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100 Americans die of drug overdoses each day. How do we stop that?

By now, virtually everyone has heard that actor Philip Seymour Hoffman died last Sunday of an apparent heroin overdose. What fewer people know is that, on the same day, roughly 100 other Americans also likely died from drug overdoses -- statistically speaking.

Jae C. Hong/Associated Press Jae C. Hong/Associated Press

The rise of fatal overdoses over the last 15 years is startling. In 2010, according to the Centers for Disease Control and Prevention, there were 38,329 fatal drug overdoses in the United States, more than double the 16,849 fatal overdoses observed in 1999.

Overdosing  is now the leading cause of accidental death in the United States, accounting for more deaths than traffic fatalities or gun homicides and suicides. Fatal overdoses from opiate medications such as oxycodone, hydrocodone, and methadone have quadrupled since 1999, accounting for an estimated 16,651 deaths in 2010.

Earlier this week, I discussed the overdose issue with my colleague Keith Humphreys. Humphreys is one of the nation’s leading addiction researchers. He teaches psychiatry at Stanford and is a scientist in the VA Palo Alto Health Care System. Below is an edited transcript of our conversation.

Harold Pollack: Let’s start by noting who you are, and why anybody would want to ask your views regarding drug abuse and overdose.

Keith Humphreys: I'm a professor of psychiatry at Stanford University and lead the mental health policy section in my department. I'm also a scientist in the VA Palo Alto Health Care System--though I should make clear that I’m a VA scientist, not a spokesperson for the VA’s official views. I've researched drugs and addiction for about 25 years. I'm also a trained clinician, and I've treated people for addiction. Last but not least, I work extensively with public policy makers. I was a senior policy adviser at the White House Office of National Control Policy (the “drug czar’s” office) for the first year of the Obama administration. I also served an advisory role within the Bush administration. I work with many states, legislatures, and governors, on how to design policies that reduce the destructive effects of addiction.

HP: Among other things, you are a prolific movie reviewer. Of course, our phone call today is occasioned by Philip Seymour Hoffman's death. Before we discuss the policy issues, how were you touched by Hoffman’s work as an actor?

KH: He was one of the very best actors this country has produced within the last 20 years. I’m struck by the range of things he could do and by his ability to make audiences care about characters who were difficult, strange or unhappy.

People will always remember him for his Oscar-winning performance in Capote. That’s appropriate because he was brilliant.. But he was also outstanding in some smaller films that not many people saw.  I've been encouraging people interested in addiction to see Owning Mahoney. It’s about a gambling addict, and it's based on a true story. The film captures how someone who seems to be doing well in many dimensions can still experience an addiction, and experience the emotional emptiness that often goes with that addiction. I don't know how much of Hoffman’s own life went into that performance, but it's pitch perfect. It only becomes more powerful when you realize that he himself was suffering from an addiction, albeit of a different sort.

HP: I believe his death is a reminder of two things. First, addiction can exist in people's lives alongside wonderful connections with other people, wonderful accomplishments, and wonderful abilities. Second, this problem touches so many people in so many different ways. We hold many stereotypes about what opiate addiction is like, what heroin users are like. These stereotypes just don't match the human experience of many people with opiate use disorders or the experiences of their friends and family members.

KH: That is true; the stereotypes don’t match reality. Most people who have drug problems also have jobs. A huge proportion of people having difficulties with prescription drugs are women; a huge proportion are "nice, middle class people." While I'm gratified that Hoffman’s death has galvanized discussion, some of this discussion has perpetuated harmful stereotypes. Some are saying: “Philip Seymour Hoffman, that’s the Hollywood lifestyle for you, they're all into drugs, and all that…”

This characterization ignores the fact that, statistically speaking, more than 100 Americans whose names we'll never know died of drug overdose on the same day that Mr. Hoffman did. Overdose is not a Hollywood story. It's an American story about an epidemic that's affecting all layers of American society.

