This is a point I made a while ago in another post, but here it is again. There is no clear way to reliably distinguish between a real pain patient and an opioid addict who is seeking to use pain medicine recreationally. They show up to their doctor, they describe their various ailments, and they explain that a certain medicine give them relief (perhaps even specifying which opioid worked for them). Even supposing it initially were the case that pain patients all exhibit Behavior X while opioid addicts don't, people are smart. They learn to game systems. It will become very clear very quickly that doctors respond better to patients who exhibit Behavior X, and recreational users will learn to fake it. This doesn't mean doctors should start seeing Behavior X as a telltale sign of addiction. It's not! It's a behavior of real pain patients that recreational users have learned to mimic! Treating Behavior X as a sign of addiction will lead to lots of genuine pain patients being denied opioids. Any such screening process is bound to be anti-inductive, meaning the harder we try to understand it the harder reality will try to thwart our efforts.
See this recent Slate Star Codex in which Scott Alexander describes several patients who were treated by their doctors like drug addicts. He makes clear that these are stylized examples, composites created to protect the identities of his patients. But plainly this kind of thing happens all the time. It's tragic. Sometimes the patient is far more of an expert in his/her own medical needs than their doctor, having fine tuned their own care in a trial-and-error process. It's pretty clear that many doctors are shirking their responsibility to treat their patients because of legal hazards. My own summary of Alexander's post is that there is no avoiding the false positives/false negatives trade-off. Any net you build to catch addicts is going to ensnare some legitimate patients, who perhaps make the "mistake" of learning how to fine tune their own medications and ask their doctor for those medicines by name.
I read a lot of literature about drug policy, so I routinely come across "opioid epidemic" stories. It irritates me when people include throw-away lines about how we've "prescribed too many opioids." Even authors who are very sympathetic to pain patients, who are perhaps also sympathetic to drug decriminalization and harm reduction strategies, often preface with something like, "While it's certainly true that we've prescribed too many opioids in recent decades..." They may even point the finger at Purdue Pharma or the Sackler family as the corporate malefactors in the opioid crisis.* I want to push back really hard on this concession and say: No, we did not prescribe "too many" opioids. We were prescribing too little in the 80s, then, mercifully, attitudes toward pain treatment changed. For the reasons described in the top paragraph, there is no clear discriminator that neatly separates pain patients from addicts. The phrase "too many" seems to imply that the addicts and the pain patients were easily separable ex ante, and we could have just positively identified the addicts and sent them home without prescriptions. It's only "too many" in an ex post sense, in that we knew only after the fact when someone was a poor candidate because they in fact became an addict or had a fatal overdose. If there was no ex ante way to discriminate, then it wasn't a mistake to prescribe opioids, and in no meaningful sense did we prescribe "too many."
For these reasons, I think we should basically give opioids to anyone who wants them. Any kind of screening process will inevitably leave some desperate pain patients untreated. Besides, we now know the consequences of denying prescription painkillers to recreational users; recent crackdowns and supply restrictions have led to a massive surge in the use of illicit heroin and fentanyl and a huge increase in overdose deaths. Restricting access to the relatively safe, standardized, factory-produced opioids isn't helping addicts. It's driving them to more lethal behaviors.
It is very clear that it was too difficult for chronic pain sufferers to get pain relief until the late 1990s, and even afterwards there was a lot of law enforcement scrutiny and even prosecutions of pain doctors. When pain patients are forced to taper off their opioids, perhaps because their doctor feels compelled to follow the CDC's misguided guidelines or perhaps because their doctor was targeted by the DEA, they often commit suicide. This is a history of too many restrictions on opioid prescribing.
