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Regulation can be painful

Summary:
In 2010, there was an growing problem of people abusing painkillers such as OxyContin.  Unfortunately, the steps taken to address the crisis may have made things even worse.  A 2018 NBER study by William N. Evans, Ethan Lieber, and Patrick Power showed that when the pills were reformulated to reduce drug abuse, people switched to other drugs such as heroin, which were even more dangerous: We attribute the recent quadrupling of heroin death rates to the August, 2010 reformulation of an oft-abused prescription opioid, OxyContin. The new abuse-deterrent formulation led many consumers to substitute to an inexpensive alternative, heroin. Using structural break techniques and variation in substitution risk, we find that opioid consumption stops rising in August, 2010,

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In 2010, there was an growing problem of people abusing painkillers such as OxyContin.  Unfortunately, the steps taken to address the crisis may have made things even worse.  A 2018 NBER study by William N. Evans, Ethan Lieber, and Patrick Power showed that when the pills were reformulated to reduce drug abuse, people switched to other drugs such as heroin, which were even more dangerous:

We attribute the recent quadrupling of heroin death rates to the August, 2010 reformulation of an oft-abused prescription opioid, OxyContin. The new abuse-deterrent formulation led many consumers to substitute to an inexpensive alternative, heroin. Using structural break techniques and variation in substitution risk, we find that opioid consumption stops rising in August, 2010, heroin deaths begin climbing the following month, and growth in heroin deaths was greater in areas with greater pre-reformulation access to heroin and opioids. The reformulation did not generate a reduction in combined heroin and opioid mortality—each prevented opioid death was replaced with a heroin death.

In addition, the government has begun pressuring doctors not to prescribe opioid painkillers.

The Economist has a graph showing that since this study, thing have gotten even worse:

Regulation can be painful

Notice that fentanyl deaths are now far higher than before the government began cracking down on painkiller use.  That’s because fentanyl is far more dangerous:

The drug’s potency makes it easy to misjudge dosage, especially for new users without a tolerance. Increasingly, counterfeit prescription pills, resembling oxycodone tablets or benzodiazepines such as Xanax, contain fentanyl. Brad Finegood, an adviser to the public-health department for Seattle and King County, says he has seen lots of unsuspecting people casually take a fentanyl-laced pill and die.

It sounds “responsible” to crack down on the abuse of addictive painkillers, but the unintended side effects may well be even worse than the original problem.  Politico has an excellent piece on the effects of cutting off pain medication to those with severe chronic pain:

Last August, Jon Fowlkes told his wife he planned to kill himself.

The former law enforcement officer was in constant pain after his doctor had abruptly cut off the twice-a-day OxyContin that had helped him endure excruciating back pain from a motorcycle crash almost two decades ago that had left him nearly paralyzed despite multiple surgeries.

“I came into the office one day and he said, ‘You have to find another doctor. You can’t come here anymore,’” Fowlkes, 58, recalled. The doctor gave him one last prescription and sent him away.

Like many Americans with chronic, disabling pain, Fowlkes felt angry and betrayed as state and federal regulators, starting in the Obama years and intensifying under President Donald Trump, cracked down on opioid prescribing to reduce the toll of overdose deaths. Hundreds of patients responding to a POLITICO reader survey told similar stories of being suddenly refused prescriptions for medications they’d relied on for years — sometimes just to get out of bed in the morning — and left to suffer untreated pain on top of withdrawal symptoms like vomiting and insomnia.

More recently, the Washington Post has an article with lots of similar stories:

Hank, 79, has had seven shoulder surgeries, lung cancer, open-heart surgery, a blown-out knee and lifelong complications from a clubfoot. He has a fentanyl patch on his belly to treat his chronic shoulder pain. He replaces the patch every three days, supplementing the slow-release fentanyl with pills containing hydrocodone.

But to the Skinners’ dismay, Hank is now going through what is known as a forced taper. That’s when a chronic pain patient has to switch to a lower dosage of medication. His doctor, Hank says, has cut his fentanyl dosage by 50 percent — and Hank’s not happy about it. He already struggles to sleep through the night, as Carol can attest.

“He’s moaning, he’s groaning, he’s yelling out in pain,” Carol says.

“Why am I being singled out? I took it as prescribed. I didn’t abuse it,” Hank says.

He is part of a sweeping change in chronic pain management — the tapering of millions of patients who have been relying, in many case for years, on high doses of opioids.

I’m not even in favor of treating a 29-year old this way, although I can sort of follow the logic.  But let’s face it, a 79-year old who’s had lung cancer and heart disease is on his last legs.  Why can’t he live out his brief time remaining without being tortured by pain?

The argument for drug regulation is that people might abuse drugs if they weren’t required to get a prescription from a doctor.  I don’t believe that the benefits of drug regulation outweigh the costs, but it’s at least a plausible argument.  But now we are saying that we don’t even trust doctors to act in the best interest of their patients. Instead, we seem to believe that DEA agents who have never met the patient should make the decision.  Here’s Politico:

“I will no longer treat chronic pain. Period,” said Sue Lewis, a primary care doctor who works in an urgent care clinic in Portland, Oregon. “There is too much risk involved,” she said, adding that if a patient doesn’t take the medications as she prescribes them, they could jeopardize her license.

Steven Henson, an emergency room doctor in Wichita, Kansas, described how his license was suspended after six patients illegally sold the medications he prescribed, without his knowledge.

“The DEA should be working with doctors when this happens,” as opposed to punishing them, Henson said.

There will never be a perfect solution to the problem of addictive drugs (including alcohol.)  We should be focusing on minimizing the damage.     In most cases, the least bad outcomes will occur when the decision making process is decentralized, with those closest to the issue making their choices.  When it comes to federal regulation, we should never lose sight of the Hippocratic oath: First, do no harm.  When I look at the soaring rate of fentanyl deaths, I suspect that our regulatory regime hasn’t even met that minimal threshold, and that’s not even counting the cost of pain that is no longer being managed.

PS.  I wonder if the attempt to demonize drugmakers has contributed to our policy overreaction.  The same issue of The Economist has a review of a new book that critiques the role of the Sackler family, which controls the drugmaker that introduced and promoted OxyContin:

Shiftless third-generation types are rendered with evident loathing, skilfully skewered by their own words in court or by Mr Keefe’s (anonymous) sources. One aspiring fashionista wishes an obstreperous journalist would focus less on her last name and more on the hoodies she designs.

Really?  Is it unreasonable to want people to judge you on your career and not on your last name?  During the Chinese Cultural Revolution, people were punished because their parents had been capitalists.  I thought we were beyond that sort of guilt by association.

Scott Sumner
Scott B. Sumner is Research Fellow at the Independent Institute, the Director of the Program on Monetary Policy at the Mercatus Center at George Mason University and an economist who teaches at Bentley University in Waltham, Massachusetts. His economics blog, The Money Illusion, popularized the idea of nominal GDP targeting, which says that the Fed should target nominal GDP—i.e., real GDP growth plus the rate of inflation—to better "induce the correct level of business investment". In May 2012, Chicago Fed President Charles L. Evans became the first sitting member of the Federal Open Market Committee (FOMC) to endorse the idea.

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