Popular Article on Opioids is Misleading

This post, from the Inspire.com member forum, Ehlers-Danlos Discussions written by “Seshet“, is an excellent and thorough analysis of the Vox article “Solving America’s Painkiller Paradox” – Sep 2018

The recent article on Vox called “Solving America’s painkiller paradox“ is getting a lot of attention.

This is unfortunate, because the Vox article has a number of major errors and misconceptions that are causing more harm than is generally realized. So I’m going to go through it in detail.

“This year, researchers uncovered a simple method for getting doctors to reduce profligate prescriptions of drugs like OxyContin and Percocet that have contributed to America’s opioid epidemic: informing doctors that one of their patients had died.” 

Not really. The “nudge” only worked a bit, and its effect tapered off quickly. Moreover, this assumes that opioid addiction and overdoses start with prescriptions.

The vast majority (around 80% by most estimates) start with recreational use, so this “nudge” is tantamount to monitoring wine tasting parties as a way to cut down on binge drinking

“Congress is currently considering setting caps on how long doctors can prescribe opioids for…

Congress has been doing this for years. But per the 10th Amendment and Supreme Court rulings like Gonzales v. Oregon, Congress can’t really do anything here. The regular practice of medicine is regulated at the state level, not the federal level.

“While most opioid deaths are now linked to illicit opioids like heroin and fentanyl, the roots of the epidemic lie in the easy prescribing of opioid painkillers…”

No. The current heroin epidemic started in the late 1980s, and the drug crisis itself goes back to at least the 1970s, arguably back to the 1770s.

This is a key misunderstanding that is greatly impairing an effective public health response. It also ignores the complexity of substance use disorders, which typically involve a history of mental illness or childhood trauma and multiple substances

“It’s also important to make non-opioid pain treatment available to patients, while training health care providers in the right way to wean patients off opioids.”

Yes, but this ignores the virtual lack of research on how to taper patients. Scientific American just had an article about this, but the Vox article makes lack of training seem to be the problem, when in fact lack of knowledge is the problem. Moreover, this idea assumes patients need to be tapered (some probably do, but some don’t).

“While CDC data shows US opioid prescribing is down since 2010, the amount of opioids prescribed per person in 2015 was more than triple what it was in 1999.”

Sort of. A more realistic count using FDA data shows that the number of outpatient opioid prescriptions dispensed from US retail pharmacies increased from 174.1 million in 2000 to 256.9 million in 2009, a 67.7% increase

“In fact, the research increasingly suggests that opioids are far from a panacea for pain in general and are likely a bad idea in the majority of cases for chronic pain — in large part because people develop a tolerance to opioid effects so quickly that the pain relief over time wears off, even as the risks of overdose and addiction remain or increase.”

Not at all. Research increasingly shows that opioids work reasonably well for many people for a variety of disorders.

Moreover, research shows that the risk of abuse and addiction has more to do with risk factors like mental illness, prior substance abuse, and severe childhood trauma. In addition, tolerance often dosen’t develop at all

“On the chronic pain front, Erin Krebs at the University of Minnesota conducted the best study on this topic to date, releasing the findings earlier this year. Her findings: Patients on opioids did not have superior pain outcomes compared to those who avoided opioids.”

No. Vox routinely misrepresents the findings of the Krebs study. In this study, 11% of the people in the non-opioid arm had to switch to opioids.

And no one in the opioid arm showed any signs of misuse, abuse, addiction, or diversion during the year-long study period. [See “Krebs Study” Shows Opioids are Safe]

Last, Krebs looked specifically at knee and hip osteoarthritis, not at a wide range of chronic pain conditions. Generalizing from her results to neuropathic pain disorders would be inappropriate.

“There is a problem if you don’t give doctors flexibility, because there are exceptions,” Jane Ballantyne, president of Physicians for Responsible Opioid Prescribing (PROP), told me. “But at the same time, if you don’t have rules that reflect what should be done in most cases, then it’s very hard for there to be any control at all in prescribing.””

Vox should have looked more closely at Ballantyne. She’s the pain management physician developing the “pain acceptance modality” and pushing in WA state for hard limits on prescribing of all forms

“Kolodny, who’s also a member of PROP, instead suggested requiring a signed informed consent form for every first-time prescription that’s written for more than three days. The patient would have to sign a form acknowledging that the doctor informed him or her about the risk of opioids.”

Vox should also look closely at Kolodny’s work, which includes pushing for a virtual elimination of opioids outside of acute and end-of-life care.

It’s also worth asking how a person in a car crash, ER, or emergency surgery is going to give informed consent for anything. And Kolodny refers to opioids as “heroin pills,” so I think it’s worth finding out what specifically he thinks this consent form should include.

“In fact, only a minority of people who ever use opioids become addicted. (Some research conservatively estimates that about 8 percent of opioid painkiller patients become addicted.)”

This is not a conservative estimate. This is the best estimate, given by NIDA and director Nora Volkow, MD. Other estimates are much lower, even under 1% in some cases

“a consistently high dose of opioids can create big risks — of future addiction, future overdose, or other opioid-linked problems, from increased risk of bone fracture to constipation.”

