Tag: Health Policy

Last month I wrote an op-ed and a follow-up blog post critical of a proposal to expand Colorado’s prescription drug monitoring program. I pointed out (among other things) that the program was promoted and financed largely by federal law enforcement; that law enforcement agents can access the information in the database (by warrant) for purposes of pursuing criminal investigations; that the program does little to curb drug abuse, in part because drug abusers easily can switch to different drugs, and in part because some drug abusers steal their drugs (or, I’ll add here, buy them on the black market); and that the proposal seeks to force doctors (and other prescribers) to register with the database.

My main point was that it is not the government’s proper role to save drug addicts from their own dangerous behavior—particularly given the government’s actions in this area inevitably make it harder for some people to obtain the drugs they desperately need to manage their excruciating pain.

On March 31, someone who identified himself only as “John” replied to my web page:

Ari, hello. My name is John and I am a retail pharmacist. I rely heavily on our prescription monitoring program here in Nevada. As pharmacists, we use it to make sure people are not filling multiple controlled substance prescriptions at different pharmacies, using multiple doctors for controlled substances, and that they are not misusing or abusing controlled substances. This tool has prevented abuse and diversion in our state and is a very useful tool. Also, to stress an important point, a good pharmacist understands true pain (cancer) and always strives to take compassionate care of the patient.

Following is my open reply:

Dear John,

As a pharmacist, you are undoubtedly a smart fellow; you must realize, therefore, that you have not actually responded to any of the observations or arguments I make in my op-ed and related post.

I have no doubt that the monitoring programs set up by the governments of various states prevent some drug addicts from obtaining certain drugs from certain sources. (Whether it substantially prevents drug addicts from abusing drugs, on the other hand, is extremely doubtful.) My primary philosophical objection is that it is not the government’s proper role to address or prevent the problem of drug abuse; rather, it is to protect people’s rights, including the rights of consenting adults to contract freely. Although a full defense of that position lies outside the scope of this short letter, I will note here that there are other—and much better—ways to help drug addicts with their problems.

I will also note here that my criticisms of government-run drug prescription drug monitoring programs (run largely at the behest of federal law enforcement agents) do not constitute reasons to prohibit doctors and pharmacists from independently sharing certain information about potentially dangerous situations. And of course nothing in my position implies that reckless doctors should be free from civil and even (if circumstances warrant) criminal liability.

As a pharmacist, your ability to “take compassionate care of the patient” is inherently limited. After all, you are not legally authorized to diagnose any disease or to write drug prescriptions. Thus, there is no case in which you can actually expand the delivery of pain medications to the patients who desperately need them. Your actions can have one and only one effect in this regard: to block or delay such delivery.

Of course, your actions might also have the effect of subjecting the doctors and other medical professionals, who are legally authorized to write drug prescriptions, to the actions of federal and state law enforcement agents. Those agents, in turn, have the power in some cases to arrest doctors and to help other government agents prosecute doctors or strip them of their ability to practice medicine.

As a pharmacist, John, you are not in any danger of having your power stripped to write drug prescriptions (as you have no such power) or of being prosecuted for writing drug prescriptions (as you do not write any). You are, however, quite capable of assisting federal and state drug enforcement agents create a climate of fear and intimidation among those who do write drug prescriptions, such that, on balance, those who prescribe drugs tend to err on the side of legal precaution and not help people coping with excruciating pain obtain the drugs they desperately need. Such a result is possible—and I think likely—even assuming (as I’m sure is the case) that most uses of the monitoring program do not involve law enforcement. And the more the program is expanded, the more substantial will be its effects in this regard.

In using the monitoring program, you act primarily on guesswork and speculation. Consider the activities that you regard as inherently suspicious: people “filling multiple controlled substance prescriptions at different pharmacies” and “using multiple doctors for controlled substances.”

Again, I do not doubt that such behavior describes some drug addicts. But I also do not doubt that such behavior also describes some people coping with excruciating pain due to cancer or other serious diseases.

