Dr. D’Onofrio Is Correct about Stigma but Seems Too Reticent Regarding Policy Proposals

In her response to Travis Rieder’s lead essay, Gail D’Onofrio laments that stigma presents obstacles to patients seeking treatment for substance use disorder, and on that we agree. And not all people with substance use disorder desire treatment.

I have written here about the stigma attached to the nonmedical use of certain substances, pointing out that there are many “functioning addicts” who, if they live in the right neighborhood, have the economic means, and the right connections, are able to live productive and meaningful lives while keeping their lifestyle choices confidential. There is no doubt that there is a racial basis to the stigmatization of the nonmedical use of certain drugs over others. For a detailed portrayal of the role of racism in this issue, I recommend Johan Hari’s Chasing the Scream—The First and Last Days of the War on Drugs.

As I pointed out in a letter to the editor of the Wall Street Journal, the stigma attached to certain substance use disorders is responsible for many of the harms wrought by these disorders, by driving addicts to the dangerous black market and away from medical attention.

Unfortunately, it appears that Dr. D’Onofrio still subscribes to the standard narrative that the opioid overdose crisis is a direct result of the overprescribing of opioids to treat pain, largely due to an aggressive advertising campaign by Purdue Pharma, makers of OxyContin (released in 1996), and other drugmakers.

In my response to Travis Rieder, I stated that data from the National Survey on Drug Use and Health as well as the Centers for Disease Control and Prevention show no correlation between prescription volume and the incidence of prescription pain reliever “misuse” or use disorder. Furthermore, research published last year by the University of Pittsburgh Graduate School of Public health found that overdoses from the nonmedical use of licit and illicit drugs have been on a steady exponential increase since at least the late 1970s, and current data show no evidence of deviation from the trend line. An NBC News reporter who interviewed the lead author summarized the study by writing, “[The overdose crisis] started before the availability of synthetic opioids, and may have only a little to do with the prescribing habits of doctors or the pushy habits of drugmakers, the team at the University of Pittsburgh found.”

I am not here to defend the aggressive marketing strategies of Purdue Pharma. But it is important to note that there were several studies throughout the 1970s, 1980s, and 1990s criticizing the undertreatment of pain and arguing for liberal prescribing of opioids. In fact, a 1993 newsletter from the National Institute on Drug Abuse stated, “these drugs [opioids] are rarely abused for medical purposes…thousands of patients suffer needlessly,” and in 1992 and again in 1994 the U.S. Department of Health and Human Services issued guidelines encouraging a more liberal use of opioids to treat postoperative and cancer pain. I think it is undeniable that “opiophobia” was responsible for the undertreatment of pain prior to the mid-1990s. Unfortunately, in reaction to the overdose crisis, the pendulum has swung back in the other direction, and “opiophobia” is back with a vengeance today.

It has become fashionable to place the blame for the overdose crisis on doctors and drugmakers, but in fact, the problem has been going on for decades and has complex sociocultural and psychosocial etiologies. To be sure, many unscrupulous doctors and pharmacists teamed up with drug dealers to run “pill mills,” but they were the exception, not the rule—and they were not treating patients as much as they were supplying nonmedical users with their drug of choice. While they deserve some blame, the ultimate blame should be placed where it belongs: on drug prohibition and its tendency to corrupt health care practitioners, police, and politicians with the lure of easy money.

Further complicating the fashionable narrative, last month the Washington Post obtained access to a database maintained by the Drug Enforcement Administration. It revealed that Purdue Pharma’s OxyContin accounted for just 3 percent of the prescription opioid market from 2006 to 2012.

I also disagree with Dr. D’Onofrio regarding the risk of opioid misuse or addiction when used to treat acute or chronic pain. While she provides sources, I too provide sources and will argue that the 0.6 percent misuse rate with opioids prescribed for acute postoperative pain published in the January 2018 BMJ by Brat, et al, as well as the two Cochrane systematic reviews I referenced showing a roughly 1 percent addiction rate associated with long-term treatment of chronic non-cancer pain patients are more recent, comprehensive, and rigorous studies.

