When it Comes to Stopping Opioid Misuse and Diversion, the Emperor Is Naked!

April 25, 2014
B. Eliot Cole, MD, MPA

Do National Prescription Drug Takeback Programs really make an impact on opioid misuse and diversion? Why doesn't the DEA go after people who overdose on opioids that were probably diverted?

On Saturday, April 26, 2014, the US will hold its 8th Annual “National Prescription Drug Take Back Day” in which Americans will be asked to dispose of their unwanted medications. The goal of this program is to remove controlled substances (opioids) from medicine cabinets of millions of Americans that are commonly diverted to the streets. On paper, this makes some sense; if grandma isn’t stockpiling opioids for some rainy day her grandson or granddaughter can’t take her medications for recreational or other purposes. If Bubba doesn’t sell his extra opioids, muscle relaxants, and benzodiazepines to his fishing buddies perhaps fewer of them will die when they overdose on them.

In reality, there’s little evidence National Prescription Drug Take Back Programs make any meaningful difference, and sadly Americans keep overdosing and dying at record levels. A diligent search of the Internet (including the DEA’s own diversion website) using a variety of search terms found no actual data that controlled substances are being taken away from anyone. In fact, one article published in the Portland Press Herald suggested that the DEA itself does not want such determinations to be made, as pill counting by pharmacy students may lead to even more opportunity for diversion!

National Prescription Drug Take Back Programs remind me of airport safety programs. I may stand in long lines; take off my shoes, coat, and belt; and empty my pockets and allow full body scanning while some 16-year-old kid hops a fence and climbs into the wheel well of my airplane. Do takeback programs really take back meaningful amounts of controlled substances? Are there better solutions for curbing the opioid overdose problem?

Do you know that the DEA never prosecutes people who overdose on opioids? The DEA never asks those who overdose to produce a prescription to establish that opioids were lawfully obtained. The DEA never prosecutes grandma for leaving her opioids on the kitchen table, nor does it prosecute the grandson or granddaughter who takes the medication for non-medicinal reasons. The DEA has no idea when naloxone is used in an ER. When I asked DEA representatives why such obvious efforts directed at low-hanging fruit were never done, I was told it was too difficult to prove intent!

I am not the sharpest tool in the shed, but if my son or daughter is brought into an ER unresponsive, not breathing well, with pinpoint pupils, and then recovers after receiving naloxone, but doesn’t have a lawful prescription for an opioid, shouldn’t someone connect the dots and assume that the source of the drug taken was probably illicit? This is shooting fish in a barrel, isn’t it? How much easier could it be than asking someone who just recovered from an opioid overdose to prove that he or she had a lawful opioid prescription?

In the US the only thing a drug abuser has to fear is overdosing if the quality is too good or the amount taken exceeds tolerance. There’s no criminal prosecution of end consumers, even if the source of the drug taken was diverted. No American faces prosecution for sharing medications with family members, unless the family member is a small child (then child protective services may have jurisdiction). We expect medication sharing within families, we never throw away controlled substances, and we believe that medications we paid for are ours to use as we wish, right? Welcome to America where the streets are lined with gold, there’s a chicken in every pot, and no one lacks for opioids, muscle relaxants, benzodiazepines, barbiturates, marijuana, or anything else!

Yes, I am being completely sarcastic! I do hope that National Prescription Drug Take Back Programs work. I don’t want my children or grandchildren to overdose on my opioid-containing or other controlled substance medications. I do my best to keep my medications secure and unavailable to those who enter my home. I have twice done ER/LA opioid REMS training to be a better and more thoughtful prescriber.

We should encourage our patients to properly dispose of their unused medications and explain to them the risks of casual storage. We should tell aging Americans that their grandchildren may be looking for controlled substance medications for purposes of experimentation and intoxication.

We are in the midst of an epidemic and people are dying. We may eventually legalize marijuana in America (state by state), but I don’t know of an established LD50 for that drug, and there’s no reversing agent commercially available. In the meantime, we need to make naloxone readily available for anyone who wants it and provide appropriate training for its use (which could conceivably be everyone dispensed an opioid).

What do you think? Send your comments to Editors@HCPLive.com.

B. Eliot Cole, MD, MPA, is a member of the Pain Management editorial advisory board. He has served in executive positions for several prominent pain management organizations and societies, including the American Society of Pain Educators and the American Academy of Pain Management. He has been a pain management fellow, clinician, educator, and advocate for nearly 30 years and has practiced in a variety of settings serving a wide range of patients.