Five lawmakers, including Senator Elizabeth Warren, have renewed their demands for the DEA to double down on its policy of limiting pain patients’ access to their medication. Their position is premised on a misunderstanding of the ever-worsening overdose crisis—which is currently driven by an illicit heroin and stimulant supply adulterated by the synthetic opioid, fentanyl.
In an October 6 letter to acting DEA Administrator Timothy Shea that is almost exactly the same as one from July 2018, Sen. Warren, who has a track record of supporting harm reduction services, called on the drug-war agency to update the agency’s medication “partial fill” regulation to clarify that pharmacists can voluntarily withhold some of an opioid prescription, as advised by the patient’s prescriber. Patients can also request them.
The bipartisan Comprehensive Addiction and Recovery Act (CARA) of 2016 authorized these partial fills of Schedule II controlled substances when pharmacists are “unable to supply the full quantity.” This was an attempt, the bill states, to “address the prescription opioid abuse and heroin use crisis” by cutting patients’ access to medications. But due to the DEA’s “foot dragging,” as the five politicians describe it, part of the legislation remains unimplemented
“We can’t afford to neglect the opioid epidemic, nor the communities it is affecting the most, while we continue to combat COVID-19,” wrote Senator Warren in an op-ed published by a local Massachusetts newspaper less than a week before her latest letter to the DEA.
But her advocacy in the name of people who use opioids may have mixed results for their wellbeing. Warren’s press team did not respond to Filter‘s request for comment.
Opioid analgesics can be crucial for pain patients’ mental and physical wellbeing, and partial fills may function as a type of harm reduction support. “If someone’s having trouble controlling their medication, it’s a good thing,” pain patient advocate Anne Fuqua told Filter. The current accepted use of partial fills for when pharmacists run out of a medication is also beneficial to patients, she added. “If my pharmacy is out, I’d have to wait or forfeit [my prescription]. You’d have to get a second prescription and some doctors don’t care.”
On the flip side, for Fuqua, partial fills could make pain patients’ lives more difficult. “If the doctor writes a script for once a month but you have to pick it up every week, that would be a tremendous burden.”
They therefore risk adding one more barrier for patients who have already been harmed by other prohibitionist attempts at getting a handle on the overdose crisis. “Clinicians might universally stop prescribing opioids, even in situations in which the benefits might outweigh their risks,” the Centers for Disease Control and Prevention (CDC) wrote in a 2017 commentary. “Such actions disregard messages emphasized in the guideline that clinicians should not dismiss patients from care, which can adversely affect patient safety, could represent patient abandonment, and can result in missed opportunities to provide potentially lifesaving information and treatment.”
Politicians’ fixation on the prescription opioid supply further misses what is driving record-breaking, preventable overdose deaths—especially among poor communities and communities of color, both of whom have been made vulnerable to drug-related harms by the federal governments’ austere health policy.
Deaths involving cocaine and methamphetamine reportedly surpassed those of most opioids for the first-time in August 2019, an apparent turning point in the nature of the drug-involved deaths crisis in the United States. The latest CDC data show that, in the last month of that summer, more people’s predicted deaths involved cocaine (15,206) and/or “psychostimulants with abuse potential” (15,180)—a vague category that includes crystal meth—than those involving heroin (14,674), “natural & semi-synthetic opioids” (12,093), meaning opioid analgesics, and/or methadone (2,849) combined.
Black Americans who use cocaine are disproportionately likely to die from an overdose or overamp. According to a September 2020 study, 11 percent of reported cocaine users are non-Hispanic Black, yet more than one-quarter (27 percent) of cocaine-related fatalities involved non-Hispanic Black people. In 2018, the non-Hispanic Black cocaine-involved death rate was twice that of whites, despite past-year cocaine use prevalence being about the same between the two groups.
The synthetic opioid fentanyl is playing a large part in the current overdose crisis too. As of February 2020, it was by far the most common substance involved in the historic death toll. But its supply is mostly through illicit markets, not patient diversion, as the DEA has reported.
Warren’s recent op-ed failed to recognize these trends. Instead, she continued to characterize the issue as an “opioid crisis” and made no mention of the role of stimulants. She did mention fentanyl, but only to say that pharmaceutical companies left people who use drugs “vulnerable to developing addictions to more dangerous and illicit substances like fentanyl.” While some people have come to prefer fentanyl (which doesn’t necessarily indicate addiction), many who experience its harms don’t know about its presence in their drugs.
Warren has worked to advance laws that hold greater promise for ending the crisis. In April 2018, she and the late Representative Elijah Cummings introduced the Comprehensive Addiction Resources Emergency (CARE) Act—a bill, yet to become law, that would provide to frontline interventions what CARA failed to: money. Billions in federal funds would go to bolstering hard-hit jurisdictions’ responses; advancing public health research and surveillance; supporting treatment, prevention, recovery and harm reduction; and expanding professional and public access to naloxone, the opioid overdose reversal medication.