Hearing on Prescription Drug Abuse: Obama's Got a New Plan

The House Committee on Energy and Commerce held a hearing yesterday on the menace of prescription drug abuse. Who testified? Drug Czar Gil Kerlikowske (written testimony here) and DEA chief Michelle Leonhart (testimony here.) What did they say? Aside from providing a bunch of questionable statistics, the Obama Administration, through the DEA, is planning on ratcheting up the war on pain medication. The plan will be unveiled as early as next week, as the 2011 National Drug Control Strategy. (You can get the gist from the proposed 2012 budget for drug control policy which the White House summarized here, here and here.)

Here's the 227 page, $15.5 billion 2011 Federal Drug Control budget, which covered Obama's 2010 National Drug Control Strategy. The DEA's 120 page proposed 2012 budget submission and justification is here. There's 2,044.7 million for domestic enforcement, $322 million for diversion, $433 million for international enforcement. [More...]

On page 7:

DEA requests 124 positions, including 50 Special Agents, 50 Diversion Investigators, and 9 Intelligence Analysts, and $30,885,000 to support regulatory and enforcement activities of the Diversion Control Program. This request includes $9,393,000 in non-personnel funding for rent, task force officer overtime, administrative support, and training for Tactical Diversion Squads (TDS). These resources will support DEA’s efforts to fulfill both the regulatory control and enforcement aspects of the Diversion Control Program.

Expanded details for the budget on prescription drug enforcement begin on page 70. The reasons for the increased amounts sought are on page 78. The increases are broken down beginning on page 101.

The Department of Justice share of the 2011 drug budget takes up 34 pages. For its Organized Crime Drug Enforcement Task Force (OCDETF) Program, it got $579 million. By function: $362.7 million went to investigations, $168 million went to prosecutions and $48 million went to "intelligence." By agencies involved in OCDTEF, the DEA got $220 million, the FBI got $149 million and ATF, got $14 million. U.S. Attorneys (prosecutors) got $162 million. (This doesn't include the OCDTEF amounts for ICE, the IRS, or the Coast Guard, which are funded with direct appropriations of the Departments of Homeland Security and Treasury.)

The 2012 DOJ OCDTEF numbers are here.

More from Kerlikowske on the Obama approach is here.

As an aside, just how many DEA agents are there? From the 2012 budget justification:

DEA has approximately 6,000 sworn domestic law enforcement officers, of which 3,800 are onboard DEA special agents and 2,200 are cross-designated, state or local Task Force Officers (TFOs). These TFOs work full time with DEA and comprise more than one-third of DEA’s entire domestic investigative workforce.

Back to yesterday's hearing: Also testifying were Florida Governor Rick Scott, who is backtracking off his opposition to Florida's prescription database program and Kentucky's Governor Steve Beshear. Other witnesses included several parents of deceased children and spokespersons for pro-drug war organizations, one of which is channeling MADD: Mothers Against Prescription Drug Abuse.

Was anyone allowed to speak for pain patients? The lone voice opposing the crowd of drug warriors was Patrick Coyne, RN, MSN, Clinical Director, Thomas Palliative Care Unit, Virginia Commonwealth University Medical Center on behalf of the Oncology Nursing Society. I recommend reading his testimony.

There are plenty of issues with this expanded war on pain medications and doctors. The prescription monitoring databases are huge civil liberties intrusions. The tactics used against so-called pill mills as well as pain doctors and even patients are straight out of the playbook of the War on Drugs:

  • aggressive undercover investigation and undercover buys,
  • asset forfeiture, take everything they have, cars, houses, office buildings, jewelry
  • informants – bust the "addict" patients and squeeze until they give up the doctors
  • oppose bail for doctors to increase quick plea deals
  • get warrants for searches of doctors' offices and computers, patient records, bank records and residences. Leave no stone unturned.
  • partner up with state law enforcement: share information and conduct joint investigations through the DEA Tactical Diversion Squads.

Here's some reading from the side not represented at yesterday's hearing: CATO Policy Analysis: Treating Doctors as Drug Dealers, The DEA’s War on Prescription Painkillers. Especially read the section on the DEA's flawed conclusions from available data on prescription drug-related deaths. And on law enforcement's fundamental misunderstanding of the differences between addiction, tolerance, and dependence. And on the erroneous statistics on risk of death associated with OxyContin.

