I disagree with you on the no free needles front.
A big chunk of my volunteering has been with harm reduction organizations, including at a needle exchange. Giving IV drug users access to sterile injection supplies is not the same thing as giving them access to the drugs themselves. It is a health promotion strategy that reaches beyond the user to the wider community. Blood borne pathogens don't just affect those who use dirty needles themselves, but also anyone with whom they have intimate contact and those health care providers who may later be exposed to them. Further, providing sterile injection supplies can be coupled with other services and outreach efforts. Our clinic used needle exchange as an opportunity to get used needles off the street (literally), to provide access to Narcan and overdose prevention education, and information about rehab and other community services. I don't have the hard data to prove it, but I would expect that we also served to reduce the number of bacterial endocarditis and local abscesses that presented to local emergency rooms.
And, most importantly, there is the core motivation behind all harm reduction efforts... if you can get drug users to begin using less harmful methods, to begin treating themselves with a modicum of dignity and self-respect by taking precautions with their health, you can start to reverse some of the stigma they have internalized. You can get them to see themselves as people who are worth helping, who might have a future.
You are right that addiction is a huge problem, and opiates aren't remotely the only drug of abuse (so bupe only goes so far.) My comment above that some patients need different, or at least more, services than pain management is equipped to provide doesn't mean that there are great places to which they can be referred. You and
@drusso are absolutely right that there is a dearth of services available to treat addiction. That is especially a shame given how much (opiate and benzo) abuse begins with iatrogenically.
The vast majority of the addicts I met at the needle exchange got their first taste from a physician, generally not a pain specialist. They had low back pain, or a car accident, or a work injury and were given a prescription. And golly, did it help. These weren't people that the public service ads show you, people who were trying street drugs for the kick and weren't able to quit. They were the folks mentioned in the OP, who started out at their PCP with a prescription that was (often) inappropriate to their needs. A few refills and doctor shops later, they ended up in pain management. Once they wore out their welcome there, after a relapse or two, that is when they washed up at the needle exchange. Where we tried to help them locate rehab options, if at all possible.
My purpose in hanging around this forum, as a future PCP, is partially to absorb what I can to keep me from setting too many folks down that path. And to figure out how best to manage them when it inevitably happens, so that I don't just dump my troubles on the local pain specialists. Part of addressing the addiction epidemic is owning it, recognizing that it has been fueled by prescriptions as much as by cartels, and to hold ourselves accountable along with our patients. UDS is a tool that can be used punitively, or with wisdom and skill, to make our practice safer... for us and for our patients.
I agree with you that addiction needs a lot more attention, and that it is a major problem for a huge portion of the public. Since it is, I consider that responsibility for it begins in the primary care physician's office, and that is where I will try to do my part.
