In what is the biggest “I can’t believe we have to prove this academically” story of the year, three Johns Hopkins researchers showed that 66-92% of people who got a pile of prescription opioids, didn’t use them all. Not only did 67-92% of patients report unused opioids (92!) but up to 71% of opioids obtained even by surgical patients weren’t consumed. This review of 6 different studies drives home the need for much of the mainstream addiction/treatment community to modernize their thinking when it comes to harm reduction and human behavior. Unsurprisingly, 3 out of 4 people didn’t secure their opioids properly (yes, the FDA legitimately believes that people should store pain pills in locked containers). Even more unsurprisingly, no more than 9% of patients in any study “disposed” of their drugs “properly.” What does disposing drugs properly look like? This:

One of the stupider tenets of most anti-drug programs introduced by the state involve “Take-Back” Days. These days & national programs (which receive millions in funding paid for by your tax dollars, don’t forget) are focused towards telling the average citizen to take time out of their day to go to a government facility (usually local law enforcement sites/police precincts), and give them your unused opioids or other “harmful” medication. This is explained on the FDA.gov website in this way:

Is your medicine cabinet full of expired drugs or medications you no longer use? How should you dispose of them?Many community-based drug “take-back” programs offer the best option. Otherwise, almost all medicines can be thrown in the household trash, but consumers should take the precautions described below.
~How To Dispose Of Unused Medicines, FDA.gov (Reviewed 4/25/16)

The idea that someone with an opioid prescription would return the pills they paid for (even if “they” is Medicare) is completely stupid, both from a data-driven and common sense perspective. Even if they didn’t need them, they bought them. Or, in a lot of cases, an elderly relative bought them, and they’re discovered by a grieving family member who is probably coping with final expenses for a loved one as well. The idea that they wouldn’t either a. use the substances themselves (correctly or recreationally) or b. sell them in their community to friends, neighbors or co-workers, is insulting. It reflects a profound misunderstanding about the financial precariousness & substance use levels in this country.

To be clear, I would never suggest that the solution is to do nothing, I just don’t believe we’re evaluating the market correctly. It’s not that medications shouldn’t be disposed of properly, it’s that we’ve given people no incentive to do so, and a LOT of incentive not to. How much incentive? I don’t know, how much is oxycodone going for in your zip code? How much is gabapentin selling for at the IDM party? Even if you give the drugs away for free, you’re not shielded from a drug charges, so you might as well make a few bucks selling the Vyvanse, Percoset or Oxycontin grandpappy had lying around. This is one of the reasons why that stupid meme about Halloween candy drugs pisses me off so much.

No one, I repeat, no one, is giving away drugs. Was anyone ever given drugs besides a hit off a joint or a line when some skeezeball is trying to get into your pants at a party? This is why the value proposition suggested when it comes to drug buy-backs is dead on arrival.  If you care so much about “the children,” why not just pay for the stuff and get it off the market? We’ve subsidized the pharmaceutical industry for decades now, and now we’re struggling to find a carrot to tempt some of these pills off the market. Isn’t the whole point of the “War on Drugs” to make it more difficult to start using prescription opiates in the first place? Of course, this won’t ever pass or even be suggested seriously, but we’ve been told time and time again that pharma sales people have access to data, prescribing trends and behavior of doctors, down to the single prescriber. The idea that they couldn’t adjust their sales pressures to ensure that people don’t receive more pain pills or unnecessary medication is preposterous. Salesforce, CRM Data & opiate use/prescription data exists for every state in the union (Except Missouri but they just changed that back in April, so it will be online soon).

This may seem extreme, but when you look at cases where hundreds of millions of pills were released into tiny communities over a decade, it becomes hard to ignore. Combine a plurality of pills with findings that most people start using prescription opiates before moving onto illicit or street opiates, and you have a potent recipe for disaster in all 50 states. The explosion of fentanyl overdose deaths is directly tied to the surplus unused pills that loose prescribing habits, big pharma profiteering and pill mills flooded streets with across the USA, Canada and Europe. There needs to be a way to get them off the street without the person currently possessing them feeling like the state is ripping them off or planning to arrest them. Gun buy-backs have seen some success when deployed as ways to reduce gun violence and shooting deaths, so why do we expect those with a surplus of a different illicit commodity to give them up for free?

Ultimately, we only have a couple of different intervention points when it comes to the opiate crisis. Either we prevent people from becoming dependent on them in the first place, or we keep them safe doing pure/unadulterated drugs until they’ve entered recovery and aren’t using street opiates/illicit fentanyl anymore. Those are our options. The research does not mince words about this, the more you get when you’re injured or post-surgery, the more likely it is that you become dependent. And it looks like, at least according to JAMA, that most people don’t need most of the pills they are being prescribed. This means that the easiest way to keep people from building a habit, is to make sure they never get enough of a supply to develop one in the first place.

Of course, this will probably have nowhere near an effect size necessary to bend the hyperbolic curve that is opiate & fentanyl overdose death growth in the USA. But it might save a life or two, perhaps keep a few extra in each community from starting on the habit after they get dumped or a sprained ankle they should be taking Aleve for. What do you think? Let us know in the comments.