Pain experts maintain that:

  • Properly prescribed and used opioids rarely, if ever, lead to addiction.
    there is no upper limit of safety for opioid dosages. "[A]s long as the dose is [started] low and increased gradually, large doses [may] be taken [and are] limited only by adverse [side] effects."
  • Unlike non-opioid analgesics, opioids do not cause damage to major organs.
  • Different patients require different amounts. The correct amount is what reduces or eliminates the patient's pain without unacceptable side effects.

[Added: on the distinctions between tolerance, physical dependence and addiction:]

Tolerance results when exposure to a drug leads to a reduction in one or more of the drug's intended effects over time so that an increased dose may be required to maintain the same physiological effects.

Physical dependence is a condition manifested by withdrawal symptoms when a drug is abruptly terminated or reduced in dose.

Addiction, in contrast, is a condition resulting in "impaired control over drug use, compulsive use, continued use despite harm, and craving."

While most individuals receiving opioid therapy do develop physical dependence, many studies confirm that patients treated with narcotics rarely become addicts.

The therapeutic approach believes the number of pills consumed is not an appropriate measure. Doctors must be allowed to trust the patient's reporting of pain and individualize the patient’s treatment. Law enforcement, on the hand, has moved to the view that patients complaining of pain who need large volumes of medication are likely addicts or diverters and, therefore, prescribing to them is not a legitimate medical purpose.

One last link for now: Dr. Frank Fisher (a doctor who was prosecuted and acquitted) on The Criminalization of Pain Management.

Next Tuesday, Kerlikowske is scheduled to release a "national action plan" to address the prescription drug abuse epidemic. Hope and change? Not where the War on Drugs is concerned.

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    i hope funding for (5.00 / 1) (#1)
    by observed on Fri Apr 15, 2011 at 06:54:50 AM EST
    This does not take funding away from the critical need for more sex stings with fake underage boys and girls

    Totally off-topic (none / 0) (#23)
    by sj on Fri Apr 15, 2011 at 11:56:54 AM EST
    but not a current open thread.

    Has anyone checked out today's Google home page?  

    (Sorry for attaching to your comment observed, but I was just too delighted for words.)


    there will be an open thread soon (none / 0) (#25)
    by Jeralyn on Fri Apr 15, 2011 at 12:02:21 PM EST
    Please discuss this there when it opens. Thanks.

    We have a fiscal crisis, that needs every dollar (5.00 / 1) (#2)
    by SeeEmDee on Fri Apr 15, 2011 at 06:58:34 AM EST
    we can scrounge...and we still have money for the War on Drugs lunacy?

    Every dollar spent on this farce is a dollar not spent on Unemployment Insurance for the 99ers, elder care, food stamps, school lunches, hospitals, roads, etc. on and on and on, but we are going to blow billions more after the estimated 1 Trillion-with-a-'T' we've already poured down the crapper in this modern-day 'Children's Crusade' cum witch-hunt?

    Where are the so-called 'progressives'? Why aren't they raising holy Hell about this continued fraud on the taxpayers? We need doctors and teachers, not more DEA agents.

    I'm so (5.00 / 2) (#3)
    by Ga6thDem on Fri Apr 15, 2011 at 07:47:46 AM EST
    tired of this nonsense. Good grief. Does anyone in Washington care about JOBS!!!

    They love jobs... (5.00 / 1) (#6)
    by kdog on Fri Apr 15, 2011 at 08:18:45 AM EST
    dirty jobs...cops, prosecutors, drug lab techs, prison guards, probation officers, and assorted tyranny support staff.  One of the few ever-growing employment sectors.

    If you don't mind lacing up jackboots and f8cking with people they'll find a job for ya...if you want a job doing something positive you're outta luck, thats when we're reminded we are broke.



    Well (none / 0) (#7)
    by Ga6thDem on Fri Apr 15, 2011 at 08:31:17 AM EST
    you should like the fact that even here in GA they are cutting back on prisons.

    Now if they'd just un-privatize them, they'd probably save a ton of money.


    Glass half full.. (none / 0) (#10)
    by kdog on Fri Apr 15, 2011 at 08:58:30 AM EST
    States don't have the ability to print money or borrow as easily as the feds...we might actually close a couple prisons in NY too...and less state/local mercenaries are being hired to do the dirty.