Consider that cancer patients and others coping with serious illnesses typically see multiple doctors in multiple locations to manage their diseases. They also typically use different types of pain medications concurrently to cope with their diseases. Moreover, cancer patients often end up leaving their jobs, moving to a different location, and switching their insurance companies—developments that can result in them seeing more doctors in more locations. Add to this the fact that people suffering from a variety of diseases often require supplemental surgeries—surgeries that initially cause enormous pain and that involve yet more medical facilities. For all these reasons, people coping with such diseases very often get multiple drug prescriptions, written by multiple doctors, filled at multiple pharmacies—the very behaviors that you claim to “make sure” to treat as suspicious.

As a pharmacist, John, you typically lack access to the pertinent information about such patients, and when you lack such information you cannot possibly “take compassionate care” of them. With respect to such patients, your actions can have one and only one result: to make it harder for them to obtain the pain medications they so desperately need.

I will thus repeat here what I wrote at the outset: “the answer is not for the government to monitor and harass people who suffer from devastating pain—and make it harder for them to manage their pain—in a misguided attempt to save drug abusers from themselves.”

Sincerely, Ari Armstrong

Image: Wikimedia Commons

Yesterday the Greeley Tribune published my article, “Prescription Drug Monitoring Punishes the Responsible for the Sake of the Irresponsible,” written for the Independence Institute. That article begins:

Prescription drug abuse is a serious problem, sometimes a fatal one. But the answer is not for the government to monitor and harass people who suffer from devastating pain — and make it harder for them to manage their pain — in a misguided attempt to save drug abusers from themselves. Unfortunately, that is precisely the effect of House Bill 1283, sponsored by Rep. Beth McCann of Denver.

Here I thought I’d take the opportunity to offer more details about the program and my research of it.

Health Information Designs

One interesting fact about the Colorado database that tracks (some) prescription drug use is that it is operated by a limited-liability corporation, Health Information Designs (HID).

Colorado’s Department of Regulatory Agencies (DORA) links users directly to HID for information about the Electronic Prescription Drug Monitoring Program (PDMP). Interestingly (or perhaps disturbingly), HID originally went into business producing “data mining software” for prescription drugs.

So let us clarify what’s going on here. The Colorado government encourages doctors and pharmacies to enter patients’ personal medical information into a central database, run by a for-profit corporation, and this information is available to a wide range of medical professionals—whether or not patients wish their records to be so distributed—and to law enforcement agents who obtain a warrant to see the records.

One thing McCann wants to do is force all prescribing doctors and pharmacies to register with the database. McCann’s bill would not force prescribing doctors and pharmacies to actually use the register, but does anyone seriously doubt that’s the Drug Enforcement Administration’s eventual aim? The goal here is for Big Brother to be able to monitor every individual’s use of prescription drugs, every doctor’s prescriptions, and every pharmacy’s drug sales. And, of course, the government wants to subject violators of the (ambiguous) prescription laws to penalties, including the penalty of getting locked in a metal cage.

The Funding for the PDMP

Tellingly, the Colorado PDMP, launched in 2005, got its primary funding from the U.S. Department of Justice—of which the DEA is an agency.

The legislator’s fiscal note for 2005 House Bill 1130 states the following:

The bill is assessed at having a conditional fiscal impact of $547,156 . . . in its first year of implementation and $271,484 . . . in its second year of implementation. . . . During the current fiscal year, the Department of Regulatory Agencies has received a $50,000 U.S. Department of Justice grant in support of the Harold Rogers Prescription Drug Monitoring Program. . . . Additionally, the federal government will make a $350,000 grant available to implement the program once statutorily authorized.

I do not have complete funding details about the program. However, it is apparent that the program is driven primarily by federal law enforcement.