It’s not that simple. Addiction risk doesn’t correlate well with dose. Nor does it correlate well with risk of future overdose. And although the risks of bone fractures and constipation are real and important, there are important side effects for other pain meds

“The good news, Lembke said, is she’s seen many patients do much better at the end of the process. She pointed to patients who actually reported less pain after they were tapered off opioids, perhaps because they no longer experienced painful withdrawal, or perhaps due to diminished opioid-caused hyperalgesia (when opioid use heightens sensitivity to pain).”

Opioid-caused hyperalgesia is an isolated phenomenon, seen in some lab experiments and a few clinical situations. It may occur in selected patients and, anecdotally, some patients do seem to respond to an opioid taper or rotation to another opioid class. However, claims that OIH is a common clinical entity are not consistent with current reviews and evidence

“There are all sorts of evidence-based, non-opioid interventions for pain. As a few examples, there are self-management strategies, movement-based physical therapy, psychological treatments such as cognitive behavioral therapy, acupuncture, chiropractic, and more than 200 non-opioid medications (yes, including marijuana).”

I’m still not sure why anyone includes acupuncture or chiropractic in these lists of alternative pain management modalities. Cochrane reviews and other studies clearly show minimal benefit in most cases (and harm in some).

“Krebs of the University of Minnesota argued that non-medication treatments have an even stronger evidence base because there’s longer-lasting research for them than for opioids.”

I can’t seem to find these studies or reviews. Krebs and Vox keep talking about them but never provide names or links. Cochrane reviews are fairly clear: A handful of approaches (in particular PT) are beneficial to some people with certain disorders

“A key problem here is that doctors receive very little training on pain — only about 11 hours on average in US medical schools (out of thousands of hours of total training), according to a 2011 study published in The Journal of Pain.”

This is a red herring. Doctors receive relatively little training on any one clinical subject in medical school, mostly because they receive their clinical training during residency.

Since pain is caused by thousands of different diseases and disorders, there’s no reasonable way to train up medical students on pain.

“Lembke has long argued that it’s the structure of the health care system — and the “pressure on [doctors] to see a large quota of patients in a single day” — that helped cause the opioid epidemic in the first place.”

Lembke is obviously wrong about this.

The majority of opioid addiction is happening among young, otherwise healthy people who in general aren’t seeing physicians at all. So the operational flaws in our healthcare system aren’t relevant.

“More broadly, some experts I talked to spoke of having to rethink, as a society and culture, how pain is viewed. “Something needs to be worked through the culture as well about how pain is part of life,” Humphreys of Stanford said.”

This is weird. People with chronic disorders don’t expect to be pain free. They want to be able to function reasonably well. And given how poorly chronic painful conditions are often managed, most people with these disorders are well aware that pain is a part of life.

“There’s a famous case study that describes a construction worker who came into the emergency room with a 6-inch nail in his boot. It was so painful, the report says, that the patient had to be sedated with powerful opioids. When the shoe was removed, it turned out the nail had passed clean between the toes. There was no injury.”

This story gets repeated a lot, but it’s real message is missed. As soon as the patient saw that there was no injury, he stopped hurting. In far too many cases, doctors (as well as family and friends and even society at large) write off people with apparent psychosomatic pain, but then these people turn out to have a major medical condition

“A 2017 study published in the Journal of the American Board of Family Medicine found that 51 percent of recipients of opioid prescriptions suffer from depression, anxiety, and other mental health conditions.”

This study gets mentioned a lot, too. But this is an association. In closer studies of patients with chronic conditions, the patients are often found to be mentally very healthy even when compared to the general population.

“So for people who can’t access a clinic that offers comprehensive services, and for the doctors seeing such patients, a pill seems like a relatively easy answer. And that’s the problem.”

No. Comprehensive services like integrated pain management programs (we used to have these, until insurance companies and hospitals decided they weren’t profitable back in the 1980s) worked rather well in many cases. But we still had abuse, addiction, and overdoses back then

As I’ve said many times, there is no simple explanation for the opioid crisis (or really, the drug overdose crisis, to use NIDA’s term).

There is no single cause or a couple of major factors driving it. This is a fundamental mistake in Vox’s article (and all the other articles from the journalist), and it has us chasing public health policy, regulations, and laws that aren’t doing much to help, and arguably may make matters worse

The Vox article is also problematic for what is omits. There’s little mention of drug diversion, no mention of the role the FDA, DEA, or insurers played in the flow of opioids (or other drugs), no mention of rising rates of overdose in the face of falling rates of prescribing, no mention of any drug other than opioids (except cannabis, and that was as a pain management modality, which is not the only way cannabis gets used), and no mention of how countries like Canada with very different healthcare systems and approaches to pain management are nonetheless managing to have an “opioid crisis” too

Ordinarily I wouldn’t nitpick one article this closely. But this Vox article is getting a lot of attention as the best example of what the crisis is about and what we should do in response.

That concerns me. If this is the best we can do, we are in serious trouble.

I absolutely agree with this analysis and sentiment. We ARE in serious trouble and the nation’s mood reflects that.

More and more people are depressed and anxious as lifer in the U.S. has soured for all except those few at the very pinnacle of the economy, those who are sucking all life out of the rest of us in brutal working conditions, a continually shrinking safety net, and a complete lack of compassion.