Planting the Seeds of a New Heroin Epidemic

In our recent discussion at Washington Post’s Wonkblog, Harold Pollack and I talked about the astonishing scale of prescription opioid consumption in the US, which has no parallel anywhere else in the world. Americans consume 99% of world’s supply of hydrocodone, with the rest of the human race accounting for only 1%. Each year, U.S. health care professionals write more prescriptions for opioids than there are adults in the country.

Some of this prescribing has unquestionably been a blessing to people in pain. Some of it has however been highly destructive. Sally Satel highlights one of the adverse consequences of flooding the country with prescription opioids:

According to the 2012 National Survey on Drug Abuse and Health, four out of five new heroin users had previously abused painkillers.

The recent surge in heroin use is thus fundamentally different from its 1970s precursor. Its seeds were planted not in Southeast Asia but in doctor’s offices, emergency rooms and pill mills all across the country.

As policy makers focus attention on the resurrection of heroin in American life, they should remember that it remains a small problem compared to the painkiller addiction epidemic that fomented it and is still doing so: Deaths from legal prescription opioids exceed those from heroin by a factor of five. If we want a lower prevalence of heroin addiction five years from now, we should be looking upstream at policies that will combat the mis-marketing, mis-prescribing, diversion and abuse of prescription opioids.

The FDA’s Mixed Signals on Pain Pill Policy

The FDA’s policy on prescription opioids has been internally contradictory this year, and that’s bad for public health

Prescription opioids like hydrocodone are remarkably useful for acute pain relief but are also capable of fomenting addiction and overdose. The most effective public policies regarding these medications keeps both of those realities in mind rather than yielding to an extreme anti- or pro-opioid stance. No federal government agency grapples with this challenge more than the Food and Drug Administration, and the evidence of the last week is that it has yet to come to an internal consensus on how to proceed.

First, the FDA recommended after years of study that hydrocodone combination products like Vicodin would be moved from Schedule III to the more restrictive Schedule II. This is a significant tightening of control over the most widely prescribed drugs in the U.S. (not just for pain, for anything). The impetus was the leading role of hydrocodone combination products in overdose deaths and emergency room admissions.

Yet 24 hours later, the FDA overruled its own expert panel and approved Zohydro, a pure hydrocodone pain medication that is 5 to 10 times more potent than Vicodin. In the process, FDA also overturned a precedent it had set only six months ago to not approve easily abused-opioids. After refusing in April to approve generic oxycontin because it lacked abuse-resistant properties, the FDA approved a drug whose full potency can be instantly released merely by crushing it or dropping it into alcohol (Get ready for a rash of Zohydro-cocktail deaths).

What the country needs on prescription opioids is carefully designed, balanced and consistent policy. What we are getting is policy that contradicts itself month-to-month and even day-to-day.

Prescription drug abuse and broader drug policy

Yes, prescription drug abuse is now a big problem. And cocaine/meth/heroin are a big problem. And alcohol is the biggest problem of all. Those statements are all consistent; the idea that we should stop paying attention to cocaine because kids are abusing Vicodin doesn’t logically parse.

Damien Cave reports that the upsurge in diverted pharmaceutical use is causing a re-thinking of drug policy generally. I’m all for a re-thinking, and especially for a new policy not based on the fantasy that drug law enforcement can substantially reduce international drug flows if we just keep doing it, or do more of it, or do it in some more clever way.

But it’s not as if the upsurge in abuse of oxycodone and hydrocodone has displaced the abuse of other drugs: indeed, there’s good evidence of a stepping-stone effect from the prescription opioids to heroin, which is much cheaper on a dose-equivalent basis. The volume of cocaine has been shrinking as the cocaine-using population ages, but cocaine (along with meth) remains a major problem, especially among people arrested for non-drug crimes. So the notion that the prescription-drug problem makes the problem of strictly illicit drugs irrelevant doesn’t seem to make much sense.

If the argument is that strictly illicit drugs represent a small fraction of the total drug abuse problem, that’s true, but it’s true primarily because alcohol dwarfs everything else.

So, yes, we need a prescription-drug-abuse policy, with the usual triad of enforcement-prevention-and-treatment looking even less promising than usual; if we’re looking for a treatment for hydrocodone dependence, methadone seems like an odd fit. And we need a better approach to the strictly illicit drugs. And we need to pay some serious attention to alcohol. Those are “ands,” not “buts.” Drug policy should be able to walk and chew gum* at once. Right now, it can barely do either one.

* (No, Lyndon Johnson did not say “walk.” But the newspapers weren’t willing to print what he actually said.)