Since 2000, the Drug Enforcement Administration has embarked on a muscular campaign against prescription painkiller abuse. It has utilized undercover investigations, SWAT raids, asset forfeiture, and high profile trials against “kingpin” doctors. These tactics should be familiar to anyone who has studied the drug war, but the results are a shocker. Prescription opioids have actually grown scarce.
To put it bluntly, the DEA has finally found a drug war it can win.
“Opiophobia” is a term that describes doctors’ increasing unwillingness to prescribe opioid painkillers — a class of drugs that includes Vicodin and OxyContin — and especially high-dose opioids, to those in pain. This fear is rooted in the DEA’s practice of jailing those doctors it deems are prescribing outside “legitimate medical standards.”
Because pain doesn’t show up on an MRI, doctors work together with their patients to achieve proper dosage. And, thanks to individual chemistry, pain level, drug tolerance, or typically, all three, patients vary tremendously in the number of milligrams they require. But when the only thing doctors know for certain is that prescribing large amounts of opioids endanger them, it is those suffering the worst who go undermedicated.
Call it “opiophobia,” call it a “chilling effect,” or simply, doctors behaving rationally, the result is the same: massive underprescription of opioids and radical undertreatment of pain. A Stanford study puts the number of undermedicated chronic pain patients at about 50 percent. According to the American Pain Society, fewer than 50 percent of cancer patients receive sufficient pain relief.
Retired Marine James Fernandez is a Gulf War vet, a helicopter copilot, and a longtime chronic pain sufferer. While injuries sustained during the Gulf War left him reliant on nearly a gram of OxyContin and MS Contin per day, it was the war on drugs that would ground him.
Following his return from Iraq, Mr. Fernandez was ping-ponged from one doctor to the next, none willing to prescribe at the dose necessary to treat his crippling pain. He reports one military physician even explicitly making mention of his fear of being “red-flagged” by the DEA. Under-medicated but still fighting for his right to pain relief, Mr. Fernandez describes his long-suffering, bed-ridden existence as “mostly miserable, most of the time.”
Today, Mr. Fernandez’s cause has been picked up by energetic advocates like Dr. Alex Deluca of the Pain Relief Network, but many are not so fortunate.
Take those treated with Vioxx, a popular alternative to opioids that rang up $2.5 billion in sales the year before its discontinuation in 2004. To its credit, Vioxx treated pain, though not nearly as powerfully as opioids. But it was Vioxx’s unfortunate side effect of causing heart attacks that led to its discontinuation, not its middling analgesic effect.
Today risk-averse doctors trot out a motley mixture of placebos, from anti-epileptics to tricyclic antidepressants. Risky spinal fusion surgery is performed 20,000 times each year, despite the New England Journal of Medicine finding “no acceptable evidence” of the procedure’s efficacy.
But ineffective therapies and dangerous surgical interventions do not draw the DEA’s eye — painkillers do.
Some patients attempt to skirt these problematic treatments, not because they’ve necessarily read the literature, but, more commonly, because they know what has worked for them. The medical community has come to regard them as “doctor shoppers,” no different than junkies seeking a fix. The hardening of doctor attitudes against their patients represents another casualty of the DEA’s campaign.
The DEA is so used to losing the drug war it has trouble understanding the effect its campaign is having. “To the million doctors who legitimately prescribe narcotics to relieve patients’ suffering,” counsels DEA Administrator Karen Tandy, “you have nothing to fear.”
But doctors have very different incentives than drug dealers, including a wealth of options available to them that do not endanger their lives and livelihood. With doctors cutting back, pain patients — unlike the abusers the DEA is trying to target — are running out of options.
This is the legacy of the drug war’s lone success.
Zachary David Skaggs is a fellow specializing in pharmaceutical policy at the Competitive Enterprise Institute.