by Stephen Lamb, M.D.
“It would be hard to think of an area of U.S. social policy that has failed more completely than the war on drugs.” So begins The Fix, by Michael Massing, a book that chronicles U.S. federal drug policies over the last 40 years!
Most of these failed, but there is one success which has implications for our current epidemic in Kentucky:
In the early 1970s there was an epidemic of heroin addiction in U.S. cities. Increases in drug-related crime and disease such as hepatitis B accompanied this outbreak. President Richard Nixon, campaigning for re-election in 1972, had promised to reduce crime. Nixon lacked sympathy for addicts. He felt that drug dealers should receive the death penalty. He initially hoped that reducing the supply of heroin from overseas would stem the epidemic. However, at a meeting with John Ingersoll, the official in charge of interdiction, “Ingersoll told Nixon that seizures of heroin were up, arrests were up and more investigations were under way. The president then said: ‘Let me ask you this, are we taking one step forward and two steps back? Is there any less narcotic coming into the United States? Are we solving the problem?’ And there was just silence.
Convinced that interdiction alone could not solve the problem, Nixon allowed the establishment of methadone clinics in cities across the U.S. The results were dramatic. Drug-related crime, overdose deaths and hepatitis B dropped significantly. During that time the number of federal and state inmates surprisingly fell. Nixon had kept his campaign promise and was handily re-elected.
The Problem in Kentucky
According to researchers at the University of Kentucky, of over 4 million Kentucky residents, more than 5 percent, or at least 200,000 people misuse prescription painkillers such as OxyContin, Lortabs, Vicodin and Percocet, which are similar in their chemistry to heroin.
“Misuse” can mean anything from casual recreational use to severe addiction with compulsive daily use and an inability to stop using. Extrapolating from other data there are at least 40,000 people who have this severe addiction. Neither detoxification nor 12-step programs nor incarceration will stop people from using prescription opiates. In addition, the cost of these drugs runs $20,000-$30,000 per year or more. Thus, it is not surprising that the vast majority of crime (doctor shopping, altering prescriptions, selling pills to purchase more pills, and stealing to afford pills) is committed by this group of people. Most of these people are hard working family oriented citizens who are driven by their addictions to commit crimes.
Some Possible Solutions:
Stopping supply
Impressive gains have been made in closing Kentucky’s “pill mills.” However, people are now going to Florida to get pills. When the supply in Florida is stopped, there will still be many other places, such as Mexico, where narcotics can be obtained. Since most data indicates that a prevalence of pain killer addiction is increasing, especially in young people, it does not seem likely that stopping the supply alone will solve this problem.
Incarceration
What if we incarcerated all 40,000 hard-core addicts (who are responsible for most drug-related crime)? This would certainly reduce criminal activity but would cost at least 100 million dollars a year, As we cannot afford to hold the 20,000 or so people already in jail or prison, it would be difficult to afford further incarcerations. In addition, most evidence suggests that the vast majority of this population return to drug use and related criminal activity once they are released.
Drug Court
Drug court is offered to non-violent drug offenders in Kentucky. It incorporates drug testing, drug counseling, mandatory 12-step meetings and obtaining court approved living situations. Persons who do not adhere to drug court regulations can be incarcerated. Those who graduate from a drug court program may have their records expunged and are much less likely to re-offend. There are presently over 3,000 graduates and 2,800 current enrollees of drug courts in Kentucky. This system can work very well for users of marijuana, cocaine and casual opiate users. Unfortunately, the severe opiate user cannot abstain for prolonged periods of time. Kentucky drug court policy forbids the use of the only two FDA approved medicines which can successfully treat severe opiate addiction (methadone and Suboxone). This means that the chances of these severely addicted persons be properly treated in Kentucky drug courts are slim. Research on this is scarce but it appears that most of these people relapse to prescription opiates and are quickly incarcerated.
Legalization
What if it were suddenly legal to use any opiate without fear of punishment? The answer of this can be found in the history of alcohol prohibition in the United States. During prohibition the amount of alcohol-related diseases declined in the United States. Simultaneously, organized crime flourished. When prohibition was repealed, criminal activity declined but alcohol-related diseases rose dramatically, Since opiates are for most people at least as addicting as alcohol, it seems safe to assume that complete legalization in prescription pain killers would result in even higher numbers of addicted persons then is presently the case.
Medication-assisted Treatment: Methadone
In this modality, patients attend clinics in Kentucky (daily for at least first 90 days) and receive a therapeutic dose of methadone: that is, enough methadone to stop withdrawal symptoms and the preoccupation with drugs but not enough to cause sedation. Freed from the constant search for drugs, the patient is able (and required) to begin prosocial activities such as working, parenting and getting an education. Mandatory counseling for learning stress management and achieving a drug-free lifestyle is given on site. Random observed drug screenings are obtained.
In Kentucky 85-90 percent of people who begin methadone-assisted treatment are still in treatment one year later. They have stopped using drugs almost completely and no longer commit drug-related crimes. There are approximately 2,000 people on methadone treatment in Kentucky today. There are several drawbacks to methadone-assisted treatment. As it requires daily attendance and there are only a few clinics in the state, it is difficult for people who are employed to get to work on time. While receiving methadone under medical supervision in a clinic is quite safe, if the patient chooses to take drugs such as Xanax, Valium or alcohol while on methadone it could be dangerous or even lethal. Sometimes methadone can be diverted to the street.
The standards of care in methadone clinics vary widely from state to state, However, under the watchful eye of Michelle McCarthy, director of the State Narcotic Authority, Kentucky’s clinics are among the best in the nation and are emulated by other states attempting to improve their patient care. In spite of this, methadone maintenance tends to be viewed with great skepticism by many prosecutors, judges and law enforcement personnel. I believe this is because they tend to see only the few who have failed treatment by mixing methadone with other drugs, or those who are arrested for driving while impaired or selling their methadone. They tend not to see the 85-90 percent who are drug free, working and parenting.
Suboxone
In 2000, Congress passed the Drug Addiction Treatment Act which allowed physicians to treat opiate addicted patients using the medication, Suboxone. There are currently about 5,500 patients in Kentucky being treated with Suboxone. Like methadone, Suboxone stops withdrawal symptoms, stops the persistent drug craving and frees the individual up to begin living a normal lifestyle. This medication has several advantages over methadone. It causes little, if any sedation and is much safer in overdose. Rarely produces any euphoria and is much less likely to be abused. Another advantage is that Suboxone can be obtained in a doctor’s office, eliminating the stigma of going to a methadone clinic. Some drawbacks to treatment with Suboxone are that is relatively expensive ($2,000-$8,000 per year) and as mentioned above, there are not nearly enough treatment slots available to fit the need (there are currently about 100 doctors prescribing Suboxone in Kentucky and each one is legally limited to a maximum of 100 patients.) Finally, some severe addicts benefit from the structure provided by methadone clinics.
Ending the Epidemic
It seems clear that neither interdiction alone nor mass incarceration nor drug courts in its current form and size nor legalization can end this epidemic. How then? If The Fix is any guide, the only conceivable way it can be done is for treatment to be available to the 40,000 or more people severely addicted to opiates. The two ways this could be done would be to establish more methadone clinics and to have more physicians prescribing Suboxone. If these measures are undertaken, the epidemic can end.
Stephen Lamb, M.D.