    Unfortunately that doesn't appear to be the federal trend...no federal credit limit for tyranny, only humanity.


    Makes me so sad (5.00 / 2) (#4)
    by Militarytracy on Fri Apr 15, 2011 at 08:02:44 AM EST
    My spouse with RA probably has some stuff that they flip out about on hand.  He ONLY ever takes any of it if he has to.  He does not like taking it, it has its own set of side affects.  He can't function some days without it though.  He hurts too much.  When Josh has surgery I have to fight with him sometimes to take the codience, he hates it.  He will have to start taking valium on his next surgery because he is beginning to have too much surgery anxiety and is then throwing up all morning from nerves before he goes in.  Yesterday another mom I know whose daughter just had another extension surgery for her scoliosis was going through the same thing too, she was refusing her pain meds one day out of surgery, and that is a lot of stress to deal with because when the pain breaks through it takes awhile to get back on top of it and lots of crying.  But all they can think about is the people who might take any of it who don't need it.  When they begin to make it even harder for those who need it to get it, then they have lost their damned minds utterly.

    It's their typical thinking (5.00 / 2) (#16)
    by sj on Fri Apr 15, 2011 at 11:27:37 AM EST
    But all they can think about is the people who might take any of it who don't need it.  

    Remember why HAMP was created instead of HOLC? Didn't want help homeowners in trouble because some "unworthy" homeowners might benefit.

    Their starting position is that there are more malingerers than chronic pain sufferers.  And more fraudulent homeowners than honest homeowners.  

    It's a variation on Bush's "Poor people are lazy" attitude.  The idea that most people involved are corrupt and are trying to game the system and those who need the assistance are very few.


    For the life of me... (5.00 / 1) (#18)
    by kdog on Fri Apr 15, 2011 at 11:34:55 AM EST
    I can't understand why the puritans care if people pop pills for fun....its not their liver, kidneys, or life.

    And there are certainly worse hobbies that do society more harm...like day trading or shooting wolves from helicopters.


    I think it's mostly because.. (none / 0) (#21)
    by sj on Fri Apr 15, 2011 at 11:47:13 AM EST
    ... the puritans don't believe in fun.  Certainly not for you.  And their fun has always been in hidden in darkness.

    It's been that way since the Mayflower.


    Textbook... (none / 0) (#24)
    by kdog on Fri Apr 15, 2011 at 11:59:54 AM EST
    Don't tread on me, tread on them...say no more:)

    So more money (5.00 / 1) (#5)
    by Zorba on Fri Apr 15, 2011 at 08:15:34 AM EST
    for this, but they want to cut everything that actually helps people.  Add this to the calls for cutting Medicare (I don't think that Ryan's privatization plan will ever be adopted, but I do think that they will make big cuts to Medicare) and what you get is:  "Let's kill Grandma, but let's also make sure that, while she's dying, she dies in excruciating pain."  Sorry for the bitterness, but this Administration and its skewed priorities are making me crazy.

    I think this is supremely silly, but (5.00 / 2) (#11)
    by andgarden on Fri Apr 15, 2011 at 09:40:00 AM EST
    Properly prescribed and used opioids rarely, if ever, lead to addiction.

    Really? I'm skeptical. I'm sure I know of people (if I don't know them) who found themselves continuing to take, e.g., the Percocet long after the pain wore off.

    Color me skeptical, too. (5.00 / 1) (#13)
    by Anne on Fri Apr 15, 2011 at 10:09:10 AM EST
    My son-in-law, who had a herniated and bulging disk that was compressing his sciatic nerve, spent several months taking prescription pain medication while hoping the problem would resolve; after his successful surgery, he had to wean himself off of them and says there's no question in his mind that while he may not have had a mental addiction to them, he certainly had a physical one.

    I think it's something that ought to be handled on a case-by-case basis, and the vast majority of providers and patients should not be made to feel like criminals, or forced to justify care for something that simply cannot be measured by anyone other than the person who is afflicted by it.

