Part of the Series
The Policing of Pain: Inside the Deadly War on Opioids
The Drug Enforcement Administration (DEA) issued a “public safety alert” this week warning people about a sharp increase in the availability of counterfeit prescription pills — a potentially toxic drug supply that experts say ballooned in the wake of policy failures and heavy-handed enforcement by the DEA.
Citing a rapid increase in the number of counterfeit pills confiscated by drug police, the DEA warns of a “nationwide surge” in counterfeit pills containing black market opioids, stimulants and benzodiazepines that are made to look like popular prescription medications such as Percocet, Adderall and Xanax. Counterfeit pills are contributing to the overdose crisis, the agency said, which reached terrifying new heights during the pandemic lockdowns last year.
The increased demand for prescription pills in the illicit market comes amid a nationwide crackdown on the prescribing of controlled substances that followed sensational coverage of the overdose crisis, which the media often links to aggressive marketing of opioid painkillers in the late 1990s and early 2000s. However, experts and advocates for medicine access say the link between painkiller “overprescribing” and the overdose crisis is overblown and ignores a complex web of socio-economic factors, especially now that opioid prescribing has plummeted to the lowest levels in a decade.
The prescribing crackdown has made it more difficult for patients suffering from chronic pain, anxiety, and other conditions to access medicine, according to Claudia Merandi, an advocate for pain patients and founder of The Doctor Patient Forum. In an interview, Merandi said she receives requests for help from 300 to 400 patients every week who suffer acute or chronic pain but are unable to access painkillers. Others are forced to take lower doses of medicine they have depended on for years or taper off altogether.
“People have taken their lives because they have been cutoff of medication that gave them a quality of life,” Merandi said. “People have lost their livelihoods — they just stopped living and retreated to their beds.”
Experts say women, low-income people and people in rural areas are disproportionately affected by the prescribing crackdown. The same goes for people of color and Black people especially, who are more likely have their pain dismissed by doctors or be profiled as a drug addict or dealer due to stigma and racism.
Despite the crackdown, the number of overdoses involving prescription opioids continued to increase until 2017, although researchers now say the Centers for Disease Control “misled” the nation for years with faulty data that grossly exaggerated the number deaths involving prescription painkillers. Now, the CDC reports that skyrocketing rates of fatal overdose are driven by drugs laced with synthetic opioids such as fentanyl and stimulants such as methamphetamine, the same drugs pressed into counterfeit pills that have replaced what experts call a “safer supply” of prescription medications.
Prescription pills are considered safer to use than counterfeit pills even if a user does not obtain them legally from a doctor. Counterfeit pills contain drugs produced in foreign black market labs and can vary widely in quality and potency. For example, a counterfeit pill made to look like a 10-milligram Percocet, a common opioid painkiller, could potentially be much more powerful, putting a user at increased risk of overdose.
Ryan McNeil, the director of harm reduction research at the Yale School of Medicine, said counterfeit pills have been around for years. Demand for prescription pills remains high despite the decrease in prescribing, particularly of opioids for pain and benzodiazepines such as Xanax often used to treat anxiety. Counterfeit pills are increasingly filling the gap. Experienced drug users can often tell the difference between a counterfeit and pharmaceutical pill, but a naïve user or patient who recently lost a prescription may not, making them vulnerable to side effects and even overdose.
“We know that people who were cut off from pain medications turned the illicit market to gain access to medication, that is basically an inarguable point at this stage of the overdose crisis,” McNeil said in an interview. “Currently, these counterfeit pills are meeting that gap, as well just generally a demand for psychoactive substances that has been around as long as humans have existed.”
Opioid prescribing rates slowed over the past decade and dropped dramatically during the Trump administration, which capped painkiller production quotas and attempted to reduce prescribing by more than 30 percent. In 2016, the CDC released restrictive prescribing guidelines that have divided medical experts and were widely misapplied by doctors and state policymakers. The guidelines also enraged pain patients, who are clamoring to have them rewritten or removed.
