Towards Effective Public Policy Regarding Pain Pills

I gave a plenary address at the American Academy of Pain Medicine about opioid-related public policies that might promote pain relief while minimising addiction and overdoses. I suggested five approaches that seem promising (if I had had time, I would have added a sixth, which is increasing access to naloxone).

What I was most struck by in spending a few days with pain medicine experts is that hardly any of them were at the screaming extremes of the policy debate. Lots of them are worried that their field has over-prescribed opioids. Rarely was this worry based in fear of the DEA; rather as doctors should be, they were worried that patients have been harmed.

Many were struggling with an dysfunctional regulatory environment in which it is almost impossible to get rid of excess opioids. A number told me they engaged regularly in illegal behavior, for example taking back opioids returned by patients who had had a relative die in hospice and who understandably didn’t want all the remaining pills lying around in a house full of teenagers (Yes, it is stupid that it should be illegal for the doctor to take the pain pills back in such a situation, but that’s where we are).

The seriousness and decency of the pain medicine professionals was impressive, which makes some of the more oversimplified media discussions of the issue all the more disappointing. Pain medicine professionals are looking for guidance in handling a tough problem. They are seeking thoughtful, rational advice from each other, from their patients and from those who follow public policy. I hope people who write about and analyze the issue in the media will respond with equal seriousness and balance.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

11 thoughts on “Towards Effective Public Policy Regarding Pain Pills”

  1. Given the post below, why should we imagine the best data in the world will win over pre-determined ‘moral values’?

    The scientists will get great data about what works, and the politicians will flush it down the toilet in favor of simplistic slogans.

    I don’t expect them to listen to the scientists – but even pretending that it exists and matters is a step in the right direct.

    1. MobiusKlein: Given the post below, why should we imagine the best data in the world will win over pre-determined “moral values”

      Relieving pain IS a moral value and so is valuing the lives of addicted people. We want those morals to guide our priorities, and science to tell us the mechanics. It’s a strange idea that we would ever want amoral policy…the entire public health endeavor is based on a moral commitment to other human beings, and we don’t want to throw that out.

      1. Politicians claim to both follow the facts, and care for the moral values of the people.

        What they end up doing is to neither follow the facts, nor take action to alleviate the pain, nor value lives of the addicts.
        Hence my cynicism.

        Many (R) politicians specifically do not hew to the public health endeavor in the slightest.

  2. Just back from Southern Ohio, where a notorious oxycodone mill just got shut down. Local law enforcement folks reported that the result had been the creation, for the first time in the area, of a heroin market.

    Note that heroin had never been a problem in Appalachia. But once people get strung out, shutting off the Oxy creates a market for substitutes; people who never would have started with heroin switch to it when oxycodone becomes unavailable, or when their habit exceeds their budget and they have to trade down. (Oxycodone trades at about a 4x premium to heroin, milligram-for-milligram.)

    It’s not as if the dispassionate scientists have a solution to this one. There are people in pain, and there are people seeking recreational opiates for personal use or resale – either to party with or to feed a habit – and it’s impossible to make the drugs more available to the pain patients without making them more available to the others. And even the pain patients may not benefit if unskilled or soft-hearted doctors write too much oxycodone. It’s a very easy drug to get hooked on, and a very hard one to get off.

    1. Mark Kleiman: it’s impossible to make the drugs more available to the pain patients without making them more available to the others

      In an absolute sense this is probably true, but there are regimes that do a better and worse job of balancing these priorities, and that’s what the public policy debate should be about.

  3. What’s the problem with getting rid of these pills? After my chemo I had all sorts of nasty stuff left over, not to mention some, yes, opioids. (Some parts of chemo can be painful.) Just brought them into the pharmacy, they took them, no problem.

    Mind, I thought it a horrible waste that several hundred dollars of drugs were going to be destroyed, rather than given to people who needed them who had worse or no insurance. But that’s a separate matter from not being able to get rid of them.

    1. Brett: Just brought them into the pharmacy, they took them, no problem.

      They probably broke the state law and federal law as well, Brett. Many pharmacists would have said no, because they don’t want to get in trouble (and yes, that is bad, but it’s the law we have at the moment).

    2. Some pharmacies have take-back programs that supposedly exclude controlled drugs. Some law enforcement agencies will take those.

      The Drug Enforcement Administration (DEA) has scheduled another National Prescription Drug Take-Back Day which will take place on Saturday, April 28, 2012, from 10:00 a.m. to 2:00 p.m. This is a great opportunity for those who missed the previous events, or who have subsequently accumulated unwanted, unused prescription drugs, to safely dispose of those medications.

      National Take-Back Initiative

      1. They will, but that is only 1 or 2 days a year, and under current law the DEA has to formally deputize a local to received the controlled substances.

  4. You’re saying they could hand me the controlled substance, but were breaking the law when they took back the portion I never used? Ok, that is remarkably insane.

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