To the Editor:
Re “The D.E.A. Should Get Out of Public Health,” by Shravani Durbhakula (Opinion guest essay, March 25):
The chilling effect on the legitimate prescribing and dispensing of opioid medications provoked by the Drug Enforcement Administration’s actions is having devastating real-world consequences among people living with chronic pain.
Although opioid therapy is not a panacea for pain management, which often necessitates a complex approach, certain patients undoubtedly benefit from these medications for long-term pain relief. People living with severely disabling pain conditions can participate in life’s activities if their opioid therapy is properly managed.
The D.EA., serving in a policing capacity, is not helping our country deal appropriately with the concerning drug overdose crisis. Public health evidence could not be clearer: The significant decline in opioid prescribing has not correlated with a significant decline in drug overdoses. Cutting the medical supply of opioids is not addressing overdoses and risks the health and lives of people who need access to essential medications.
Regulation of health-related activities to protect the public health of Americans must be guided by experts on those topics, not law enforcement agents.
Juan M. Hincapie-Castillo
Pittsboro, N.C.
The writer is a pharmacist and an assistant professor in the department of epidemiology of the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill, and the board president of the National Pain Advocacy Center, a nonprofit that receives no industry funds.
To the Editor:
Dr. Shravani Durbhakula’s critique of the Drug Enforcement Administration is misguided and unjustified.
It is worth noting that the opioid epidemic was started in the mid-1990s by OxyContin, a potent analgesic agent approved by the U.S. Food and Drug Administration, promoted by Purdue Pharma, and overprescribed by clinicians. Overprescription and overconsumption of opioid analgesics continued rising until 2010, when the D.E.A. began to crack down on “pill mills” run by physicians.
Since 1995, hundreds of physicians have been criminally prosecuted for opioid-related offenses, with drug trafficking, fraud, money laundering and manslaughter accounting for the majority of the convictions.
On average, Americans consume about 20 times the amount of prescription opioids as the rest of the world. It is no surprise that the opioid epidemic is primarily endemic to the United States. Given that the ongoing opioid epidemic is driven by illicit fentanyl, the D.E.A. has an indispensable role to play in controlling this public health crisis.
Guohua Li
Montebello, N.Y.
The writer is a professor of epidemiology and anesthesiology at Columbia University.
To the Editor:
Limiting the supply and prescription of opioids for chronic pain is crucial to addressing the opioid epidemic.
In fact, there is no lack of supply of opioids for dying patients, in whom such use is appropriate. Opioids are still overused for chronic pain, for which they don’t work well, and there is overuse for acute situations, such as oral surgery, in which nonopioids are more effective and safer.
Many people seeking opioids on the street — now a dangerous market because of adulteration with fentanyl — became addicted after receiving an opioid prescription from a physician or a dentist. The Drug Enforcement Administration’s role in regulating the opioid market should be applauded, not condemned.
Adriane Fugh-Berman
Gary M. Franklin
Dr. Fugh-Berman is a professor in the pharmacology and physiology department at Georgetown University Medical Center. She is also paid as an expert plaintiffs’ witness, mainly for the government, in litigation over pharmaceutical marketing. Dr. Franklin is a research professor at the University of Washington and the medical director of the Washington State Department of Labor and Industries.
To the Editor:
Dr. Shravani Durbhakula’s guest essay implicitly repeats a mistaken belief that opioids maintain effectiveness for reducing chronic pain when given daily over long periods, if addiction is not present.
This false belief was promoted by pharmaceutical companies 25 years ago and led to the opioid crisis that has affected the United States. Actually, there is compelling biological, epidemiological, experimental and clinical evidence that when taken daily, opioids cause neuroadaptations that enhance sensitivity to pain (including with patients who show no addictive behaviors).
I have been treating opioid-dependent chronic pain patients for more than three decades. The culture of opioid overtreatment has been difficult to overcome because of a confluence of factors, but since the 2016 guidelines from the Centers for Disease Control warned against extended use, opioids are being prescribed less and deaths from the legal use of prescription opioids have declined.
When physicians try to taper opioids, it often produces resistance from the patient because of physiological and psychological withdrawal discomfort. Thus, physicians are at a loss as to how to treat opioid-dependent chronic pain patients other than maintaining opioids. Good treatments are available, though, and it is quite fulfilling to work with these patients.
Jon Streltzer
Honolulu
The writer is a psychiatrist and emeritus professor of psychiatry at the John A. Burns School of Medicine at the University of Hawaii.
To the Editor:
As a pain management physician myself for more than 30 years, I believe that Shravani Durbhakula presents what may be charitably deemed a distorted view of the management of pain in this country.
Throughout the piece, it is indicated that poor pain management is mainly because of restrictions on prescribing opioids. This conveniently overlooks the fact that much pain, such as neuropathic pain, which includes cancer pain where the tumor either invades or stretches the nerve, responds better to nonopioids.
Other conditions, such as diabetic neuropathic pain and fibromyalgia, are just as poorly managed, and all are better managed with anticonvulsants and certain antidepressants. Perhaps Dr. Durbhakula might have explained this.
And as Dr. Durbhakula briefly alludes to at the end of the essay, the main reason that pain is so poorly managed in this country is that most physicians receive little education in pain management in medical school and postgraduate training programs.
A more useful piece would be entitled “Medical Schools Need to Get Into Pain Management.”
Steven A. King
Philadelphia
To the Editor:
Dr. Shravani Durbhakula’s essay mirrors my own experience. I am horrified that my primary care physician of many years dismissed my pleas for pain medication for sciatica, an excruciating and common nerve disorder.
Instead of prescribing an opiate, my doctor gave me an anti-inflammatory that did little to reduce the bolts of electricity shooting from my hip to my toes, which make walking and sleeping impossible. It wasn’t until six weeks after the onset of sciatica, when I threatened to use street drugs, that my doctor came through with a prescription for five milligrams of oxycodone every six hours, which did not relieve the pain. As a result, I am seeing a pain management specialist.
The American Medical Association and the D.E.A. seem to be in lock step in denying adequate pain medication to patients with genuine chronic pain, while veterinarians have no problem providing pain relief to animals.
How, as a society, have we gotten so far off-track, punishing patients for the abuse of addicts? If such a law were applied to driver’s licenses, we would take cars away from safe drivers to keep bad drivers off the road.
Stacia Friedman
Philadelphia
To the Editor:
The guest essay about the role of the Drug Enforcement Administration uses the word “overdose” in relation to incidents where individuals suffer serious and sometimes fatal effects from using opioids.
Overdose suggests that the person either knowingly or accidentally took an excessive amount of a medication with known potency. In the current epidemic of incidents involving street drugs, the correct term is “poisoning,” since the drugs have typically been adulterated with either very potent synthetic opiates or with a variety of other drugs. The user, being unaware of the actual potency of what is being used or what adulterants have been added, can be seriously affected even when taking his or her usual dose.
Calling these incidents overdoses is a way of blaming the victims, while calling them “poisonings” opens several avenues to reduce harm, such as making tests for opiate potency readily available to users, or making medical-grade opioids accessible as a viable alternative to street drugs.
I encourage your writers, editors and contributors to use poisonings rather than overdoses unless it is clear that the episode being described involved a genuine, correctly labeled, prescription opioid medication.
Henry Olders
Westmount, Quebec
The writer is a geriatric psychiatrist and a retired assistant professor in the department of psychiatry at McGill University.
