Nobody would argue with the fact that there is an opioid crisis in our country – it is a demonstrable fact. However, there has recently been a significant focus on whether drug wholesalers and their business partners including lobbyists have caused people to die from overdoses, including a recent segment by 60 Minutes. While the segment sought to educate viewers on the causes of prescription drug abuse and the alleged slowdown in enforcement efforts by the government, it is of course journalism and takes a strong position against drug companies. Aided by reporters from the Washington Post and former employees from the Drug Enforcement Administration (“DEA”), the 60 Minutes segment, while dramatic in its presentation, only told the facts relevant to the position it was taking – which is what makes good headlines.
In the segment, a former employee of DEA provided heartfelt and explicit accusations that drug companies, through their lobbyists – especially drug wholesalers – were responsible for the drug epidemic, placing profit above public health and safety. The accusations oversimplify the problem and attribute causation unfairly rather than looking at the totality of the circumstances and the contributing factors. Moreover, the attribution of decreased enforcement to recent legislation amending the Controlled Substances Act was incomplete and unbalanced.
Despite repeated finger pointing against certain members of the supply chain, the DEA employee made no mention of the two vitally important factors related to the surplus of controlled substances in our communities – DEA controls on manufacturing and over-prescribing by some physicians (or other prescribers). There did not seem to be a significant effort on the part of the reporters to challenge the former DEA employee’s assertions or attempt to look at the plethora of factors influencing the prescription drug abuse epidemic.
One significant factor that is often overlooked by reporters, policymakers, legislators, and the general public is that the total quantity of the most widely abused and diverted controlled substances produced and available in the United States is controlled and set by DEA. Even if the claim that Big Pharma’s lobbyists persuaded Congress to legislate in its favor is true, DEA still has the power and autonomy to limit the pharmaceutical company’s profits, by limiting the amount of drugs that can be produced. Unless, of course, the former employee is also insinuating that DEA itself was beholden to drug lobbyists.
Instead of using its significant authority to limit the supply of these widely abused controlled substances, DEA actually became complicit in the problem by allowing significant increases in the manufacturing of these substances while the prescription drug epidemic was exploding. It is more than a bit of irony that the same former DEA employee blaming the epidemic on the regulated industry was the one whose hand was on the spigot, setting and approving the annual quota from approximately 2006 through 2016 – the heart of the prescription drug abuse epidemic. To be clear, these were not small increases over time (oxycodone quota increased by more than 300%). The graphics below show DEA-issued quota from 2004 through 2013.
While much attention is given to the bill passed by Congress and signed by President Obama, there was shockingly no reference to the actual content of the legislation which was only 7-pages long. The bill did not strip DEA’s enforcement authority. It clarified an important legal term/standard that had not previously been defined. Instead of reporting both sides of the issue, 60 Minutes left its viewers thinking that one act of Congress crippled an entire agency’s enforcement operation. That is disingenuous at best. It is well known that administrative enforcement actions, including Immediate Suspension Orders, came to a screeching halt three years prior to the passage of the legislation in question. This was due to a number of factors that were not explored.
Also absent from the reporting is any discussion or acknowledgment that over-prescribing of controlled substances is at the heart of the prescription drug abuse epidemic. We need to ask (and hopefully answer) a fundamental question – why do prescribers in the United States prescribe the overwhelming majority of opioids that are consumed in the world? DEA, state regulators, and trade associations, including the AMA, must not only hold prescribers accountable, but they must educate prescribers and significantly change prescribing practices and the medical approach to treating pain. Minimal credits in prescription drug abuse, treating pain, and prescribing opioids should be required for all attendees of medical colleges and universities. State medical boards should require minimum CME requirements every year for these same topics. And perhaps we need to consider limiting the authority to prescribe opioids to certain types of practitioners.
Finger-pointing and Monday-morning quarterbacking only deflect our attention from addressing this serious epidemic. There is no shortage of great minds inside and outside of government, who, when working together can make measurable progress in protecting the public health and safety from prescription drug abuse. Treating pharmaceutical companies as “drug dealers in lab coats” is the failed approach of previous management at DEA. While maybe not the silver bullet, I expect that collaboration with industry will bear more positive results.