Fighting Pain vs Fighting Addiction

Over the weekend I wrote about how the war on drugs interferes with the war on chronic pain, and Stephen Smith has an excellent followup, taking note of talk on restricting hydrocodone/acetaminophen blends like Vicodin:

Regardless of the merits of this new wave of regulation, it’s worth examining why Vicodin, which is a compound of the opioid painkiller hydrocodone and acetaminophen (a.k.a. Tylenol), is so popular to begin with. Reading The New York Times gives you the impression that it’s simply a popular and effective medicine, but there’s another benefit to the combination found in Vicodin over straight hydrocodone: It’s less regulated.

Pure hydrocodone is a Schedule II drug under the 1970 Controlled Substances Act, whereas hydrocodone compounded with acetaminophen is a more loosely regulated Schedule III drug, supposedly for its lower abuse potential. Wishing to avoid greater scrutiny, doctors prefer prescribing Schedule III substances like Vicodin over purer Schedule II formulations which don’t contain liver-damaging acetaminophen. But why does adding a sometimes-unnecessary ingedient make it difficult (but not impossible) to abuse? For the same reason that the FDA is now regulating it: Because it’s poisonous, and can even cause fatal liver damage in the quantities necessary to sustain a heavy addiction. Researchers refer to it as an “abuse deterrent formulation”—the modern-day equivalent of the government spiking industrial alcohol during Prohibition. Except rather than blindness-inducing methanol, we now use deafness-inducing acetaminophen.

Opioid addiction is bad, and it’s perfectly reasonable for policymakers to try to minimize its incidence. But short of dying, experiencing chronic pain is one of the worst things that can happen to someone. The correct ordering of priorities is to try to make sure that nobody suffering from treatable chronic pain goes untreated, and then try to minimize addiction risks within that framework. The view that people suffering pain should get relief subject to the binding constraint that we need to fight addiction has a nice Puritan logic to it, but it doesn’t make any real sense.