Intensive Care for Pain As an Overdose Prevention Tool: Legal Considerations and Policy Imperatives

Abstract

The United States is experiencing a historic crisis of opioid-related harms. The rate of fatal overdoses has tripled since 1999, driven primarily by opioids. Spurred by large numbers of new initiates, the incidence of injection-related infections like HIV is now rapidly rising. Despite concerted policymaker attention and the investment of more than ten billion dollars from all levels of government and civil society, the rate of opioid-related harms remains at astronomically high levels. With nearly 200 people in the United States dying of overdose every day, hundreds of preventable HIV infections, and countless other avoidable harms, progress is far too slow.

Experience in other countries suggests that one important tool for reducing drug-related harms among marginalized individuals is access to a stable and safe supply of opioids. But in view of wide-spread concerns about over-utilization and diversion of opioid analgesics, we propose providing this health service within a well-recognized healthcare model: Directly-Observed Therapy (DOT). A framework for Directly-Observed Therapy for Pain (DOT-P) would resemble a specialty intensive pain care clinic, where healthcare professionals would provide pharmaceutical-grade opioids like hydromorphone in a monitored setting, along with key wraparound services. DOT-P would address concerns with polypharmacy and overdose, while also operationalizing a “closed system.” Operating similarly to iOAT clinics that exist in other international settings, a DOT-P model would be reserved for highly vulnerable people who inject drugs, have diagnosable acute or serious chronic pain, and have not benefited from other pharmacotherapy. This approach would provide essential care to a marginalized population while minimizing risk of diversion—a principal concern in the context of the current crisis. Though distinguishable from maintenance, iOAT, and SCFs, DOT-P shares some of their strengths including overdose prevention, providing linkages to services, reducing drug use in public settings, and reducing community disorder. Unfortunately, DOT-P is not currently implemented in the United States in a robust or systematic way. We argue that to reduce overdose risks and other health harms from drug injection, far more must to be done to address the patients’ underlying pain.

This Article begins in Part II by explaining the co-occurrence of pain, opioid use disorder (OUD), and housing instability through a vignette and through a review of relevant epidemiological research. We then describe the benefits of DOT-P for this population in terms of underlying theory and related evaluation research. In Part III, we provide a reasonable legal roadmap for operationalizing such an approach. We conclude in Part IV with some normative observations and predictions.

Keywords: opioids, Directly-Observed Therapy for Pain, DOT-P