I Still Don't Prescribe Heroin

Not long ago, I gave my take on the absurdity of linking the use of legally prescribed narcotic pain relievers with the nationwide heroin "epidemic."

Recent studies have demonstrated that poly-drug use progressing to heroin is the most common path leading to heroin use.  That path mostly begins with alcohol and continues through cannabis, pills, psychedelics/hallucinogens, and cocaine, until finally reaching heroin.  Also of note is that the escalation from marijuana to heroin occurs three times more frequently than that from narcotics to heroin.   A recent report by the National Academies of Sciences Engineering and Medicine noted that in a recent survey of 22.2 million people using cannabis in the last 30 days, 90% were using it for recreational, not medical purposes.

Beginning with California in 1996 and as of late December, 28 states and D.C. have enacted laws for the "medical" use of marijuana, though medical studies have not clearly demonstrated the efficacy for the majority of "accepted' indications."  Unfortunately, the powers that be have motivations to pass such legislation, though contrary for the good of individuals and society, seemingly unaware of or uninterested in the ease of obtaining marijuana by concocting one of the required medical grievances.

To understand how irrational our governments approach to the problem of heroin has become, consider the logic of fixing your home roof as the solution to the flat tire on your car.  There seems to be a practiced method at work that runs as follows: a bad law is better than a good law or no law at all, since a bad law will beget more law, and more law means job security for the writers, interpreters, and enforcers of the law.

Over the past several months, the reaction to the heroin "epidemic" by state governments has become increasingly absurd, based on the number of states legalizing or decriminalizing marijuana, another federal schedule I controlled substance.  In addition, there are now 49 states, the most recent Pennsylvania, with some type of Prescription Drug Monitoring Program.  Making what's legal illegal, and what's illegal legal, seems to be a government operating principle these days.

The stated purpose of Pennsylvania's drug monitoring program is to "alert medical professionals to potential dangers" and "to aid regulatory and law enforcement agencies in the detection and prevention of fraud, drug abuse and the criminal diversion of controlled substances."  The Pennsylvania Department of Health, having been given authority to administer the program, is apparently in the process of making up...I mean interpreting the law.  For instance, the Pennsylvania Department of Health is now redefining words within the law such as "employee."  On their website, in the "Q&A for physicians" section, "employee" means "employee or delegate."  Orwell would be proud.

As in Islam – "[n]one of Our revelations do We abrogate or cause to be forgotten, but We substitute something better or similar" (Qur'an 2:106) – American law suffers from the concept of abrogation.  New legislation can essentially contradict old legislation since the repeal of old legislation is not required, the assumption being that the citizen will understand what the contradictions within the new law mean, if in fact that was considered to matter.

Originally, Act 191 of 2014 required prescribers to query the prescription databank the first time a controlled substance was prescribed; however, it also contained non-violation and immunity clauses to protect the prescriber should he not query the system.  I kid you not.  Act 124 of 2016, however, abrogated the query requirement by adding the need to query the system each time narcotics or barbiturates are prescribed.  Logically, since there is only one first time, and both laws state that (though allowing for legal logic, it may depend on what "first" means), the non-violation and immunity contained within the first law should still stand.  But keep in mind the principle that bad law begets more law.

Circling back to the issue of heroin abuse and its relation to the prescribing of narcotics, the NY Times Magazine did an exposé on the matter, published on January 6 and titled "Inside a Killer Drug Epidemic: A Look Inside at America's Opioid Crisis."  The piece noted greater than 33,000 deaths from opioids in 2015 (legal or illegal?); overdose deaths nearly equal to car crash deaths; and, for the first time, heroin deaths greater than gun homicides.  Given these statistics, it seems that overdose deaths from legally prescribed narcotics are relatively few.  From my count, heroin was stated 23 times in the article, while general drug terms or other specific drugs were mentioned 20 times.  Seems to me that heroin, which remains illegal, should be the opioid of greatest concern.

Moving along, the exposé profiled seven stories from around the country.  Although anecdotal, they are still illuminating when you actually read what people say, and by people, I mean the addicts themselves.

It was the third anecdote that was the most enlightening because it underscored inherent problems with legislation and why the founders' vision of limited government was spot on.  The profiled male drug abuser, who started with marijuana and whose adventure led to ecstasy, cocaine, and finally heroin, but who is now apparently clean, conveyed remarkable insight by stating, "My addiction has been replaced with addiction to other things: going to the gym, smoking, girls, getting tattoos[.] ... All of us have some real impulse control problems[;] that's why we're drug addicts."  At this don't, you want to knock on your legislators' heads and ask, "Hello?  Is there anything in there?"

So what is the solution?  One idea was offered by Tim Lahey, M.D., writing in an op-ed in the NY Times, titled "Let Opioid Users Inject in Hospitals."  Eye roll, but maybe he's on to something.  How would this help the heroin epidemic, you ask?  Well, as Dr. Lahey explains, if there were safe drug rooms in hospitals with clean needles and equipment, addicts would have reduced conflict with staff, it would protect patients and providers from dirty needles and other drug hazards, and it would enable respectful high quality of care and offer treatment for addiction – the caveat being that hospitals must guard against the risk of overdose or unseemly behavior.

So an epidemic is addressed with feeding the epidemic?  Isn't this Enabling 101?  I thought it was unwise to add gasoline to a fire.  What – no impulse control therapy?  As if that's going to work – but if nothing else, it can contribute to the bottom line of the pharmaceutical companies manufacturing OCD medication.

America does have an opioid "epidemic" of sorts.  However, its solution is not to be found in the medical exam room.  Physicians can do only so much when parenting or personal responsibility is what's needed to correct a personal behavior problem.

Government intrusion in the doctor-patient relationship is certainly no fix.  Improper use of narcotics, the bulk related to schedule I – i.e., illegal – drugs, is a crime properly directed toward the criminal.  And since I still do not prescribe heroin, I am neither a criminal nor one needing addressing...unless, of course, you were looking to beget new laws.