HP: Many people don't realize that overdose is the leading cause of accidental death in the U.S. I gave a talk about five years ago in Chicago, and I mentioned that we had more overdose deaths than traffic fatalities. My audience literally did not believe me. People were absolutely convinced that I had mis-transcribed the numbers. Every year, America loses a little over 32,000 people in auto crashes, and something like 38,000 from overdose deaths annually.

KH: Yeah, it's remarkable if you compare overdoses to AIDS, which at its peak was taking about the same number of lives. The difference in reaction is really startling. We appropriately became galvanized about HIV/AIDS, and implemented much better public policy to prevent HIV-related deaths. It's much harder to get traction on the overdose issue, or even to get people to believe how prevalent the problem actually is.

HP: Why do you think it's hard to get people galvanized around overdose?

KH: AIDS inspired incredible activism in part because it was localized in particular communities that already had a shared identity. That probably helped groups like Gay Men’s Health Crisis organize politically. People knew each other. They loved the people who were dying. There isn't a comparable pre-existing  community of people affected by overdose. It's spread all over. The people who are dying and their loved ones don't necessarily know each other.. Also, there are also many people — as was true of AIDS — who feel that overdose is just punishment for immoral behavior and therefore isn’t a problem at all.

I should add one other thing which you know well. In drug policy, we have so much culture war screaming that it's very hard to address issues like overdose that take some planning, thought, and reflective approaches to public policy…. The polarized and uncivil atmosphere in drug policy  generates much heat but very little light regarding what we should do to address this problem. Evidence is often left aside as people start screaming at each other. Overdose is a public health problem and everyone should be working together to save lives.

HP: Within the world of injection drug use, the HIV epidemic sometimes overshadowed the continual reality that overdose was always a prevalent cause of mortality. If you read the classic cohort studies of street injection drug users, you’ll find that there tended to be a one or two percent annual overdose fatality rate in many of those studies. That’s incredibly high in groups of fairly young people who are not dying of other things.

The overdose threat was always there, perhaps in a fashion that led people to think of it as a condition rather than a problem. It became easy to see overdose as just another unavoidable background fact, which we couldn’t really influence. It became easy to see overdose as yet another cost of doing business if you're engaged in this behavior.

You recently mentioned that most "overdoses" are really not overdoses in the sense that one might think, where people are getting a much  more powerful dose than they were expecting. Can you explain that?

KH: News reports about batches of “killer heroin” are typically overblown. But unusually strong doses of a drug are in fact rarely the cause of overdose. Toxicology results after a fatal overdose usually indicate that the victim has consumed either their normal dosage level or a dose slightly lower than their normal level. It’s too late to fix the language, but “poisoning” might be a better term than overdose.

You might ask: Why would an experienced user die from taking their normal dose? Typically overdose occurs because they've had a loss of tolerance. This loss of tolerance often arises because they haven't used for a while. Maybe they had a voluntary period of abstinence. Maybe they were in jail, and their body can no longer handle the same dose.

The other leading cause of loss of tolerance is consumption of other substances. This is particularly true of alcohol, which seems to lower the body's ability to tolerate opiates (so do benzodiazepines). Most of what we call “opiate overdoses” are really polydrug overdoses: alcohol and heroin, alcohol and oxycontin, benzodiazepine, alcohol and Vicodin, combinations like that.

HP: This is an important point easily lost. Many, maybe most people who have a serious drug problem are using more than one substance. Alcohol and other substances are usually in the mix. That poly-substance use complicates efforts to treat people medically. It also complicates the behavioral dimensions of substance use disorders.

KH: That is true, and that is even more true today than it was 20 years ago. If you go back to people who are now in their 60s, there were a lot of people who just were alcoholics. They did not touch other drugs. You see more mixing as you move through the baby boomer generation. And now with adolescents and young adults there's really a poly-pharmacy of everything: legal pharmaceuticals, illegal street drugs, alcohol. You meet a drug user, and virtually always you're meeting a poly-drug user.

HP: Philip Seymour Hoffman was a little older, age 46. That's a pretty typical age for many overdose fatalities. He was having this interrupted period of use in some form. It is ironic that people's efforts to quit or to reduce their drug use can create such vulnerability for overdose.