Meanwhile, DEA agents scrutinized prescription drug monitoring databases set up by most states in response to the overdose crisis that track patients, doctors and prescriptions in order to raid and shut down medical clinics and pharmacies accused of overprescribing.
“We can confirm that law enforcement, the DEA and insurance companies all have access to patient information that they use to target to the highest prescribers,” Merandi said, arguing that drug police should not be able to access to sensitive patient data without a court order. “That’s new, we didn’t know that was happening a few years ago.”
While some problematic prescribers were targeted, advocates say respected physicians and community pharmacies are also caught up in the enforcement dragnet, and untold numbers of patients lost access to medications and health care in the process. Some doctors became increasingly wary of prescribing opioids and other controlled substances. Other avoided accepting new patients with longstanding prescriptions. In some cases, patients suffered fatal overdoses of illicit drugs and others committed suicide.
In a previous statement, the DEA said it does not “interfere with or advise on the practice of medicine,” and providers who follow the law and practice within the “normal course of medicine” are not subject to enforcement.
Private companies have also combined the prescription monitoring data with personal health records to build algorithmic programs that are supposed to help doctors identify potential problem patients, but some patients say they have been unfairly singled out and denied medication due to errors. People with disabilities and chronic pain who struggle to access medication have found each other online and formed a growing movement that often spars with pundits and policymakers pushing to limit opioid prescribing.
The DEA’s counterfeit pill alert assures the public that medications obtained from licensed pharmacies are “safe when taken as directed by a medical professional.” Merandi, who helped pass legislation in Rhode Island aimed at making it harder for the DEA to shut down prescribers based on CDC’s highly controversial prescribing guidelines, said such a statement is ironic coming from an agency that prevents doctors from prescribing to patients in the first place.
“I work with doctors who are still prescribing, and I do my best to be sure the doctors are prescribing safely, and I do my best to protect the doctors from the feds,” Merandi said.
The DEA says it has seized 9.5 million counterfeit pills so far this year, more than the past two years combined. McNeil said that’s likely only a drop in the bucket; law enforcement has never put a meaningful dent in the drug supply and prohibition has never quelled demand during the past five decades of continuous drug war.
A main goal of the prescribing crackdown is to prevent the “diversion” of prescription pills to people who are not prescribed them. In theory, preventing diversion also prevents people from misusing drugs and eventually overdosing. Yet rates of fatal drug overdose remain stubbornly high.
McNeil said diversion would become a moot point if policymakers changed laws to allow people access to a “safe supply” of pharmaceutical grade opioids in a compassionate setting.
“A consequence of the crackdown on heroin and pills is that we now have a toxic drug market made up of adulterated drugs,” McNeil said. “Fears about diversion undermine our ability to intervene in the drug supply and provide safer alternatives.”
For patients suffering from chronic pain, anxiety or ADHD, a safe supply typically means the ability to obtain medicine they depend on from a doctor and pharmacy rather than being turned away, stigmatized for treating their condition with controlled substances, or forced to taper off in order to receive care.
For drug users living with addiction and marginalized by the harsh impacts of drug prohibition, a safe supply could mean access to their drug of choice and a safe place to use it. For example, medical grade heroin is available by prescription in other countries and credited with stabilizing patients and preventing overdose deaths. In the U.S., policymakers are slowly embracing safe consumption sites where people can use illicit drugs under medical supervision and access addiction treatment services, a model proven to prevent overdose deaths.
Researchers are already discussing models for legalizing non-medical opioids that would include robust public education and training for those who wish to use them. After all, current policy has failed to end the overdose crisis or the illicit drug trade fueling the availability of counterfeit pills. But don’t expect to hear that from the DEA, which would face an existential crisis if the “war on drugs” finally came to an end.
“With its counterfeit pill warning, DEA is almost making an argument for a safe supply here by pointing out how dangerous the illicit market is,” McNeil said.
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