Hopefully Ruan is a first step towards better governance

Interesting.  From The Other Opioid Crisis: How the Criminal Justice System Imperils Patients and Physicians by Nita Ghei.  The subheading is Law enforcement agencies have had broad powers to pursue and punish opioid prescribers, but a recent Supreme Court decision offers some hope.

For years now, mainstream media have seemed to conflate the prescription treatment of pain with drug overdose deaths.  As an outsider, this has always seemed to be peculiar as it seems obvious from the data the overwhelming majority of drug overdose deaths arise from rising imports of illicit fentanyl.  

Control the borders where fentanyl floods in, and you control the 100,000 drug overdose deaths each year.  Control pharmaceutical prescriptions for pain medications and I would guess you at best are reducing drug overdose deaths by a very small percentage.

NPR, for example, is always harping on about deaths from prescribed pain medication combined with alcohol.  But when I research the issue, I find that such deaths are in the low double or triple digits.  Nothing like 100,000.

NPR additionally is one of the mainstream media news outlets which forefronts prescribed pain medication as a significant part of the 100,000 annual drug overdose deaths.  I have never been able to make the numbers add up to this theory.

I have rheumatoid arthritis and periodically have major flare ups which cause debilitating pain.  I use the opioid medications  Oxycodone and Hydrocodone for pain management during those events.  I have been aware of constraints on prescriptions for those medications in the past and there are often issues between pharmacy and insurer which cause delays or constraints or price gouging before a prescription is filled.  And I blessedly only have occasional flare-ups.  I can only imagine the destruction in quality of life for those whose pain conditions are sustained.

There is no denying that pain management is a difficult medical task and also an entirely legitimate one.  That all pain medications have to be managed closely when mixed with other medications as well as other consumed items such as alcohol.  But those are entirely separate issues from whether pain management medications are a significant contributor to ever escalating tragedy of accidental drug overdoses.  The evidence is that the government is straining at a gnat while swallowing a camel.  The drug overdose deaths are due to uncontrolled access to fentanyl, not to pain management medications.  

Oddly, it is reporting on a Supreme Court decision this summer which for the first time affirms my assumptions and explains why there is this persistent misrepresentation of reality.

Not unsurprisingly, it arises from badly drafted legislation, badly interpreted law enforcement, scope creep by regulatory agencies (including, of course, the persistently underperforming CDC), and moral fervor mixed with medical ignorance.  

In most popular depictions of the “opioid crisis,” ranging from Hulu’s “Dopesick” to Stanford physician Anna Lembke’s 2016 book, “Drug Dealer, MD,” the driving force of the crisis is physicians—who in this narrative are helpless pawns of the pharmaceutical companies—overprescribing opioids. This narrative has been taken up and repeated by politicians, law enforcement and interest groups seeking solutions to the harms caused by substance use disorder.

This narrative has at best a tenuous link to reality. It is, however, deeply entrenched in culture and widely accepted as true. As a result of this narrative, combined with ambiguous statutory language in the Controlled Substances Act of 1971 and the poorly drafted 2016 “Guideline on Prescribing Opioids for Chronic Pain” from the Centers for Disease Control and Prevention (CDC), law enforcement has had an inordinate influence in medical decision-making, as physicians desperately sought to treat patients while protecting themselves from the threat of civil forfeiture and loss of livelihood.

Because of the Controlled Substances Act’s ambiguous language, there has historically been no legal definition of “overprescription.” So matters stood for half a century, until the Supreme Court handed down its unanimous ruling in Ruan v. United States in June 2022. The decision establishes a narrow definition of what constitutes overprescribing, leaving physicians with greater discretion in their medical decision-making. But the long-term effects of Ruan on law enforcement and physician behavior remain to be seen. 

 

Law Enforcement Discretion and Physician Uncertainty

In the decades between the Controlled Substances Act and the Ruan decision, law enforcement agencies had extraordinary latitude in their hunt for “overprescribing” physicians. This high level of discretion affected not only how the Drug Enforcement Administration (DEA) pursued the so-called war on drugs for half a century, but also how medical decisions were made for both acute and chronic care, as physicians were uncertain what behaviors would run afoul of the agency and state and local law enforcement. The DEA persisted in its focus on prescribed opioids for medical use, even as illicit drugs flooded the nation and a vast majority of the skyrocketing fatal accidental overdoses were caused by a combination of street drugs and alcohol, not by prescription opioids.

The legal landscape is dominated by fear and increasingly adversarial relationships that should be cooperative. Physicians, pharmacists and patients have grown increasingly fearful of DEA investigation, particularly after the agency seized on the metrics provided by the CDC’s 2016 “Guideline on Prescribing Opioids.” Ruan offers some protection to physicians against DEA investigations, but civil forfeiture, as always, remains a stumbling block.

And underlying everything else, there is simple empirical ignorance.  

The DEA continues this hunt for “drug-dealing doctors” even today, despite the fact that there is very little diversion of drugs from medical channels and almost none from patients. On the contrary, patients across the board are having their pain relief options limited, including patients with cancer where opioids are the first-line treatment.

[snip]

Just to underscore what seems like an increasingly Kafkaesque world, the DEA announced a special task force targeting medical prescribers in New England on June 29—two days after the Supreme Court handed down the Ruan decision. New Hampshire, one of the states included, had just three fatal overdoses where opioids were implicated, out of a total 230 fatal accidental overdoses in 2022. 

So in New Hampshire prescription pain medications are implicated in 1.3% of fatal accidental drug overdoses and yet that is where the government focuses seemingly the entirety of its efforts.

Read the whole thing.  Lots of detail and further examples where the governing agencies such as DEA and CDC, in pursuit of one legitimate goal, end up often making the overall problem much worse and creating new problems in the process.  

Eventually we might get the legislation, law and law enforcement right.  But not before hundreds of thousands more die.  But it sure would help if the mainstream media could actually get the story straight and make it clear to the public.  Its not hard, and I don't understand why they don't, but they do seem inured to propagating misleading story-lines which favor bad governmental actions and destroy citizens lives.