• Injection;
  • opioids;
  • overdose;
  • pain;
  • pills;
  • prescriptions

Eastern Kentucky and southern West Virginia share a border, but they also share other distinctions. Besides being geographically at the center of rural Appalachia, they both have high incidences of poverty, low levels of educational attainment and general health and, sadly, the nation's highest rates of prescription drug abuse and unintended overdose deaths [1].

This study by Young & Havens [2] does a commendable job of analyzing the many social, structural and drug-specific factors that affect the likelihood and timing of the transition to injection use. The authors also delineate clearly the consequences of injection and make reasonable, although difficult to implement, recommendations for decreasing the rate of transition.

The corollary to their conclusions is that prescription drugs, such as oxycodone and hydrocodone, are ‘gateway’ drugs to injection use, yet the report inadequately addresses the morbidity, mortality and social upheaval caused by opioid pill use alone. This is unfortunate, as it should be much easier to control illicit parenteral drug use by instituting policies that address directly the inappropriate use of these oral medications rather than strategies that are only intended to limit the transition to injection.

Two expert clinical guidelines were introduced in 1997, both of which encouraged more compassionate pain management by clinicians, leading to expanded use of opioids. In the ensuing decade, per capita purchases of oxycodone and hydrocodone in the United States increased ninefold and fourfold, respectively [1]. Unfortunately, with the increase in appropriate uses for chronic pain syndrome, post-surgical discomfort and end-of-life palliative care has also come the dramatic rise in criminal uses of these legal drugs leading to addiction and preventable deaths. This happens when providers write prescriptions under questionable circumstances and the pills are then used non-medically, shared with friends and family or sold on the street.

As both a physician and a West Virginia state senator, my challenge is to incentivize good pain management while minimizing the various forms of illegal diversion. To do this, government's options fall generally into the categories of controlling access and decreasing demand.

Regarding access, the key is a comprehensive state prescription monitoring program (PMP) that tracks sales and creates a database. This should then be supported by a process to review proactively the database looking for aberrant prescribing behavior and, if found, to report it to licensing or law enforcement entities. West Virginia has also joined a regional compact with surrounding states to share this information. Next, Florida, which has been the source of the vast majority of oxycodone sold in this country, recently enacted ‘pill mill’ laws which have already shown great benefits even outside the state. Included are provisions barring most Florida doctors from dispensing certain addictive medicines in their offices or clinics and regulations requiring closer monitoring of pharmacies [3]. Finally, states should consider incentivizing providers and dispensers to review the PMP database when prescribing certain drugs, enhancing oversight of pain clinics and properly scheduling drugs with increased abuse potential.

Other opportunities are largely those that address demand. At least 70% of all West Virginia prisoners are victims of substance abuse and dependence. Rather than sending many of these non-violent offenders to jail, treatment and rehabilitation should be an easily available alternative. Recent studies have confirmed that those given therapy have re-arrest rates approximately 50% lower than for convicts handled conventionally [4]. Probation reform, such as the Hawaii's Opportunity Probation with Enforcement (HOPE) program in Hawaii, in which violations lead to swift, certain and short terms of incarceration, also works. In a randomized controlled trial, HOPE probationers were 72% less likely to subsequently use drugs [5].

States should also look to policies with long-term potential to address the cultural issues affecting all types of antisocial behavior. These include adequate funding for early childhood education, high school dropout prevention and expansion and improvement of out-patient mental health services.

Physicians can also play an independent role in reducing threats from prescription diversion without compromising pain management. They should take an adequate substance abuse history when prescribing such medications, be quick to recommend behavioral health management, consider the use of opioid treatment agreements and be meticulous in the scheduling of follow-up visits [6].

Continued failure to deal aggressively with this insidious epidemic early in its course will lead to escalating health-care and corrections costs and depressing loss of human capital and productivity.


  1. Top of page
  2. Declaration of interests
  3. References
  • 1
    Hall A. J., Logan J. E., Toblin R. L., Kaplan J. A., Kraner J. C., Bixler D. et al. Patterns of abuse among unintentional overdose fatalities. JAMA 2008; 300: 261320.
  • 2
    Young A. M., Havens J. R. Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis. Addiction 2012; 107: 58796.
  • 3
    Alvarez L. Florida laws shutting pill mill clinics. 31 August 2011. Available at: (accessed 14 September 2011).
  • 4
    Huddleston W. Drug courts: a viable solution to drug dependent offenders. J Glob Drug Policy Pract 2010; 4.
  • 5
    Hawken A., Kleiman M. A. R. Managing Drug Involved Probationers with Swift and Certain Sanctions: Evaluating Hawaii's HOPE. Washington, DC: National Institute of Justice; 2009.
  • 6
    McLellan A. T., Turner B. Prescription opioids, overdose deaths, and physician responsibility. JAMA 2008; 300: 26723.