
The most remarkable feature in my mind of the British experience is how long it took the old system to break down. Part of this was a reflection of British national character prior to the 1960s, which put some cultural constraints on recreational drug use. But lack of information and difficulty of travel also played some role. If you were living in Stoke-Upon-Trent in 1930, and heard a rumor that there was a particular physician in Harley Street who was loose with the cocaine or heroin, would you have believed the rumor? Would you have troubled to go investigate, given the cost of the journey? In both cases, probably not.
In contrast, today, anyone who wants to know where the pill mills are need only log onto the Internet. It is public information that 50 of the top pain pill prescribing doctors in the United States are working in a single county in Florida. From my home state of West Virginia, you can catch the “O.C. Express” flight down to Florida for some pills and back for less than a hundred dollars. Almost any American who decided today that they would like a handful of Oxycontin in the next 24 hours could get it.
These changes in technology mean that even if only one tenths of one percent of U.S. physicians is a dishonest or sloppy prescriber, it’s enough to start a drug epidemic, and it will take hold much faster than it would have in prior eras. Because no profession can guarantee perfect compliance with professional standards across 100% of its members, this implies that the prescribing of physicians is going to have be monitored externally more than in prior eras, which isn’t fair to most of them nor needed for most of them. But the damage the few bad apples can cause has grown exponentially, such that there really is no other alternative.