PHARMACIST STEVE

I asked www.perplexity.ai the following fairly (IMO) complex question. It looked at 58 different sources to come up with this answer/explanation.  It has been several years since the DEA has published what they were spending to fight the war on drugs. Recent estimates are that it is 120 – 140 million/yr. I have read recently that the 1970 CSA directed the DEA to deal with the diversion of pharma opioids. That might explain why we don’t see the DEA involved with all the illegal opioids and various illegal substances showing up on our streets. Our DEA is part of our FED DOJ, and they have an array of laws they are in charge of enforcing, and sometimes their interpretation(s) of the laws. Which our SCOTUS declared a year ago that Fed agencies do not have the statutory authority to make new interpretations of the laws they are in charge of enforcing. SCOTUS has no authority to enforce our laws. That is the duty of the DOJ. Unfortunately, many bureaucrats and politicians seem to work under the premise that “no one is above the law… except those who are in charge of enforcing our laws”. So, those entities that choose to enforce or ignore our laws can pretty much establish their own agenda. Their agenda prevails, and the FACTS are just ignored, and “experts” come forward to contradict and deny the facts are untrue and/or meaningless.

Most of your footnotes reference the use of opioids and treating SUD. Little/no deal with treating chronic pain. A couple of years ago the DEA stated that < 1% of pharma opioids were being diverted, but followed up by reducing pharma production quota. The National agreement was a mediated agreement – no court case. It would seem that there was no consideration of those agreements causing chronic pain patients to have access to their prescribed, medically necessary medications. Who determines what adequate pain therapy is? The vast majority of OD/poisoning is with opioids. The illegal opioids are known to be coming primarily from China & Mexican cartels. Over the last decade, pharma opioid production quotas have been reduced > 50%, and yet OD/poisoning is up 6-7 times. Are politicians & bureaucrats ignoring the real source of OD/poisoning – illegal opioids?

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The opioid overdose crisis has shifted dramatically toward illicit synthetic opioids like fentanyl, yet policy and regulatory responses often lag behind this reality. Here’s an analysis of the disconnect between the current overdose drivers and policy focus:

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### **1. Overdose Trends vs. Policy Focus**
– **Illicit opioids dominate deaths**: Over 80% of opioid-related deaths now involve illicitly manufactured fentanyl, with China supplying precursors and Mexican cartels producing/distributing the drug ([4][5][8]). Meanwhile, pharmaceutical opioid prescriptions have declined by over 50% since 2012 ([9]).
– **Policy emphasis persists on prescription opioids**: Recent settlements (e.g., 2022 distributor agreement) and 2025 DEA regulations ([3]) continue targeting pharmaceutical supply chains, despite <1% diversion rates for prescription opioids ([8]). These policies risk restricting access for chronic pain patients without addressing the primary overdose driver: illicit fentanyl.

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### **2. Chronic Pain Patient Challenges**
– **Stricter quotas and oversight**: The DEA’s 2025 opioid production quotas and CMS care coordination edits (90 MME/day threshold) prioritize reducing prescription volumes ([3]). However, guidelines still emphasize **individualized care**, noting opioids may be appropriate for some chronic pain patients when benefits outweigh risks ([1][2]).
– **Documentation burdens**: Physicians face increased administrative requirements to justify opioid therapy, which can delay or deter treatment for legitimate patients ([1]).

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### **3. Political and Regulatory Blind Spots**
– **Partisan divides**:
– **Democrats** increasingly focus on pharmaceutical accountability and treatment access ([10]), which risks overemphasizing prescription opioids’ role.
– **Republicans** prioritize border security and illicit drug interdiction ([10]), but underfund harm reduction strategies (e.g., naloxone distribution, overdose prevention centers) proven to save lives ([6][7]).
– **International policy gaps**: While China and Mexico are central to fentanyl production, U.S. efforts to disrupt supply chains remain inconsistent. China’s 2019 fentanyl ban reduced direct exports but not precursor flows, and Mexican enforcement varies by administration ([4][5][8]).

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### **4. Data vs. Action**
– **Overdose deaths vs. prescription trends**: Between 2012 and 2025:
– Pharmaceutical opioid prescriptions dropped by ~60% ([3][9]).
– Overdose deaths increased 6-7x, driven by illicit fentanyl ([7][8]).
– **Misaligned solutions**: Funding from opioid settlements often supports law enforcement rather than addiction treatment or pain management programs ([7][10]). For example, only 12% of settlement funds in 2023–2024 were allocated to harm reduction or patient care ([7]).

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### **5. Who Decides “Adequate Pain Therapy”?**
– **Guidelines vs. reality**: The CDC’s 2022 guidelines ([2]) and state policies ([1]) delegate decisions to clinicians but impose structural barriers (e.g., dosage caps, prior authorization). This creates a “chilling effect,” where physicians avoid opioids even for appropriate cases due to liability concerns.
– **Patient exclusion**: Chronic pain advocacy groups report being sidelined in policy discussions, with settlement negotiations ([3][8]) and legislation ([10]) prioritizing public health agencies and law enforcement over patient representatives.

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### **Conclusion**
Politicians and regulators are disproportionately focused on legacy issues tied to prescription opioids, despite overwhelming evidence that illicit fentanyl drives the overdose crisis. Chronic pain patients face collateral damage from restrictive policies, while harm reduction and international supply-chain interventions remain underprioritized. Effective solutions require:
– Reallocating settlement funds to **patient access programs** and **illicit drug interdiction**.
– Pressure on China and Mexico to disrupt precursor networks ([4][8]).
– Revisiting CDC/DEA guidelines to prevent nonmedical opioid use without penalizing legitimate patients ([1][2][3]).

