A debate that s been squarely in the headlines in recent weeks about how to manage the rapidly growing problem of opiate addiction in the U.S., is now heating up even more. This is due to a recent JAMA viewpoint, as well as statements made by an advocacy group (see below).
There are two rather disparate camps. The most vocal critics maintain that strict guidance and regulations about prescribing narcotics will cut down on both the number of addicts and the number of deaths from these drugs. Others maintain that this will do more harm than good.
This first philosophy is clearly stated in the recent paper in JAMA entitled Addressing Prescription Opioid Overdose Data Support a Comprehensive Policy Approach, written by a group that includes Janet Woodcock, the Director of the Center for Drug Evaluation and Research of the FDA. Their paper focuses mainly on the recent, controversial approval of Zohydro a high dose, time-release form of hydrocodone (the narcotic found in Vicodin), but also discusses the global problem of narcotic abuse.
There is one glaring fallacy that stands out in the JAMA paper, says ACSH s Dr. Josh Bloom, who has written numerous times on the unintended consequences of the crackdown on prescription narcotics.
The authors write, The FDA is also actively working to incentivize, through the use of fast-track, priority review, and breakthrough therapy designations, the development of non opioid pain medications intended to treat chronic musculoskeletal and neuropathic pain conditions for which opioid analgesics are not likely to be the best treatment.
Dr. Bloom continues, Well that certainly is comforting. Right around the corner are wonder drugs that will treat severe pain with no addiction potential, and the FDA is fast-tracking them. That s just swell, except good luck finding them. I spent considerable time looking for these drugs (clinicaltrials.gov), and didn t find one single new drug for treatment of generalized severe pain currently that is in clinical trials. So, where are these drugs going to come from? If they know, they are sure keeping quiet about it.
Another group, PROP, which stands Physicians for Responsible Opioid Prescribing, has a similar philosophy. They are also dedicated to reducing the toll of narcotic addiction in this country. But their plan may even be worse:
In a publication entitled, Managing Pain with and without Opioids in the Primary Care Setting, they spell out the seriousness of the addiction problem, but their solutions don t sound all that great either:
Primary treatments for chronic pain
- Motivation/activation/self-help
- Counseling
Secondary treatments for chronic pain
- Low risk analgesics (e.g., gabapentin)
- Psych meds for depression/anxiety/post-traumatic stress disorder (PTSD)/psychosis
Dr. Bloom says, With someone with mild-to-moderate, chronic pain, this makes some sense. But it depends on where you draw the line. Treating someone with moderate-to-severe, chronic pain with self-help, counseling, gabapentin (Neurontin) and antidepressants is nothing short of barbaric. None of there will work.
He concludes, It is 2014, and there are still no good options for chronic treatment of pain. There is no magic bullet out there. Aside from narcotics, pharmacological choices are very limited NSAIDs (which will eat up your stomach), Tylenol, which won t touch serious plan, and steroids, which are very dangerous when taken in high doses over time. The real questions are, will severe restrictions on narcotic use do more harm than good, and is there any good alternative? If there is, I sure don t know about it.
The graphic below clearly shows what can happen when prescription narcotics are made less available. Note what happened to heroin use when OxyContin became abuse-proof. It increase four-fold in 18 months.