    I have a high tolerance for these medications, and a Type A personality that hates feeling out of control; when I had my second child via C-section, the nurse caring for me afterward kept opening the door to my room so the other nurses could see the woman who didn't want pain medication.  When I dislocated my shoulder again five days after I originally did it, they used a combination of Fentanyl and something else to "consciously sedate" me before putting my shoulder back in the socket; when, after 20 minutes of delivering the medication in larger doses, I was still sitting up talking to them, they decided I could not possibly be feeling any pain, as they had had big, burly truck drivers go into respiratory failure with doses that large.

    They also told me they had had prisoners from the local jail deliberately dislocate their shoulders so that they could get the drugs.

    We're all different; we feel pain differently and respond to medication differently.  

    Let doctors be doctors.


    Indeed (none / 0) (#14)
    by andgarden on Fri Apr 15, 2011 at 10:13:31 AM EST
    I'm not a fan of opiates myself. My very limited experience is that they give me an upset stomach.

    I am a fan... (5.00 / 1) (#15)
    by kdog on Fri Apr 15, 2011 at 10:33:24 AM EST
    and they have addictive qualities...to be sure. Physically and mentally...ya gotta be careful.  I also personally know a couple people who became dependent.

    One thing for sure though...nothing a prosecutor or police officer can help with...but they sure can make a bad situation worse for those that have a problem, or create a problem for those managing pain (or catching a buzz) who are not addicts.



    You made me remember that (none / 0) (#30)
    by Militarytracy on Fri Apr 15, 2011 at 05:46:04 PM EST
    I became physically addicted to nursing my son :)  Nursing kept weight on him and most babies with his syndrome end up on feeding tubes. He didn't though, and after a year I stopped nursing him because his muscles to swallow were weak and his speech therapist felt it was time for him to work on those and nursing was allowing him to keep them weak.  A few weeks later though I was shopping and the store was packed and this guy cut in line in front of me and was really hostile and rude.  I thought to myself that everything will be okay, I will go home and nurse Joshua....then I realized that I had become addicted to the hormone oxytocin that your brain releases when you nurse :)

    Agreed (none / 0) (#12)
    by Dadler on Fri Apr 15, 2011 at 09:51:49 AM EST
    Claiming opiates aren't addictive is about as ridiculous as you can get.  My grandmother was so hooked on them they all but fried her brain.  

    That said, if we're so concerned about people's health...wouldn't single payer be a good thing?

    Our absurdities, our stupidity, our utter hypocrisies are really unmatched in the modern world.


    It would be ridiculous... (none / 0) (#33)
    by Romberry on Sat Apr 16, 2011 at 10:25:58 PM EST
    ...if that was the claim. But that isn't the claim. Did you read something different outside of what was posted?

    Yeah (none / 0) (#17)
    by sj on Fri Apr 15, 2011 at 11:31:52 AM EST
    I had to read that few times because it so did not compute.

    Having said that, I have no problems prescribing the proper amount of medication to alleviate pain -- addiction be d@mned.  It leaves me completely frustrated that so many of our brothers and sisters, fathers and mothers have to die in pain because God forbid they get addicted to the meds.  


    The distinctions (none / 0) (#19)
    by Jeralyn on Fri Apr 15, 2011 at 11:35:22 AM EST
    I probably should have included this in the post as to the distinctions between tolerance, physical dependence and addiction to explain the sentence, "Properly prescribed and used, opioids rarely lead to addiction." Hope it clears up the confusion.

    From the literature:

    Tolerance results when exposure to a drug leads to a reduction in one or more of the drug's intended effects over time so that an increased dose may be required to maintain the same physiological effects.

    Physical dependence is a condition manifested by withdrawal symptoms when a drug is abruptly terminated or reduced in dose.

    Addiction, in contrast, is a condition resulting in "impaired control over drug use, compulsive use, continued use despite harm, and craving."

    While most individuals receiving opioid therapy do develop physical dependence, many studies confirm that patients treated with narcotics rarely become addicts.

    After some of my surgeries, (5.00 / 1) (#20)
    by jeffinalabama on Fri Apr 15, 2011 at 11:46:05 AM EST
    being stepped down from morphine to oxycodone or the like, I had serious withdrawal syptoms from the morphine drip. However, I didn't become hooked to the pills.

    I'm certain that there's a thought within the government that a) anyone with dependence is addicted, b) addicts can't quit, and c) addicts have to commit crimes to feed this addiction they can't quit.