News Sources

I relied on several news reports in conducting my research. 9News published a story about McCann’s current bill. Eli Stokol’s pathetic excuse for journalism on this matter essentially uncritically relates McCann’s talking points, without bothering to raise a single critical question. Hopefully in the future Stokol will take his role as a journalist more seriously and set a higher bar for himself than legislative lapdog.

Over at the Denver Post, I found Felisa Cardona’s 2011 story about the legislature’s renewal of the PDMP that year as well as Michael Booth’s 2012 story about DEA complains of low registry use.

Drug Substitution

As I point out in my op-ed, drug abusers who have a harder time getting one type of drug often switch to another type. My claim is supported by a recent news story from the Washington Post (republished by the Denver Post).

[T]he U.S. government’s decade-long crackdown on abuse of prescription drugs has run an unsettling risk: that arresting doctors and shuttering “pill mills” would inadvertently fuel a new epidemic of heroin use. . . . [A]t the same time that some pain medications have become less available on the street and pricier, many users have switched to cheaper heroin, since prescription pills and heroin are in the same class of drugs and provide a comparable euphoric high.

It should go without saying—but, in today’s political climate not even the most obvious facts may go without saying—that substituting street heroin addictions and deaths for prescription drug addictions and deaths is no great victory.

Drug Thefts

I cut the following line from my op-ed due to space restraints, but it’s an interesting detail: “In testifying in favor of McCann’s bill, Robert Valuck from the University of Colorado offered the example of a woman who robbed a pharmacy at gunpoint—but the expanded registry would promote rather than deter thefts of prescription drugs.” Valuck’s claim is included in 9News’s video, not in Stokol’s written account.

The Magnitude of Prescription Drug Deaths

In my op-ed, I claim that McCann apparently overstated the magnitude of deaths related to prescription drugs. Specifically, she said, ““More people actually die from prescription drug overdose than from traffic accidents.”

I have an email out to McCann asking for her sources, so perhaps she’ll send me something I have not yet considered. However, based on the sources I’ve been able to find so far, McCann’s claim seems not to have support.

This past October, an outfit called Trust for America’s Health published a report, “Prescription Drug Abuse: Strategies to Stop the Epidemic.” (Likening a volitional behavior—drug abuse—to an infectious disease is epistemologically and morally offensive, but I’ll leave that topic for another day.)

That report does not state that prescription drugs are responsible for more deaths than are traffic accidents. Instead, the report claims that “[p]rescription painkillers are responsible for more than 16,000 deaths” per year. The number of motor vehicle deaths exceed 30,000 each year.

Regarding traffic fatalities, the report makes a different claim: “Drug poisoning deaths—the majority of which are related to prescription drugs—surpassed traffic-related crashes as the leading cause of injury death in the United States in 2009.”

My guess is that McCann misstated this report’s (or a derivative report’s) findings.

(I also saw that Dr. Joseph Mercola makes a broad statement about prescription drug deaths surpassing auto deaths, but, if you trace back his links, you find that the statistic pertains only to Ohio. I have not traced the claim beyond a 2011 New York Times story.)

The best statistics I’ve found about the problem of prescription drug abuse are provided by the Centers for Disease Control, which report, “In 2008, drug overdoses in the United States caused 36,450 deaths. OPR [opioid pain relievers] were involved in 14,800 deaths (73.8%) of the 20,044 prescription drug overdose deaths.” (In many cases a death involves the mixing of various types of drugs.)

Of course, as the CDC also report, most people who intentionally kill themselves by overdosing on drugs use prescription drugs for the purpose. But the monitoring program will not pick up one-time drug purchases among suicidal people, nor will it prevent suicidal people from substituting one method of suicide for another.

Conclusions

I have known people who have died from terminal cancer. I know people now dealing with the agonizing pain caused by late-stage cancer and other diseases. The simple fact is that more people with serious injuries and diseases will suffer more pain because of the government’s crackdown on prescription drugs—all to save irresponsible drug abusers from their own poor choices. That policy is morally wrong.

Image of Beth McCann: Wikimedia Commons