KH: That vulnerability helps to explain why it is such a hard decision for people who are on various kind of orally-administered opiate substitute medications, like buprenorphine or methadone, to decide whether they want to stay on them. A former heroin user who is taking these medications is still taking an opiate. You have much lower risk of overdose or HIV infection while you're on them. At the same time, many people want to be weaned off these medications. Maybe they don't like the potential health consequences of being on an opiate forever. Maybe they just don't like the inconvenience or cost. People must decide: "Do I really need this, or can I go without it?"

It's a really tough decision, because if you are able to successfully transition from them, you may like your life better. On the other hand, your tolerance will decline. So if you do relapse – particularly if you return to injection use -- it could be a higher-risk event than it would if you had never gone off the opiates. Many people have strong ideologically tinged feelings about this issue and say it’s always a good idea or always a bad idea to go off of opiate substitution medication. In real life situations with real individuals, it's a hard decision.

HP: Given these realities, I am very concerned about various detox programs that advertise heavily, but that have uncertain results. If you open some airline flight magazines you'll sometimes see an ad that says, "Come to the desert for two weeks. You can tell your friends and family that you're on vacation. We'll detox you of everything, and you'll come back a new man.”

KH: What a recipe for overdose!  It’s such a horrible promise to hold out to desperate people and their families. By the way, those programs are usually cash-pay only. They promise to take away your addiction in two weeks but what they really take is your money.

HP: We know that relapse rates for straight detox are almost 100 percent, if detox is not followed up with careful interventions and monitoring. I sometimes wonder whether some very-wealthy people such as Philip Seymour Hoffman are actually getting evidence-based treatment when they seek help.

KH: I don' think they do. Some are checking into rehabs that don't seem much different than luxury hotels. I suspect, actually, that you might get better care being a working class veteran, or someone who happens to live near a primary care doctor who has trained him or herself using buprenorphine than you would being a rich and famous person in that luxury tier of care.

The other thing is—and I don't want single out Hollywood as the only example--there is a lot of enabling of high-status addicts. Rich people, high-status people such as physicians and politicians are sometimes immune from life pressures that provide other people with valuable warning flags. Powerful people can often evade many common legal, financial and social consequences of addiction . They can get into way deeper trouble before someone finally says, "Hey, I think you need to take a look at this problem."

HP: Michael J. Fox notes an episode in his memoir, when he's caught driving recklessly and is basically let off the hook by a local police officer. In hindsight Fox realizes how problematic such episodes were for him. Similar challenges arise with college drinking. Students aren’t driving anywhere if they live on campus. They don't have to wake up early because they don't have class until eleven o-clock. So they can get blasted and avoid some of the usual social constraints on alcohol consumption they would face in another environment. Most people regulate their own substance use because they start to get negative cues from their life experience. If you attenuate these cues, you may be making someone more vulnerable to longer-term problems.

KH: For related reasons, you can see why substance use disorders might become widespread in a community where there's very little employment, where people have a huge amount of time with nothing to do, not much fun to do, and not many demands on them…

HP: I want to get back to prescription drug abuse. We’re facing serious problems with medications like Oxycodone. Yet many of the problems that we associate with illegal markets are much less present in the prescription opiate scene. There's little violence on the supply side of this market. People are buying a medically produced product. They know the potency and the dosage. They're not getting street drugs that have (say) fentanyl mixed in. One might have thought that this would be a safer environment for people. It doesn't seem to have turned out that way.

KH: No, it didn't. Many people were surprised by that, and I'm one of them. I had assumed, as many people did, that heroin overdoses come from the fact that it's a black market product. This illegality implies that sometimes there's going to be impurities and the potency is going to dangerously vary from time to time.

There's a very nice paper just out by Professors Shane Darke and Michael Farrell, who are two of the world's leading experts on the topic. As these authors relate, toxicology studies of overdosed people very rarely find that impurities played an important role. As I said before, victims didn’t particularly receive high doses, either. Such findings surprised me. The fact that we've got 16,000 people a year dying from pure or legally-manufactured opiate analgesics shows you that it's really not about the unpredictability of illegal markets, it's about the drugs per se.

