Let’s page doctors, not executioners
The opioid crisis is a complicated problem, for which President Donald Trump offered his usual simplistic approach Monday. His comments emphasized force and punishment, including, as expected, the death penalty for drug traffickers — as well as an attempt to link the drug crisis to immigration by blaming it on "sanctuary cities" supposedly swarming with foreign drug dealers. He offered no new funding for drug treatment beyond the welcome-but-still-inadequate $6 billion two-year program moving through Congress, though to his credit he recommended repeal of a 1970s-era law that prevents Medicaid from paying for care at large inpatient facilities.
One reason the president's rhetoric was so inappropriate is that the drugs at issue are not all illegal. Illicit heroin and fentanyl use has indeed surged in the past halfdecade; those two drugs account for the lion's share of the 64,000 drug overdose deaths in the United States during 2016, according to the Centers for Disease Control and Prevention. However, if you eliminated them all, the country would still have a massive problem. The epidemic began two decades ago with legally prescribed opioid analgesics such as oxycodone and hydrocodone. And those drugs caused more than 17,000 overdose deaths in 2016.
The good news is that government, the medical community and patients are learning the lessons of unwise past prescription practices, especially the widespread use of opioids for chronic, non-cancer pain. In more recent years, opioid prescribing has begun to decline, from the all-time peak of 782 morphine milligram equivalents per capita in 2010 to 640 MME per capita in 2015, according to a July 2017 CDC report. That's an 18 percent decline, which has almost certainly continued, or even accelerated, especially since the CDC published more-cautious opioid prescribing guidelines in 2016.
Predictably, there is now a backlash to the backlash: Advocates for pain patients decry the lack of access to opioids and say they are being made to suffer for the mistakes of others. Such concerns need to be taken seriously — opioids must remain available for cancer pain and other clear palliative needs.
Yet these complaints also need to be kept in perspective. Data show wide geographic discrepancies in rates of opioid prescribing (poor, rural counties have higher rates than urban ones), which suggests that objective medical considerations are not the only reason for heavy usage where it occurs. Indeed, the latest research shows that opioids are not the most effective treatment for common forms of non-cancer pain. Quite often, they have been dispensed precisely because more-effective alternatives — physical therapy, for example — were not available.
Even after recent reductions, doctors in the United States still prescribe legal opioids at three times the 1999 rate. If doctors met the goal Trump set in his speech — a one-third reduction in opioid prescriptions by 2021 — they would still be prescribing at double the 1999 rate. And the United States would still be administering legal opioids far more frequently than its peer nations in the industrialized world. This country prescribes opioid pain medicines twice as frequently as Germany does, but as bitter experience has taught, that doesn't make us twice as good at treating pain.