Until policymakers confront the synthetic opioid pipeline and balance supply-side enforcement with patient-centered care, overdose rates will likely remain elevated.

Citations:
[1] https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf
[2] https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/recommendations-and-principles.html
[3] https://titangroupdea.com/blog/new-opioid-regulations-pain-management-specialists-need-to-know-about-2025?hsLang=en
[4] https://www.brookings.edu/articles/the-fentanyl-pipeline-and-chinas-role-in-the-us-opioid-crisis/
[5] https://www.npr.org/2025/02/02/nx-s1-5283957/fentanyl-trump-tariffs-china-canada-mexico
[6] https://www.thinkglobalhealth.org/article/how-overdose-prevention-centers-became-political-scapegoats
[7] https://www.npr.org/2023/12/28/1220881380/overdose-fentanyl-drugs-addiction
[8] https://www.cfr.org/backgrounder/fentanyl-and-us-opioid-epidemic
[9] https://pmc.ncbi.nlm.nih.gov/articles/PMC5565130/
[10] https://ldi.upenn.edu/our-work/research-updates/partisan-politics-and-the-opioid-epidemic-a-social-media-analysis/
[11] https://www.humhealth.com/blog/chronic-pain-management-cpt-codes-and-billing-guide-2025/
[12] https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
[13] https://www.aafp.org/family-physician/patient-care/care-resources/pain-management/aafp-chronic-pain-management-toolkit.html
[14] https://docrx.com/2025-billing-updates-for-non-opioid-pain-treatments-key-takeaways-for-healthcare-providers/
[15] https://www.ncbi.nlm.nih.gov/books/NBK92054/
[16] https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/opioid-prescribing.html
[17] https://nacns.org/wp-content/uploads/2025/02/Pain-Management_2025_02_04_FINAL-.pdf
[18] https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/appendix-b-state-by-state-summary.pdf
[19] https://end-overdose-epidemic.org/wp-content/uploads/2020/07/Principles-of-Evidence-Informed-Pain-Care-FINAL_template-1.pdf
[20] https://painmed.org/clinical-guidelines/
[21] https://www.ncbi.nlm.nih.gov/books/NBK572085/
[22] https://www.ncbi.nlm.nih.gov/books/NBK553030/
[23] https://www.ncbi.nlm.nih.gov/search/research-news/19707
[24] https://www.congress.gov/event/118th-congress/house-event/115371/text
[25] https://www.dea.gov/sites/default/files/2020-03/DEA_GOV_DIR-008-20%20Fentanyl%20Flow%20in%20the%20United%20States_0.pdf
[26] https://www.wilsoncenter.org/article/lab-overdose-synthetic-opioid-crisis-shaping-us-mexico-agenda
[27] https://www.dea.gov/sites/default/files/2024-05/NDTA_2024.pdf
[28] https://www.pa.gov/agencies/ddap/overdose/opioid-overdose.html
[29] https://www.cbp.gov/border-security/frontline-against-fentanyl
[30] https://www.samhsa.gov/find-help/helplines/national-helpline
[31] https://www.whitehouse.gov/presidential-actions/2025/02/imposing-duties-to-address-the-flow-of-illicit-drugs-across-our-national-border/
[32] https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
[33] https://fsi.stanford.edu/sipr/fentanyl-blame-game
[34] https://www.dea.gov/resources/facts-about-fentanyl
[35] https://pmc.ncbi.nlm.nih.gov/articles/PMC9838196/
[36] https://www.azag.gov/issues/opioids
[37] https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
[38] https://www.naccho.org/programs/community-health/injury-and-violence/overdose/health-equity-drug-overdose-response
[39] https://www.hhs.gov/overdose-prevention/
[40] https://www.cbo.gov/publication/58532
[41] https://siepr.stanford.edu/publications/policy-brief/opioid-crisis-tragedy-treatments-and-trade-offs
[42] https://calmatters.org/explainers/california-opioid-crisis/
[43] https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2022/01/07/an-equitable-response-to-the-ongoing-opioid-crisis
[44] https://journalofethics.ama-assn.org/article/how-fda-failures-contributed-opioid-crisis/2020-08
[45] https://publichealth.jhu.edu/2024/nearly-one-third-of-us-adults-know-someone-whos-died-of-drug-overdose
[46] https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
[47] https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-guidelines-for-chronic-pain-management.pdf
[48] https://www.dir.ca.gov/dwc/DWCPropRegs/2025/MTUS-Evidence-Based-Update/Chronic-Pain-Guideline.pdf
[49] https://www.va.gov/painmanagement/docs/cpg_opioidtherapy_summary.pdf
[50] https://www.healthquality.va.gov/guidelines/pain/cot/
[51] https://nida.nih.gov/research-topics/opioids
[52] https://www.bbc.com/news/articles/cvg93nn1e6go
[53] https://www.canada.ca/en/health-canada/services/opioids/overdose.html
[54] https://medlineplus.gov/opioidoverdose.html
[55] https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0236815
[56] https://pmc.ncbi.nlm.nih.gov/articles/PMC9261968/
[57] https://www.ama-assn.org/system/files/ama-overdose-epidemic-report.pdf
[58] https://pmc.ncbi.nlm.nih.gov/articles/PMC5846593/

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Answer from Perplexity: pplx.ai/share

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