HP: Just to note the numbers, in 1999 there were about 4,000 prescription opiate overdoses. In 2010, there were about 16,000. By comparison, there are about 10,000 gun homicides in the United States.

KH: It is pretty amazing. Many people are focusing on the return of heroin and saying, "It's all the fault of criminals." You've got to remember, 4 in 5 of people today who start using heroin began their opioid addiction on  prescription opioids. The responsibility doesn't start today with the stereotypical criminal street dealer. We basically created this problem with legally manufactured drugs that were legally prescribed. This really flies in the face of the argument that  if we just had a flow of legal drugs, the harms would be minimal.

HP: What did the industry do wrong and what did policymakers do wrong with these prescription opiates. You and I wrote a piece where we noted that a third of the Wounded Warrior group had a substance use disorder. Something is amiss here. What went wrong?

KH: In the late 1990s, many medical societies became appropriately concerned about poor pain management in the United States. Many patients were not receiving needed pain relief, which was and remains a very serious problem. That worthy concern for improved pain management became fused with  the pharmaceutical industry’s profit-seeking goals, which they pursued through aggressively pushing opioids in primary care settings and doing a lot of deceptive marketing.

Purdue Pharma was fined $600 million  for deceiving regulators, doctors and patients about the addiction and overdose risks of OxyContin. They told prescribers not to worry, saying that the drug wouldn’t be abused and there was little risk in even very high doses.  These claims turned out to be untrue.

Many good-hearted, well-intended prescribers were so swept up in the need to relieve pain that they were not sufficiently critical of the potential downsides of flooding the country with these medications. Here’s one stunning statistic. The U.S. accounts for  99% of the world’s hydrocodone consumptions is a spectacular level of prescribing.

U.S. prescribers also write more prescriptions for opiate painkillers each year than there are adults in the United States.  When an addictive substance is prescribed on that scale, there will inevitably be substantial leakage out of the medical system. This would be true even if every single doctor proved to be honest and well-trained. And every single doctor isn't.

A small number of criminal doctors realized that this was a cash cow and started setting up pain pill mills in places like Florida that had weak regulations.  The clinics advertised nakedly with promises such as, "No pill, no pain. Cash only, no I.D. required," and thereby fueled an opioid epidemic all across the Southeastern states. At one point, 49 of the top 50 prescribers of opiates in the United States were located in Broward County, Florida. That small group of doctors who were intentionally criminal were part of the problem. The rest of it was the far larger number of doctors who were well intended but just didn't know any better.

I was on a public radio call-in program yesterday and heard multiple stories  of people with mild pain being written refillable prescriptions for large numbers of opioid painkillers.. There's a lot of that andit's irresponsible and dangerous. What happens is either the person takes all the medicine, which they shouldn't, and maybe they start then developing a problem. Alternatively, they take two pills and then there's a bunch of Vicodin or OxyContin sitting in the medicine cabinet for someone else to find: a local teenager, a friend of a friend, a guest at a party. Overprescribing and then loose storage fueled the epidemic. It's still true today. When you ask people who abuse prescription opioids, "Where do you get them?" Their usual source is friends and family, not street purchases. It's frightening, we've flooded the whole country with these things and they're everywhere.

HP: It shows harm reduction is a difficult challenge, because this market doesn't have many of the harms that we usually think of when we talk about harm reduction, and yet it produces a lot of fatalities.

KH: Right, as you know there's different types of harm. There's market harms and then there's harms down at the end of a user. For sure, there is some violence around the black market in hydrocodone and oxycodone, but since these drugs are mostly coming from people who wear stethoscopes and white coats, that's not clearly not a primary locus of violence.

The more than 16,000 overdose deaths from prescription opioids each year disproves the idea that it's easy to regulate addictive drugs if they are produced and provided legally. We can reduce the violence in markets, but we’ve paid a real cost in public health harms and in safety failures from reckless corporate behavior.

HP: Can I ask you an embarrassingly basic question? If someone like Philip Seymour Hoffman presumably had access to all sorts of prescription opioids, why does he end up injecting heroin?

