Last week I traveled to Vienna, Austria, to serve as head of the U.S. delegation to the United Nations Commission on Narcotic Drugs, the organization committed to implementing international agreements to control the abuse, production and trafficking of drugs while also ensuring their availability for medical and scientific purposes. In my remarks before the commission, I outlined the Obama administration's 21st century approach to drug control policy -- an approach that rejects the false choice between an enforcement-centric "war on drugs" on the one hand and the extreme notion of drug legalization on the other. After all, addiction is not a moral failing on the part of the individual -- science shows that drug addiction is a disease of the brain that can be prevented and treated.
With this in mind, the Obama administration has adopted a mainstream approach to the drug problem, employing a balance of public health and safety approaches to reduce drug use and its consequences. All of these policies are grounded in science and research -- not politics or ideology. I was therefore surprised when I read Radley Balko's three-part HuffPost series on prescription pain relievers. The series is based on the false premise that "The biggest barrier to effective pain treatment continues to be bad public policy, much of it driven by the war on drugs."
My first act upon being appointed President Obama's drug policy advisor in 2009 was to discard the "war on drugs" approach to formulating drug policy. Approaching our drug problem through the frame of a "war on drugs" is overly simplistic and does not adequately address what is, in reality, a very complicated public health and public safety problem. All of us know someone who suffers from a substance use disorder -- we are not at war with our own people. That is why today we are spending more at the federal level on drug education and treatment than on domestic law enforcement, which still serves a vital role in protecting communities from drug-related crime. It is also why we continue to lead the world in progressive evidence-based change through our central policy document -- the National Drug Control Strategy -- which outlines over 100 specific actions to make America healthier and safer. This balanced approach extends to our efforts to reduce prescription drug abuse, efforts that are based on the premise that we must work to prevent the abuse of prescription drugs while also ensuring legitimate access to lifesaving medications for those who need them.
There is no question prescription painkillers are essential for millions of Americans. However, we cannot lose sight of how serious our nation's prescription drug abuse problem has become and the thousands of victims it has created. According to the Centers for Disease Control and Prevention (CDC), prescription drug abuse is now an epidemic:
- National data show that by 2009, drug-induced deaths had become the number one cause of injury death in America, with the 39,147 drug-induced deaths exceeding the number of deaths from motor vehicle crashes (36,216).
- The overall drug overdose death rate in the United States roughly tripled between 1991 and 2011, and in 2007 about 100 people in this country died per day from drug overdoses.
- In 2008 (the last year for which we have data), almost 15,000 Americans died from an unintentional drug overdose involving prescription pain relievers.
- The rate of overdose deaths involving prescription pain relievers experienced a nearly four-fold increase from 1999-2008.
- The consequences stretch far beyond just deaths. In 2008, for every one death involving prescription pain relievers, there were also eight treatment admissions for abuse, 31 emergency department visits for misuse or abuse, 125 people who abused or were dependent on prescription pain relievers and 838 people who used prescription pain relievers non-medically during the year.
In his series, Mr. Balko trains a skeptical eye on this data, and yet he still reaches the unavoidable conclusion that it is "likely" more people are taking pain relievers, more people are becoming addicted and more people are dying of drug overdose. In doing so, he reluctantly concedes a fact that has been accepted by the mainstream public health and pain specialist community.
At the same time, data clearly refute Mr. Balko's claim that prescription drug abuse prevention efforts are unduly restricting the availability of opioid pain relievers for legal use. A 2006 study published in the journal Pain Medicine found that when adequate documentation exists in the medical record, the risk of civil, criminal or administrative action being taken by the DEA against a physician for prescribing opioids for a chronic pain patient is small. And a 2008 study published in Pain Medicine found that there appears to be little objective basis for concern that pain specialists have been "singled out" for prosecution or administrative sanctioning for such offences. Those health care professionals who have been prosecuted under due process of law for criminal drug violations have clearly shown a wanton disregard for patient safety. There is also little evidence to show that pain relievers are difficult to obtain. In fact, according to the CDC, the quantity of prescription pain relievers sold to pharmacies, hospitals and doctors' offices was four times larger in 2010 than in 1999. This means that enough prescription pain relievers were prescribed in 2010 to medicate every American adult with a typical dose of 5 mg of hydrocodone every four hours for an entire month.
Our efforts to prevent prescription drug abuse are not the cause of the under-treatment of pain in the United States. Rather, the problem results from a lack of awareness among health care professionals, patients, policymakers and insurers about the need to manage pain and how to safely and effectively do so. The final report from the American Medical Association's first National Pain Summit in 2010 found that: "The top three barriers to receiving adequate patient care were 1) workforce issues with lack of competent pain providers, 2) lack of knowledge by peers and/or patients regarding the field of pain medicine and 3) lack of public knowledge regarding pain issues."
Both the under-treatment of pain and the epidemic of prescription drug abuse are issues of serious concern for the administration. Through the National Institutes of Health Pain Consortium, the federal government is working to establish "Centers of Excellence for Pain Education" at medical, dental, pharmacy and nursing schools across the nation. The centers will help to give health care professionals a solid understanding of pain as part of their basic education, improving pain treatment while also reducing the risk of prescription opioid abuse. Through the administration's prescription drug abuse prevention plan, we are working with federal, state and local agencies -- and Americans across the country -- to reverse the rising tide of overdose deaths and bring an end to the epidemic of prescription drug abuse. The importance of providing an effective measure of control while also allowing legitimate access is made clear on the very first page of the plan: "The potent medications science has developed have great potential for relieving suffering, as well as great potential for abuse... Accordingly, any policy in this area must strike a balance between our desire to minimize abuse of prescription drugs and the need to ensure access for their legitimate use."
We can address these two problems together and, in doing so, ensure that Americans are able to get treatment for chronic pain without falling victim to the disease of addiction.
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