I think drug reform will necessarily be a joint effort of libertarians and left-leaning harm reductionists. I want to say something to the left-leaning members of this coalition: stop falling for this "corporate malefactor" narrative of the overdose crisis. It makes you look impressionable. Producers and distributors are not morally responsible for the misuse of their products, and anyway they are not causally responsible for the recent surge in heroin and fentanyl overdoses. This ideology that lays blame on producers denies agency to patients (and more generally to consumers of non-pharmaceutical products). By the way, making money is not a sin. The profit motive doesn't inherently taint every human transaction in which money changes hands. If we as a society want to accomplish something, the best way to ensure it gets done is to allow someone to make a living doing it. There is no way for society to have a safe, legal supply of drugs if we're going to turn around and sue every manufacturer and distributor out of existence. I want to ask, "What exactly do left-wing harm reductionists have in mind?" Shall we keep the production and distribution of opioids in the black market, but have enough supervised injection facilities to accommodate drug users? There won't be any legitimate opioid manufacturers if we don't let them legally earn some kind of return on their investments. How do we accomplish harm reduction without a legal supply of opioids? Should the government sue every manufacturer and pharmacy because some small fraction of patients end up harming themselves? What kind of communication should opioid manufacturers be able to have with doctors and patients? Will any attempt to communicate information be interpreted post hoc as "deceptive advertising"? If manufacturers believe that the risk of addiction has been wildly overestimated, and they can support their beliefs with published research (which in fact tends to find low addiction rates for opioid patients), should they be forbidden from arguing their case? Should chronic pain sufferers be denied such a public advocate just because profit supposedly impugns their motives? Should the government's anti-opioid crusades (as carried out by the CDC and the DEA) have no counterweight, except for the unpaid volunteers who are motivated enough to push back? Should pain specialists (who also make a living supplying opioids to users) be subject to prosecution because some small fraction of their patients are abusing? Any one of these doctors with a large enough patient base probably "knows" that some of their patients are abusing, by sheer chance. It's just that they've made the decision to treat pain using some kind judgment about who is or isn't likely to be a real pain patient, applying some kind of plausibility threshold, and yielding a "treat" or "do not treat" decision. Should the authorities be able to second-guess their threshold? Any application of the principle that "these doctors should have been more discriminating" leads to pain sufferers being denied relief. I see a lot of opprobrium aimed at parties who make money, and it has very little to do with their moral blameworthiness. Frankly, it has more to do with the "bigness" of those parties and anti-corporate economic populism. The public loves to hate a corporate villain. Some sloppy media organizations and journalists have served the people what they want to hear. Don't fall for it. "News" stories that get the most clicks and media narratives that become accepted wisdom among "very serious people" aren't necessarily true.
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*There is even a push to blame the pharmacies who fill the prescriptions. This game of blaming the intermediary is absurd, considering that their only role is to actually fill a prescription that a doctor and patient decided was necessary. It should not be the pharmacy's business to object to such decisions. The bigness of Walmart, CVS, and Walgreens makes them compelling targets for a government shakedown of for left-wing moral opprobrium. That doesn't mean the opioid crisis is their fault. By all means, allow them to check for conflicting prescriptions and warn about drug interactions. But it makes no sense to blame these intermediaries for the sheer tonnage of opioids they handled.
I wasn't sure where to insert this in the main body of my post, so I'll put it down here. I know someone on Facebook who is at Cato and writes a lot about drug policy and the opioid crisis. He often shares stories about the opioid crisis. One of his friends, a lawyer, often pipes up to say that he sees cases in his practice of "obviously" negligent prescribing behaviors. He sues doctors for prescribing to people who "shouldn't have gotten them" (in someone else's estimation). His comments make it sound like these are open-and-shut, slam-dunk cases of inappropriate prescription. Obviously, this guys description of what he does for a living is going to be self-serving. I think it's hard to appreciate the ex ante principle, that it can be impossible to determine ahead of time whether or not something is a mistake. He has the advantage of filtering for instances where some medical misadventure has in fact taken place, and he get to craft a narrative post hoc about how obviously this patient should never have been prescribed opioids. I really hope he's losing a lot of these cases, because it's crap like this that makes it harder for pain patients to get relief. There are costly errors in both directions, but only the false positives become visible to him. This isn't even a government policy, just an out-of-control tort system that compels doctors to practice defensive medicine. Like I've said before, libertarians should spend some time thinking about how bad institutions can arise and damage society, even when it has nothing to do with a central government. If bottom-up civil society can mimic the harmful policies of a centralized government, we should worry about that, too.
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