Just Say No, to Dopesick

A friend called to alert me to the miniseries, Dopesick, airing on Hulu. Ugh, I thought to myself before telling her I couldn’t watch it. I explained that it would upset me, not because it wasn't a good book or even that it would be a reminder of my son's fatal overdose, but because its message would reinforce the gross misconception that the national overdose crisis resulted from overprescribing opioids. 

Constantly reinforced by the media, this simplified narrative has launched a misguided focus on curtailing prescribing practices at all costs, undermining doctors' expertise and abandoning chronic pain sufferers while annual fatalities continue to soar.  

What's true is that this era's drug of choice among a growing segment of illicit drug users was prescription medication, diverted to the streets due to burgeoning availability. It's also accurate that this excess in prescription pills was fueled by the aggressive marketing of greed-driven pharmaceutical companies. But drug overdose deaths have steadily grown since the 1970s, with consistent incremental increases—year by year—regardless of the proliferation of OxyContin in the mid to late 1990s.

It was the drug of choice that changed—not the number of non-medical users, or the upward trend of annual fatalities. The realization that prescription pills had flooded the black market was cause for governmental attention but forging a response—if the intent was to save lives—called for a deeper understanding and a nuanced approach. 

The pills that made their way to the streets were legitimately prescribed, but unused—a phenomenon brought on by over-prescribing, mostly for short-term pain. It wasn't a surprise to learn that 60 to 90% of people prescribed opioids after a medical procedure don't finish the prescription, generating the bulk of the leftovers. The excess did not come from chronic pain sufferers, the last people to miss a dose or to leave any medication lying around, even though they continue to pay a steep and unconscionable price for the policies forged from cursory understanding.

It's also important to understand that the vast majority of those who died of an overdose did not become addicted through treatment for pain. In fact, the odds of developing a new addiction among the recipients of prescribed medication—those without former or concurrent drug misuse—are less than 1 percent. 

Without any statistical evidence that overprescribing contributed to the number of illicit drug users, addictions, or fatalities, the Drug Enforcement Administration (DEA) launched a sweeping crackdown on prescribing practices. Included were some sensible measures such as reduced pill count for short-term pain.

But the DEA ramped up its surveillance, seemingly without much consideration given to the consequences of its tactics—to the possibility that eliminating a regulated drug supply could cause more harm than good. I guess they thought cutting people off without expanding evidence-based treatment or providing any support services would fix the problem. Such is the magical thinking of prohibition: Cutting the supply—no matter how harsh and punitive the strategies—will end the demand. 

But it didn't go that way: The last decade has seen opioid prescribing cut by nearly 60% while overdose deaths have more than doubled. Rather than curbing problematic drug use, enforcement strategies bolstered demand for increasingly deadly street heroin which, in turn, drove the rise in fentanyl. And cutting off vulnerable pain patients, who benefited from opioid medication, created a whole new set of victims, thousands of whom have been driven to illicit street drugs or suicide. 

If lawmakers and journalists could focus on addiction rather than the ever-shifting trends that involve specific drugs, the outcome could be different. The overdose crisis is the result of addiction, not a specific drug. It's not an "opioid crisis," any more than it was a "crack cocaine crisis" or will be a "benzodiazepines crisis." The crisis is one of human suffering, the dulling of pain through self-medicating. Yet, despite the underlying factors—societal despair exacerbated by stigma and reinforced by criminalization—news coverage relentlessly presents prescription medication as the culprit.

I understand the disdain for Big Pharma but we can't move forward without acknowledging that our failed policies have made matters worse, causing immeasurable suffering, and a record-breaking death toll that would have been unfathomable a decade ago, caused by poly-drug substances with a trace of prescription opioids. As more experts recognize the urgency to rethink our approach, I hope the airing of Dopesick doesn't set us back to an over-zealous focus on tactics that prevent neither addiction nor overdose.

[Top photo credit: Rod Long]