The New Drug Crisis: Addiction by Prescription

Well-intentioned pain policies plus powerful opiate meds is leading to a national epidemic of pill popping — and accidental overdosing

By Jeffrey Kluger Monday, Sept. 13, 2010
    • Stephen Lewis for TIME

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    Florida is lousy with such pain-clinic pill mills, in part because of extremely loose oversight of the people operating them. Until June, when Governor Charlie Crist signed a new law cracking down on the operations, there was nothing to prevent felons from opening a clinic and hiring doctors to write the prescriptions. Indeed, on the national ranking of practitioners dispensing Oxycodone, every doc in the top 50 has a Sunshine State address.

    "I've taken to calling the problem 'pharmageddon,'" says Dr. Barbara Krantz, Hanley's CEO and medical director. "There are seven deaths per day in Florida from prescription-drug overdoses." The state has also become a hub for opioid traffickers in the Southeast.

    What worries Krantz and other substance-abuse professionals is that an addiction scourge that is, for now, hitting the boomer demographic hardest won't stay there and instead will gather greater strength in the under-25 cohort. It's not just young cancer patients given a legal taste of Oxy who are in danger in this group; it's everyone. "A parent comes home from the dentist with 30 doses of Oxycontin and only takes a few," says Barber. "Then the pills are stored in the medicine chest, where anyone can get them."

    This is leading to a rise in the incidence of what's known as skittling, a social phenomenon with deadly consequences. "Kids steal from their parents' medicine chests, go to a party and dump everything into a bowl at the door," says Juan Harris, a Hanley drug counselor. "Anyone who comes in just grabs a handful."

    Killing the Buzz
    For kids, education programs in schools help a little, at least in terms of informing them of the risks associated with drugs. But such a rearguard action goes just so far, and a longer-term solution will come only when the government increases its control over the legal dispensation of the most popular pills. The first step would be better surveillance and tracking. An alphabet soup of agencies — from the FDA to the CDC to SAMHSA to the National Institute of Drug Abuse — all have a hand in monitoring prescription meds, but no single one is in charge. "You need Congress choosing an agency and saying, 'This is your baby,'" says Barber.

    In early 2009, the FDA announced that it was initiating a "risk-evaluation and mitigation strategy," contacting the opioid manufacturers and requiring them to participate in a study of how their meds can continue to be made available while at the same time being better controlled. The regulations the FDA is empowered to issue include requiring manufacturers to provide better information to patients and doctors, requiring doctors to meet certain educational criteria before writing opioid prescriptions and limiting the number of docs and pharmacies allowed to prescribe or dispense the drugs.

    "And with all that," warns Dr. John Jenkins, director of the FDA's Office of New Drugs, "we do still have to make sure patients have access to drugs they need." Any regulations the FDA does impose won't be announced until 2011 at the earliest and could take a year or more to roll out.

    Other solutions don't face the same regulatory maze. The U.S. Drug Enforcement Administration recently announced a straightforward idea to reduce misuse: a drug take-back day on Sept. 25, 2010, when patients can safely dispose of unwanted prescription drugs at 3,400 government-sponsored sites around the country. An electronic database of all pharmacies across the country could also help catch patients and doctors who are gaming the system, particularly those who hopscotch across state lines. Doctors need to be less cavalier about prescribing drugs and stingier with the amount they do allow. They could also do a better job of assessing patients for addictive histories and requiring urine tests if they suspect a problem. If the patients don't want to comply, they don't have to — but they won't get their drugs either.

    Insurers — the bad guys in so many policy debates — can do a lot of good, keeping better track of the number and types of controlled substances policyholders are receiving. Big Pharma must help as well, and that means climbing down off the opioid gravy train and working harder to develop more nonaddictive painkillers — even if it means fewer sales and lower profits. At least one company, New Jersey–based King Pharmaceuticals, is seeking a solution. According to a recent review article in the journal Drugs, the company is experimenting with abuse-deterrents built directly into pills. One technique involves including pellets coated with a chemical called naltrexone — which neutralizes the effects of opioids — in the pill. The pellets remain intact and pass through the body if the drug is taken as intended. If the pill is crushed, however — a trick addicts use to produce a faster, more powerful kick — the naltrexone is released, killing the high.

    Until then, it's up to responsible doctors and cautious patients to keep the epidemic in check. That, certainly, is not easy. "When drug addicts or alcoholics ask us if they can ever use substances in moderation, we tell them no," says Krantz. "Once your brain becomes a pickle, it can't go back to being a cucumber." Too many Americans are pickled already. The time to help them — and protect the rest — is now.

    This is an updated version of a story that originally appeared in the Sept. 13, 2010, issue of TIME.

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