KH: That's actually a good question. Cost drives many people to heroin. It's more expensive to buy oxycodone than it is to buy heroin. Presumably that was a less pressing concern for Mr. Hoffman. Perhaps the intensity of the rush of injected heroin was more reinforcing to him than opioid medications were. The prescription medications have a longer, slower cycle of action in the body. His heroin use could also be the result of habit. He had experienced a heroin problem before, many years ago. It could be that that was the drug that he knew best or was available in the networks of dealers he used. I'm speculating about somebody I don't know, but those are some possible reasons.

For most people it's cost. Add one other thing; when people lose their health insurance, they may need the opioids to manage their pain. People sometimes end up buying street drugs including heroin to manage their pain because they have lost the insurance that used to cover their pain medication.

HP: The first heroin user that I knowingly had ever met had actually hurt his back at work. He had been on pain medication. And that basically led him down the road to his use of injected heroin. Many people suffer some sort of muscular skeletal injury. Powerful prescription pain medications can set in motion a cycle which can lead to addiction or that can reinforce someone’s disabilities.

KH: This happens all the time.

HP: Downstream, there will be more people having overdoses. What can we do as a public health policy to be more effective to prevent people from dying?

KH: One thing is to equip more people with Naloxone. Naloxone is an opiate antagonist that rapidly knocks opioids out of the brain receptor to which they bind. For someone who has stopped breathing due to heroin, for example, or oxycodone, it immediately starts them breathing again. It wakes them up, and creates an opportunity for more extensive medical care. It doesn't remove the addiction, but in an overdose emergency it gives another 30-90 minutes to get someone to the hospital.

Some cities have distributed Naloxone (also known as Narcan) to police and firefighters. There are also programs that train family members. Let's say you're a mom or a dad and your teenager is addicted to heroin and might overdose at some point, you can learn how to administer Naloxone, and how to do CPR and put somebody in a rescue position.

That requires new laws, typically. If you're not a licensed medical professional  you can't legally administer prescribed medication to someone whom you find overdosed.  So when cities or states start expanding access to naloxone  they typically create regulations exempting people from that medical requirement and also from any liability, if, in good faith, they used Naloxone to try to save somebody's life.

There is also an important role here for what are called Good Samaritan laws. Suppose a group of teenagers are at a party. They're drinking and maybe popping some Vicodin or the like and then somebody falls to the floor and stops breathing. You don't want everyone to be afraid to call 911 out of worry that they'll get arrested. A Good Samaritan law would say that there would be a different kind of legal arrangement for people who overdosed or who are contacting authorities to say somebody had overdosed, so that the fear of punishment doesn't prevent the saving of a life.

HP: Would you give Naloxone to street users so that they could help each other in situations where they are the people present?

KH: That is certainly being done. If you had an infinite budget, maybe everybody should carry Naloxone, every single person. If you think about it from the point of view that we only have so much money, which is always the case, ninety percent of what is distributed directly to users is ultimately not accounted for, it's not used or it's lost. Whereas if you distribute to police, firefighters, ambulance, and other first responders, virtually none of it goes to waste. All of it gets used to save people. From that point of view, my policy preference is the one with the first responders because I know funds are always limited, and I think you're going to save more lives that way than by distributing it among users.

HP: Well the first responders should obviously have it. You could waste 90 percent of this stuff, and you still wouldn’t need to save very many lives to justify the return on investment for a small Naloxone kit. I guess the training would be expensive.

KH: If budget were no concern, you'd want to have everybody in the country to carry it.  But if you're a city and you've got a $50,000 grant to do a Naloxone access expansion program, and your police and firefighters don't have it, that's where you will probably save the most lives.

HP: So there's Naloxone and Good Samaritan Laws, what else should we be thinking about in policy?

KH: Expanding access to a range of addiction treatments. Such treatments could include psychotherapies, 12-step based treatment, and medications like buprenorphine, methadone and naltrexone. Residential options, such as Oxford House, are also important. Treatments that engage addicted people for long periods are especially valuable. As we discussed, short-term detoxes may be actually worse than nothing.