    I'd venture to say that few of the drug puritans ever had cronic pain from injuries or wounds.


    Agree (none / 0) (#22)
    by Madeline on Fri Apr 15, 2011 at 11:54:04 AM EST
    If you've taken opiates, you know immediately that it is a feeling that your would love to keep on having. Not that you become addicted, but the brain always remembers.  

    Prescribing is not an exact science and there are many mistakes in diagnosis and providing that cocktail of meds takes time and trial. It's very complex and time is not on the physicians side. time is money and for psychiatrists, money frequently wins. The patient is the loser in this match because these drugs have to be monitored closely.

    There was much written and discussed about the recent crack down on pill mills in South Florida.
    Most were pill mills, just go in with a script, Photoshopped or stolen and you could get anything you wanted.  Oxy of course was the main drug frequently described as having the same effect as heroin. Yes, they were run by doctors and yes they were pill mills. BTW Oxy's street value is around $98.00 a single pill and a bottle of /40/40 mg is around $2000.


    the only difference between (5.00 / 1) (#26)
    by Jeralyn on Fri Apr 15, 2011 at 12:10:52 PM EST
    between OxyContin and oxycodone is that OxyContin is a 12 hour time release. Oxycodone is the main ingredient in Percocet, Percodan, Tylox, etc.

    Absolutely not (none / 0) (#27)
    by me only on Fri Apr 15, 2011 at 02:08:27 PM EST
    after a serious burn injury I was on opiates.  I hated it.

    I'm surrounded by people who (none / 0) (#28)
    by Militarytracy on Fri Apr 15, 2011 at 05:32:49 PM EST
    seem to have zero chance of ever being addicted to pain meds.  If it requires a genetic predisposition, they don't have it....and my family history of substance addiction is less than stellar :)  Sure there are probably a very small percentage of people out there who become addicted, but this isn't how you handle that.  This demonizes medications that are needed, and throwing people who become addicted in jail is really pathetic and does nothing to actually address their problems.  I'm surrounded by the stuff, Joshua has a bottle that goes unfinished once every six months and my husband has really really good Rush Limbaugh chit.  The military gives him a 90 day supply.  I have plenty of access and nobody pays any attention around here and the only thing I've managed to become addicted to is coffee, coffee, coffee, margaritas, dogs, flowers, and comuputers :)

    I am not sure what the answer is (none / 0) (#8)
    by lilburro on Fri Apr 15, 2011 at 08:54:50 AM EST
    but the abuse and illicit trade/acquisition of opioid painkillers seems to have increased substantially in the past decade.  Not that it justifies whatever the DEA wants to do or ends up doing.

    Here's my proposal: (none / 0) (#9)
    by observed on Fri Apr 15, 2011 at 08:54:55 AM EST
    Declare marijuana legal, and release all non-violent pot users from prison.
    This will lead to a cut in prison jobs, but the luckless guards can work on the pot farms, where they might finally chill out a little.

    How many people use opiods (none / 0) (#29)
    by Militarytracy on Fri Apr 15, 2011 at 05:36:00 PM EST
    because someone they know can legally obtain them who would use pot instead if it could be legally obtained?

    I have a friend... (5.00 / 1) (#31)
    by MileHi Hawkeye on Fri Apr 15, 2011 at 07:59:23 PM EST
    ...with serious degenerative joint issues.  A few years younger than me and already several joint replacement surgeries.  He had a MM card, but was in a car accident in a rental and work found out about it.  He had to quit and went on PK's.  Told me that he'd forgotten how much pain he was in until he stopped smoking and started on the pills.

    I'm the opposite.  Different strokes.

    One thing for sure--when you're in constant pain, whatever works for you is what's right. Nobody should have the right to make that decision for you--especially the drug warriors.  


    Honesty is best (none / 0) (#32)
    by diogenes on Sat Apr 16, 2011 at 12:57:47 AM EST
    Even the I the troll locally advocate for legalizing ALL drugs, but it is because the associated criminality is massively disrupting society here and governments abroad as well as diverting police resources from prosecuting violent crimes.  I never present anything but a professional opinion that legalization will be a health catastrophe nevertheless.  Those of you who say that it is no worse than alcohol or cigarettes are right, and alcohol should be legal, but no one can deny that alcohol and cigarettes are fearsome scourges.