In recent years, our focus on the illicit drug trade shifted from the general opioid crisis to almost exclusively fentanyl. There is good reason for that, given fentanyl is a lot more potent – and, thus, a lot more deadly – and is currently flooding our streets at a higher rate than other drugs.
The fentanyl problem is massive. It’s not just the drug itself, but the fact that other drugs are now being laced with it to increase users’ dependence and continue to bring money into the drug dealers’ hands. We’re seeing just as many reports of an overdose being tied to a drug laced with fentanyl than we’re necessarily seeing from just fentanyl alone. The issue at hand is a matter of enforcement, which is a fight currently being held in Congress.
There is a fascinating op-ed in the New York Times that is somewhat related to all this, and I think it bears at least reading and considering.
In a piece titled “People Can’t Get Their A.D.H.D. Medicine, and That’s a Sign of a Larger Problem,” Maia Szalavitz lays out the case that yet another medication shortage we’re seeing – drugs for ADHD patients – is related to the fight against the opioid epidemic in the country and argues that it’s a matter of bad policy. I think, in this regard, she has a point.
The problem is multi-faceted and is related to a string of policy decisions that largely tie into the Drug Enforcement Administration (DEA).
The scarcity, which according to the Food and Drug Administration now involves the generic versions of the drug and not the brand name, has also been exacerbated by limits on supplies of all controlled substances to pharmacies, which were promised by distributors as part of opioid litigation settlements.
To make matters worse, the D.E.A. announced in February that it wants to end the pandemic-driven relaxation of telehealth rules that currently allow people who take drugs like stimulants and opioid treatment medications to get them regularly without requiring at least one in-person visit. The public has until March 31 to comment on these new rules.
These changes may seem unrelated, but they reflect an approach to drug policy that focuses on controlling supply — one that has backfired in fighting opioid addiction and overdoses and could lead to similar damage to people who use prescription stimulants.
Szalavitz’s proposed solution? Take the DEA out of the health and wellness policy game.
To avoid repeating history, the regulation of medically used controlled substances should be transferred from the D.E.A., a law enforcement agency with no expertise in medicine, to the Food and Drug Administration, which specializes in health. Supply restrictions harm patients who depend on medications, while doing nothing to treat those who are addicted. Doctors must be able to make individualized choices about care and not be hindered by shortages.
As a rule, I do believe that stricter law enforcement (within reason) should be first and foremost in the fight against the illicit drug trade in the country. The actors who deal with these substances definitely do not listen to a bunch of health and wellness policy experts when deciding what drugs to deal and who to deal them to. They are in it for the money (and it is quite a lucrative business).
However, the DEA’s ability to restrict or loosen rules pertaining to the patient-doctor relationship are somewhat troubling. The federal government should definitely not be in the business of interfering with that, and on that point, Szalavitz is spot-on. Should we go after pill mills and corrupt doctors? Absolutely. But should the DEA make sweeping enforcement rules based on them? Rules that directly affect how the doctor-patient relationship works? I do believe that’s a slippery slope to nowhere good.
If you’ve never worked with a child who has ADHD or watched someone who struggles with it, I can tell you both as an adult patient and as someone who was in a classroom for nearly a decade that it’s almost impossible for some people to function without those medications. And while there are arguments to be made about the overdiagnosis and overprescription of said drugs (almost assuredly another source of the current shortage), those who need it and cannot get access to it are facing major social and intellectual development setbacks.
And, in an era where our policies related to COVID-19 have already set those children back ten-fold, we cannot afford to do more damage to them.
The government has a tendency to regulate from the perspective of prosecution. They list the rules you might be breaking and the punishments for them. Rarely do these regulators create new rules from the perspective of who the rules help. They create those rules as a means to punish. That leads to the crisis (or crises) we’re now seeing, and it runs afoul of the idea that you are innocent until proven guilty. These rules are meant to increase the number of people who are guilty, and they expand the definition of what “guilty” is in order to encompass more and more people.
Sure, we can talk about the general problem of regulation and overregulation while we’re at it, but the bottom line here is that we need to make rules that aim to help people rather than punish them. There is no real thought given to the people who are negatively impacted despite not actually breaking them. That is where we need to do better.