Medicare officials have announced plans to crack down on prescriptions for opioids in an attempt to limit their use and thus their damage. But making it harder for people to get pain medication legally will most likely drive many to seek relief from far more dangerous and superpotent synthetic opioids. And they are surprisingly easy to obtain.
Recently, out of curiosity, I typed into Google the terms “synthetic opioid and Chinese pharmacy.” Within minutes, I found a website where I could purchase the synthetic opioid carfentanil. For just $750, I could buy 100 grams of the drug, which would be shipped to me “overnight by discreet courier.”
Carfentanil is 100 times more potent than fentanyl, another synthetic opioid that has already hit the streets, and 10,000 times more powerful than morphine. This drug is typically used to sedate large animals, like elephants. It is so dangerous that when veterinarians administer it, they wear gloves and face masks to avoid exposure.
Fentanyl is scary enough. A dose of two milligrams — a few grains of the substance — can be fatal. But with carfentanil, 0.02 milligrams — hardly more than a speck of dust — could be enough to kill a person. That means that for $750, I could in theory purchase enough carfentanil for five million fatal overdoses.
Americans are by far the largest consumers of the world’s natural and synthetic opioids, and 116 of us are dying every day as a result. Carfentanil could unleash a wave of mortality that would dwarf these numbers.
The drug naloxone, which can reverse prescription opioid and heroin overdoses, may not be effective against potent synthetics. So there may be no way to stop these new opioids from killing people.
We are just beginning to see the leading edge of the synthetic opioid epidemic. For example, in Ohio, fentanyl-related deaths surged from 75 in 2012 to 1,155 in 2015. Although synthetic opioids are relatively easy to make in back-alley labs, a majority of them are coming illegally into the United States from China, where the chemical and pharmaceutical industries are poorly regulated.
China is the world’s largest exporter of active pharmaceutical ingredients, with more than 160,000 chemical companies operating legally and illegally. President Trump, who is not afraid to flex his muscles, should apply a stiff tariff on all Chinese pharmaceuticals to encourage the government to crack down on the production of illegal drugs.
It will be hard, if not impossible, to shut down the supply, but we have to try.
On the demand side, we can do things to try to prevent addiction. But the new Medicare guidelines, which cover disabled individuals and those 65 and older, would only make things worse.
They would deny coverage to any patient taking more than 90 milligrams of morphine or the pharmacologic equivalent daily for more than seven days, except for those with cancer or in hospice (an exemption from this guideline is possible but burdensome). The Centers for Medicare and Medicaid Services estimate that some 1.6 million Medicare beneficiaries are prescribed opioids that meet or exceed this arbitrary threshold, so the change, if it goes into effect as planned next January, will suddenly put a very large number of people at risk of severe opioid withdrawal and the return of pain and suffering. This could well drive many of them to synthetic opioids.
Instead, we need a rational drug policy both to rein in the excessive prescribing of opioids and to help the people who are already dependent on them.
First, we need a national prescription database. The state-level databases that we have now are not enough. They allow clinicians to identify patients who “doctor shop” and are high consumers of opioids, but patients can still fill their prescriptions in nearby states, and no one is the wiser.
We also have to deal with doctors who contribute to the epidemic. The Drug Enforcement Administration, using that national prescription database, should identify clinicians, particularly those who aren’t pain specialists, who are outliers in their opioid prescribing patterns, review their treatments and clamp down on inappropriate and excessive prescribing.
This is tricky; we do not want to discourage doctors from adequately treating pain out of fear of legal sanction. But those who adhere to current standards of care should have little to fear.
Finally, reasonable drug policy has to take account of the fact that opioid-dependent individuals have different levels of tolerance, which means there cannot be a one-size-fits-all guideline, like the Medicare proposal, to limit prescribing.
To be sure, there is solid evidence that nonopioid treatments are safer and just as effective as opioids for certain types of chronic pain — and it’s critical that we improve pain education for all health care professionals so this becomes common knowledge.
But for those who are dependent on opioids, doctors must have the ability to adjust treatment to the neurobiological and clinical reality. The fact is that an opioid-dependent brain requires considerable time to adapt to any change in treatment.
Any opioid policy that ignores this will not just throw an untold number of people into withdrawal and misery; it could well unleash a synthetic opioid epidemic of staggering lethality.
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