There's been more beneficial movement in this regard in the last couple years than there has in the last 50. As you know, the Affordable Care Act specifies that substance use disorder treatment must be covered as a mandatory healthcare benefit. Every single plan on the health exchanges now covers drug and alcohol treatments at the same level as other disorders.

The new expanded Medicaid provided under ACA also covers addiction treatment.  Concurrent with that, the Obama Administration has just released the regulations implementing the 2008 Mental Health Parity and Addiction Equity Act which affects employer-provided insurance.. For the more than 100 million people who receive insurance through large employers, any benefits offered for addiction treatment have to be comparable to those for other medical conditions. Because of these two laws as well some recent improvements in what Medicare covers, more people have good insurance in the public and private sector to cover addiction treatments than in any time in U.S. That's an extraordinary change in the public policy environment. It will take some time for the capacity of the health care system to catch up to it, but the coverage is now there in a way it never has been before.

HP: How about the striking number of overdose deaths among people released from correctional settings.

KH: We don’t want to incarcerate anybody that we don't have to. But many people with opiate problems are in the criminal justice system. A huge proportion of property crime is driven by people with problems with opiates. Similar statistics exist for petty theft and muggings. The challenge is to find alternatives to incarceration that manages people in the community while addressing their drug use and protecting public safety. These alternatives could be drug courts, or it could also be things like Hope Probation where people are regularly tested for drug use, and if they use they endure swift, certain but not severe consequences..

For example, maybe they have to spend just one night in jail if they go back to use, and then they're out the next day. Those kinds of programs should be used much more instead of putting drug-addicted criminal offenders in prison. If someone does endure a prison sentence of any length, then it's really critical to do the transition planning, because the death rate of people just leaving prison who are addicted to opioids is appalling. In Scotland, 1 in 200 male heroin addicts dies within 14 days of prison release.

Scotland has a worse heroin problem than we do. Nonetheless, the basic principle would apply here. The stereotype is it's easy to get drugs in prison. But it’s actually much, much harder  than it is on the street. Most people who go into prison dependent on opioids are not able to get a regular supply of opioids in prison. So they're tolerance drops dramatically. They go out of prison, maybe they're celebrating their release, they have a few drinks, they take their normal dose of opioids, and they die because they don't have the tolerance anymore to be able to have that dose in their body without shutting off their breathing.

HP: Two challenges make this issue especially difficult. One is that the systems that we have are pretty passive. When you leave jail or prison you really have to present for intervention. Of course it's just not going to happen until somebody has a crisis. We could also do a better job of preparing people for predictable risks and specifically warning them about this. Because we don't want to talk to drug users about some realities of relapse, we may not be giving them sufficient resources to protect them against overdose.

KH: There's a closely watched clinical trial under way in England, run by my friend John Strang. Heroin-addicted people leaving prison are going to be given training in overdose reversal, and a supply of Naloxone. That will be very interesting to see whether that works. I suspect that it will be helpful even if no Naloxone is ever used because it will reorient prison staff as to what their responsibilities are when somebody leaves prison. It's more than just shoving them out the door and saying, "Good luck to you…."

HP: I like that there is an actual field trial. So we have an opportunity for evidence-based policy. If you take an issue like Naloxone distribution, most people have very strong policy preferences. If you talk to people about these issues, you can go an awfully long way before anyone gets to any sentence that is in any way influenced by data. It would be nice to see what we can accomplish. I suspect the impact will be more modest than what many of the supporters are hoping, but it will be real. Most substance abuse policies are helpful but not decisive when they're effective.

KH: It's hard to change human behavior. That’s not just true in addiction. It’s also true of weight loss programs, getting people to use seat belts, and more. Fortunately, even if you can change half the behavior of half of the people, you can produce absolutely massive benefits in the public health and public safety sphere.

HP: Weight loss is a great example because we know randomized trials of diets show real benefits for some of them, but very small effects. There is also almost universal non-adherence to the strictures of any of the diets. In a way, needle exchange makes us ripe for disappointment, because it requires such minor behavior change and because people generally like new, sharp needles. If you look at almost anything else, for example trying to get people to use condoms for HIV prevention, it's a much tougher behavioral challenge.

