Reduce Prescription Drug Abuse
Prescription drug abuse has been recognized as a national problem since 1914, when the Harrison Narcotics Act separated medical and nonmedical drug use – criminalizing the nonmedical use and sale of drugs but permitting legitimate medical use of drugs with high abuse potential. The explosive growth of benzodiazepines use (e.g., Valium, and Xanax) in the early 1960s fueled widespread abuse of these drugs. However, it was not until the dramatic increase in the use of opioid painkillers that began in the 1990s that prescription drug abuse became a deadly epidemic, as measured by the sharply rising annual death toll from overdoses.
The most commonly abused classes of controlled substances are:
- Opioids: used to treat pain
- Central nervous system (CNS) depressants: used to treat anxiety and sleep disorders
- Stimulants: used to treat sleep disorders, ADHD and obesity
New initiatives to prevent rampant access to these prescribed medicines have been developed in response, such as improvements in the electronic monitoring of sales, efforts to shut down “pill mills,” and in education of physicians and patients about the risks of prescription drug abuse. The Food and Drug Administration (FDA) has recently promoted the use of abuse-resistant formulations of amusable medicines, a policy pioneered by IBH over a decade ago. These new initiatives have made prescription opioids harder to obtain for nonmedical uses and more expensive to buy on illegal drug markets at a time that heroin purity is up and its price is down.
In September 2019, IBH President Robert L. DuPont, MD co-authored a new report documenting the story of fentanyl in the US and identifies key policy recommendations to address the national drug epidemic:
Fentanyl is a sentinel calling our attention to the potential for a slew of laboratory-based drugs produced by an ever-expanding illegal global drug market to meet a growing demand. Included in this threat are the fentanyl-laced counterfeit drugs manufactured to look like well-known and trusted pharmaceutical products but containing deadly amounts of fentanyl instead of the expected active pharmaceutical ingredient. Unrestrained by regulatory controls and labeling requirements, today’s drug trafficker-entrepreneur poses a serious threat to patients and non-patients alike. If we hope to meet these challenges successfully, we will need radically new thinking, better data systems, and improved technology to keep counterfeit drugs and deadly fentanyl analogs out of our communities and medicinal drug supplies.
The prevailing drug policy narrative is that the growing heroin and opioid overdose epidemic is primarily the result of two decades of over-prescribing of opioid pain medications. However, while 80% of heroin users used a prescription opioid before they first used heroin, the vast majority, over 96%, of people who have used a prescription opioid nonmedically have not transitioned to using heroin. Five years after the initial nonmedical use of a prescription opioid, only 3.6% ever used any heroin. Among prescription opiate users, the people most vulnerable to switching to heroin are those who are also abusers of other drugs including alcohol.
Among 4,493 individuals treated for opioid addiction whose first exposure to opioids was through a prescription from their physician, notably 94.6% reported prior or coincident use of other psychoactive drugs. Alcohol was used by 92.9%, nicotine by 89.5% and marijuana by 87.4%, and excluding these top substances, fully 70.1% reported other prior or coincident drug use.
In January 2018, IBH President Robert L. DuPont, MD authored an article that outlines A New Narrative to Understand the Opioid Epidemic to inform future drug policy. Another useful overview of the complexities of the opioid epidemic is provided in the June 2017 edition of Emerging Drug Trends Report from the Hazelden Betty Ford Institute for Recovery Advocacy entitled, Widening the Lens on the Opioid Crisis.
On October 26, 2017, Dr. DuPont was present at the White House for remarks by the President that the national opioid epidemic is a public health emergency.
One week later, the President’s Commission on Combating Drug Addiction and the Opioid Crisis led by Governor Chris Christie released its Final Report with recommendations on how to immediately address this crisis, ranging in scope from federal funding and programs, to new opioid addiction prevention, treatment, including access to overdose reversal and recovery, and research and development. There is strong bipartisan support to curb the epidemic of overdose deaths making it the right time for the nation to come together to improve prevention and treatment and to promote long-term recovery.
In December 2017 the National Center for Health Statistics (NCHS), part of the US Centers for Disease Control and Prevention (CDC), released new data showing that overdose deaths have reached a new high of 63,600 in 2016. This translates to an average of 174 people every day. The most common drugs present in overdose death are opioids, with deaths involving synthetic opioids other than methadone (e.g., fentanyl, fentanyl analogues and tramadol) doubling from 2015 to 2016. More young people are dying from overdose death, impacting life expectancy in the US, which has dropped for the second year in a row.
The treatment policy response to the prescription opioid and heroin epidemic has been to encourage the use of medication-assisted treatment (MAT) available through the office-based physician prescription of buprenorphine rather than an older form of MAT, methadone maintenance, available through methadone clinics. A third form of MAT, naltrexone, an opioid antagonist, is now available in daily oral form or as a once-a-month injection. It is far less commonly used than buprenorphine or methadone.
For a number of years IBH has focused on the outcomes of alternative treatments for opioid use disorders. MAT only has benefit during the period when patients take the medications, and even then while in treatment many MAT patients continue to use alcohol and other drugs. The large majority of opioid-addicted patients who enter MAT often leave treatment early and against medical advice. A relatively small percentage of patients remain in contact with the providing prescriber for as much as one year. Most of the patients who terminate MAT relapse quickly to opioid use, often with fatal outcomes. The mismatch between the chronicity of the disease of addiction and effective treatment is striking. There are a number of successful models of opioid addiction treatment that IBH has identified and studied. By focusing on MAT we do not imply that drug-free treatment has lower dropout rates or less drug use while patients are in treatment. The reality is that all forms of addiction treatment need to focus on the goal of long-term recovery, an outcome that unfortunately is the exception for treatment (see Improve Treatment).