I agree with Dr. D’Onofrio that “harm reduction strategies are imperative” in addressing the overdose problem, and I appreciate her comparison of diabetic patients whose conditions are poorly controlled to patients suffering from substance use disorder. In fact, harm reduction per se is much of what we doctors “do” every day in modern, developed countries. As I point out here, when health care practitioners medicate overweight and sedentary patients with anti-hypertensives, statin drugs, or oral anti-hyperglycemic medications, they are engaging in harm reduction strategies for what in great part are lifestyle choices made by our patients.

While I don’t disagree with any of Dr. D’Onofrio’s policy proposals, I am disappointed that they are too acquiescent to the current regulatory regime, which is in desperate need of reform. For example, Dr. D’Onofrio calls for extensive training of hospital staff, including nurse practitioners, so they can get an “X Waiver” to prescribe buprenorphine, an effective form of Opioid Agonist Treatment. Better yet, why not call for removing the requirement for an “X Waiver,” as I and many harm reduction advocates have been urging? In France, roughly one-fifth of primary care providers treat their substance use disorder patients with buprenorphine under no stricter prescribing regulations than for any other controlled substance. There is presently bipartisan legislation being considered in both houses of Congress to remove the “X Waiver” requirement.

I was disappointed there was no mention of reforming the laws governing the prescription of methadone as an Opioid Agonist Treatment. Current regulations, including the requirement that patients take the methadone under the supervision of a clinic staff member, are onerous and impractical, resulting in reduced access to patients seeking help. In the U.K., Canada, and Australia, practitioners have been prescribing methadone as OAT to their patients since the 1970s, in much the same way that U.S. doctors can prescribe buprenorphine (minus the “X Waiver” requirement) for decades, and pilot programs involving primary physicians in Boston, MA have shown great promise.

And while I agree that bringing an addiction specialist onboard to manage pain in critically ill patients with lengthy hospitalizations can be of great value, not every patient in pain fits that description. It can be impractical and inconvenient for many pain patients to have “too many cooks” involved in their care. I think it would be better if physicians were better educated on the pharmacology and withdrawal management of opioids for the treatment of pain, much as they are when it comes to the medical management of other conditions.

Dr. D’Onofrio and I find much on which we agree. We might find more common ground if she was more inclined to challenge conventional views regarding the etiology and management of the overdose crisis.

Also from this issue

Lead Essay

  • American pain medicine is desperately broken, says bioethicist Travis N. Rieder. To fix it, we must avoid swinging the pendulum too far toward over-medication—and too far toward under-medication. Either of these mistakes can drive patients toward the dangerous illicit opioid market. Instead, Rieder recommends harm reduction strategies, including safe injection sites and even prescriptions for pharmaceutical grade opioids to minimize the harms of addiction.

Response Essays

  • Jeffrey A. Singer agrees that pain is individualized and thus difficult to assess. The War on Drugs has made practicing medical pain management much more difficult, because doctors have grown averse to prescribing opioids, particularly in high doses. But it was not doctors prescribing too freely that prompted the recent crisis, and when doctors withdrew these medications, many patients turned to the streets.

  • Gail D’Onofrio says that clinicians have a good idea of what works in fighting opioid addiction and dependency. She calls for a multifaceted approach that involves medication, more treatment professionals, and ending the stigma of seeking treatment, which can often drive away people who would otherwise seek help. She outlines a variety of legislative and clinical practice reforms that she believes will help prevent and treat substance use disorders in the future.

  • “The chronic and relapsing nature of addiction—the very symptoms of addiction—are punished and criminalized,” writes Regina LaBelle, who argues that this punishment is counterproductive. The criminal justice system has become the default primary care provider for many and perhaps most addicts, and this situation helps no one in society, not even those who never use drugs at all.