KH: That's right. That's been the challenge for the oral version of the medication naltrexone. If you are addicted to opioids and you get buprenorphine or methadone, it's still reinforcing. You're activating opiate receptors, and that feels good. Naltrexone blocks the effect of opiates, and it's been very hard to get drug users to take that up.  It's kind of like walking into a bar and saying, "Hey, everybody, I have a pill that would make the alcohol you're now consuming not feel very good. Line up everybody, no crowding please." Nobody would give you the time of day. That medication has had a hard time getting traction just because it doesn't sound very appealing to the average opiate addict.

HP: It's very appealing if you have many other cues in your life that are raising your urgency, if you're already very highly motivated. Some of these methods are especially effective for doctors are trying to get off of opiates because they have many powerful external motivations that are further reinforcing their efforts to address the behavior.

KH: We've learned a lot from the way doctors are managed when they have an addiction. They face regular testing with swift and certain responses. A lot of people say, "Well, that's doctors, but they are different from most addicts." But it turns out that those same principles of regular testing with consequences has worked really well in tougher populations. That's the findings of Hope Probation, and for Alcohol 24/7 Sobriety too.

Diffusing those principles would be really productive, because most of these people wind up in the criminal justice system. They engage in other crimes, and the criminal justice system normally does nothing, nothing, nothing, and then suddenly brings down the hammer. We have to do a better job of responding mildly but consistently and swiftly to the drug use of people who are on probation and parole. It's a much better way to change people's behavior.

HP: Let's talk a little bit about some upstream issues. Given that these opiate medications are out there and they're being widely misused, how can we change the way we do business so that there are fewer people emerging with these addiction disorders on these medications?

KH: We need to have way-better prescribing practice. Most of that involves provider education for well-intended medical professionals. A small amount involves criminal justice actions against few really bad people who run pill mills that should be shut down. A model of what is needed most is what happened in the Puget Sound Health System. They internally decided among their own staff to take a look at how they were prescribing opioids. They met in groups, they developed consensus procedures, they took a look at providers who were prescribing at high levels, patients who were being prescribed high levels. They learned about alternative methods of pain management.  It’s a great example of responsible group practice medicine, and they were able to keep the people they were taking care of healthy while prescribing a lot less opioids. We need more examples of that around the country so that people don't think pain management always means more opioids.

We also need better ways for the public to dispose of excess of opioids. Many people don't realize that you can't legally just walk back to your doctor or your pharmacist and say, "I didn't take these 15 fentanyl tablets, can you take them?" They're not allowed to accept them. There's been some movement on fixing that in Washington, but far too slow. The DEA runs “take back prescription” days. That's fantastic, but that's one or two days a year. Disposal needs to become normative, so that when you went into Wal-Mart, for example, there would be a bin where you could just toss your extra prescriptions in, the things you didn't use.

It's kind of like where we are now is like the beginning of recycling. Recycling glass and plastic was once this weird practice that a few people did. Then maybe there were special events and special centers that did recycling. Now millions of people do it without thinking,it’s automatic. We need to make it simple so that it just becomes automatic. You'd never leave leftover medication in your cabinet. You bring it back to the pharmacist on your regular trip to the grocery store.

We could also implement better procedures around surgeries. We have 40 million surgeries a year. Something like 5 to 10 percent of those result in persistent pain, persistent opioid use, or both. That means we are potentially generating a large number of people at risk for  prescription opioid dependence.  And some of those people may end up ultimately  going to the street heroin market, as did  the person you knew with the back injury.

There's some exciting work underway that could teach us how to reduce this risk of iatrogenic addiction after surgery. The amount of pain and fear patients have right at the time of operation predicts how much pain and opiate use they'll have later.  Relaxation exercises or anti-anxiety medications administered moments before surgery could therefore produce long term benefits in terms of reduced pain and opiod use down the road.   My colleague Dr. Ian Carroll is leading a clinical trial on this question now, and along with some related studies being done around the country it could teach surgical teams  how to reduce post-operative pain and the risk of opioid addiction at the same time.   That would be a huge benefit to public health.

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