Journal of Medicine - America’s drug problem is shifting from illicit substances like cocaine to abuse of prescription painkillers, a change that is forcing policy makers to re-examine the long and expensive strategy of trying to stop illegal drugs from entering the United States.

This rethinking extends beyond the United States, where policy makers are debating how to better reduce demand for painkillers. The effects would also be felt here and in Central America: With the drug wars in Mexico inflaming violence, some argue that the money now used for interdiction could be better spent building up the institutions — especially courts and prosecutors’ offices — that would lead to long-term stability in Mexico and elsewhere.

“The policies the United States has had for the last 41 years have become irrelevant,” said Morris Panner, a former counternarcotics prosecutor in New York and at the American Embassy in Colombia, who is now an adviser at Harvard’s Kennedy School of Government. “The United States was worried about shipments of cocaine and heroin for years, but whether those policies worked or not doesn’t matter because they are now worried about Americans using prescription drugs.”

The same sense that there is a need for a new approach was expressed last week by Gov. Chris Christie of New Jersey, a former federal prosecutor, who declared the war on drugs “a failure” that imprisons people who really need treatment. 

Now the drugs most likely to land Americans in emergency rooms cannot be interdicted. Studies show that prescription painkillers, and stimulants to a lesser extent, are the nation’s biggest drug problem. The same survey that identified 1.5 million cocaine users in 2010 found 7 million users of “psychotherapeutics.” Of the 36,450 overdose deaths in the United States in 2008, 20,044 involved a prescription drug, more than all illicit drugs combined. 

And whereas cocaine and heroin have been concentrated in big cities, prescription drug abuse has spread nearly everywhere. “Today there is drug use in every county in Ohio, and the problem is worse in rural areas,” said Mike DeWine, the attorney general of Ohio.

“This is an urgent, urgent issue that needs to be addressed promptly,” said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse. So far, she said, the response from government and the health care industry has been inadequate.

But momentum for a broader change in domestic drug policy — as in foreign policy — appears to be building. D.E.A. officials say they have recently created 37 “tactical diversion squads” focusing on prescription drug investigations, with 26 more to be added over the next few years.

“Unfortunately,” said Representative Mary Bono Mack, a Republican from California who is co-chairwoman of the Congressional Caucus on Prescription Drug Abuse, “it’s because more and more members are hearing from back home in their district that people are dying.”

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