It seems simple to say that the evident increase in prescription drug misuse is an argument against regulating illicit drugs. Pharmaceuticals are legal, and in some regions they are being misused more widely than illicit drugs, ergo regulating illicit drugs would only increase their use as well, right?
That statement overlooks not only the reality of chronic drug dependency, but also the dangers of prohibition to both people who use drugs and the wider community. In over 40 years of the War on Drugs, we have seen the rapid expansion of lucrative markets controlled by criminals . Far from reducing drug use, we have seen usage rates continue to remain stable or even increase in some regions [2,3]. The old adage of supply reduction does little to deter those who are already dependent, or those seeking to profit from the black market.
Prohibition fails to take into account the complexities of drug dependency, which cannot be solved simply by incarcerating users and low-level dealers. Chronic drug dependency is not simply a matter of the availability of drugs. A number of other factors, such as mental health, social isolation, past trauma, and financial situation can influence someone to develop a drug dependency.
These factors likewise can influence a dependency on legal drugs, and a number of demographics are susceptible. High rates of comorbidity between mental health disorders and substance misuse has frequently been reported [4,5] and suggests demographics with mental health issues are particularly vulnerable to drug dependency, misusing drugs as a form of self-medication . There is also evidence to suggest that in the majority of cases, any existing mental health problems often precede substance dependency. People with alcohol dependency and chronic pain are also highly vulnerable to pharmaceutical misuse, and students are another demographic likely to misuse these drugs .
Oxycodone prescribing has increased markedly, with the highest rates amongst older Australians . Older, depressed pain patients are found to be at high risk of suicide . An analysis of fatal overdoses involving oxycodone between 1999 and 2008 in New South Wales found one in five to be a result of suicide, occurring almost exclusively among older patients . Increased mental and physical frailty, isolation, and prescription of multiple medications are the likely cause for pharmaceutical drug-related suicide to be highest amongst this group.
One study  determined that of their study sample, a large number of prescription opioid users obtained their drugs from non-prescribed sources. While this is one snapshot of the wider prescription drug-using community, it indicates that prescription opioids can be obtained fairly easily, and suggests they are frequently prescribed to certain patients who are then on-selling them to others.
Levels of pharmaceutical drug-related harm are also impacted by social determinants. For example, there is evidence that overdose deaths are a more common occurrence among socially disadvantaged and rural communities .
Deaths involving fentanyl appear to be most common amongst at-risk Australians with a history of injecting drugs , and the increase in fentanyl use is likely caused by fluctuations in the availability of illicit drugs such as heroin.
These pre-existing factors are complicated by the history of unregulated prescribing of certain drugs, such as oxycodone, and the belief that they are a cure-all for many types of chronic long-term pain [14,15]. Whilst a crackdown on unregulated prescribing has since been implemented, it has done little to deter those who are already dependent, and has even worsened the problem in many regions by unintentionally diverting many dependent users to alternative, more potent opioids such as heroin and fentanyl [16,17].
Restricting access to prescription drugs will not solve the dependency problem; if anything, as with illicit drugs, it will create a black market and increase drug-related crime. The challenge for physicians and public policymakers is how to deter prescription drug misuse while maintaining patient access to appropriate treatment .
As with illicit drugs, reducing pharmaceutical drug misuse and associated harms requires a comprehensive public health approach focusing on preventative measures and harm reduction .
More research is required to establish levels and patterns of pharmaceutical drug misuse in Australia, and the nature of associated harms, in order to develop effective regulatory measures and responses for prescription drug use . Currently this issue has not been covered widely enough, and significant gaps remain in the literature.
Despite the potential for misuse, these drugs continue to provide therapeutic benefits for many people, and it is important to ensure they continue to be available for medical purposes without being stigmatised . Governments must tread a fine line between supporting the economy and and the profit interests of powerful drug corporations, whilst ensuring the public has safe, regulated access to effective and affordable medicines .
Harm reduction measures are also extremely important. This has long been advocated by Australia’s National Drug Strategy .
Given that fluctuating availability in drug markets results in shifts between use of licit and illicit opioids amongst people who inject drugs (PWID), tolerance levels change and the risk of overdose increases. We’ve seen the dangers resulting from fluctuating purity levels in heroin, and its status as a prohibited drug has not protected PWID from harm. Treating prescription drugs in a similar manner is likely to do nothing but increase the risks to PWID and the wider community. Instead, we should be looking at every measure possible to keep people as safe as possible, whilst acknowledging that tackling drug dependency is an ongoing process.
A harm reduction philosophy that is holistic and comprehensive can have positive outcomes for problematic use of both prescription and illicit drugs. Harm reduction strategies for prescription drug misuse include providing information on prescription drug harms to PWID, needle-syringe exchange, and access to injecting equipment such as filters which assist in reducing injecting-related harms .
Given there is evidence that PWID will misuse pharmaceuticals as the availability of illicit drugs changes over time, public health strategies to reduce pharmaceutical misuse and associated harms should complement existing approaches to illicit drug misuse .
Canada, for example, has recently amended laws to allow doctors to prescribe medical-grade heroin as a treatment for those showing severe dependence on street heroin . Evidence shows that, if done in a supervised, clinical manner, it can reduce patients’ exposure to health risks and increase treatment success . Part of a harm reduction approach to Australia’s increasing problem with prescription drugs could include a similar approach.
The idea that a potential prescription drug epidemic can be solved by simply by placing restrictions upon certain medications, and is therefore an argument against regulating drugs, does not address the pre-existing factors that influence drug dependency in the first place. We have not seen illicit drug dependency eradicated through prohibition, and we will likely not see any meaningful reduction in prescription drug misuse through tighter regulation. This is because drug dependency is a complex problem, often co-occurring with other issues requiring different kinds of treatment and intervention.
If we want to truly solve drug dependency, we need to devote more resources towards treating the psychosocial characteristics that influence it in the first place.