Non-medical opioid users were not pain patients

Today’s nonmedical opioid users are not yesterday’s patients; implications of data indicating stable rates of nonmedical use and pain reliever use disorder – Journal of Pain Research – Jeffrey a  Singer, Jacob Z Sullum, Michael E Schatman – Feb 2019

This paper published in the Journal of Pain Research calculates the numbers and types of overdoses over the years and finally puts to rest the unsubstantiated story that pain patients are the ones overdosing and dying.

According to the narrative underlying current policies aimed at reducing opioid-related deaths, the problem can be traced to a dramatic increase in opioid prescribing that began in the late 1990s.

This trend supposedly was fueled by unscrupulous pharmaceutical company representatives who convinced practitioners that opioids posed a low risk of misuse and overdose (although a recent analysis suggests there were probably 30 or more root causes of the crisis).  

The President’s Commission on Combating Drug Addiction and the Opioid Crisis: Origins and Recommendations. – PubMed – NCBI – Jun 2018

The United States has the ignominious distinction of leading the world in opioid prescribing, and in opioid-related overdose deaths. The Centers for Disease Control (CDC) estimates that over 40,000 people died of an opioid-related overdose, with fentanyl-related deaths exceeding those of heroin or prescription opioids.

Opioid overdoses are now the leading cause of unintentional deaths in the US and of declining lifespan expectancies.3 With a worsening crisis, agencies of the US government and others produced an array of reports on the opioid crisis. Yet the death rate escalated further from 2010 to the present.

To illustrate this narrative, politicians and journalists have cited examples of patients who accidentally became “hooked” on opioids while taking them for pain, such as teenagers with orthopedic injuries who found the analgesics prescribed for them so alluring that they progressed to lives of drug abuse and addiction

This narrative drives policies targeting the prescription of opioids to patients in pain, with the goal of reducing the risk of addiction as well as the diversion of prescription opioids to the underground market.

These policies include state prescription drug monitoring programs (PDMPs), abuse-deterrent formulations of prescription opioids, prescribing guidelines, and legal restrictions on prescribing for both acute and chronic pain.

Despite these efforts, opioid-related deaths have continued to rise.

Here’s your hint that the current policies aren’t working, but the anti-opioid zealots are just doubling-down and hardening their stance.

The deaths have continued to rise despite the fact that per capita high-dose opioid prescriptions (90 MME or greater) fell by 58% from 2008 to 2017,4 while the total volume of opioids dispensed fell by 29% from 2010 to 2017

Since 2010, deaths involving heroin and fentanyl have risen much more dramatically than those involving prescription opioids. The share of opioid-related deaths involving “synthetic opioids other than methadone” rose from 14% in 2010 to 60% in 2017.

that category consists almost entirely of illicitly produced fentanyl and fentanyl analogs, manufactured in Asia or Mexico and smuggled into the United States, often via mail or private courier.

The incredible potency of this drug requires such tiny doses that a batch to be sold can easily be sent through the mail in a normal business envelope.

Adding other drugs to the analysis of the CDC’s data makes the role of prescription opioid analgesics appear even less significant.

For instance, 68% of deaths involving prescription opioids in 2017 also involved

• heroin,
• fentanyl,
• cocaine,
• barbiturates,
• benzodiazepines, or
• ethanol.

Thus, fewer than 10% of opioidrelated deaths involved prescription pain relievers without those other dangerous substances.

Research suggests that the advent of abuse-deterrent opioids was a significant factor in this shift.

There is also some evidence that PDMPs have contributed to the replacement of prescription opioid analgesics with heroin and fentanyl.

Challenging the standard narrative

The data suggest that the overdose crisis is largely an unintended consequence of drug prohibition.

Prohibition provides powerful economic incentives for illicit manufacturers, transporters, and dealers to supply banned substances

as diverted pain pills became more difficult to obtain in recent years, the black market filled the void with cheaper (and more dangerous) heroin and illicit fentanyl.

Yet defenders of the standard narrative believe [still?] that the population of nonmedical users consists primarily of patients who were inappropriately prescribed opioids for painful conditions.

Based on that premise, they reason that reducing opioid prescribing in conjunction with better drug interdiction and expansion of drug treatment should gradually eliminate the problem.

Unfortunately, the data do not support that expectation.

The National Survey on Drug Use and Health (NSDUH) has repeatedly found that <25% of nonmedical prescription opioid users obtain these drugs from a prescriber; the rest obtain them from friends, relatives, or dealers.

In a 2007 study of more than 27,000 OxyContin addicts who entered rehab between 2001 and 2004, Carise et al found that

• 78% said the drug was never prescribed for them for any medical reason,
• 86% took the pills to get “high” or get a “buzz”, and
• 78% had a history of prior treatment for a substance abuse disorder.

The rate of “past month nonmedical use of pain relievers among people aged 12 or older” was essentially flat in that survey from 2002 through 2014.

Yet, the volume of opioids prescribed in the United States almost doubled between 2002 and 2014.

Conversely, reducing prescriptions has not reduced opioid-related deaths. To the contrary, it seems to be driving up the death toll by pushing nonmedical users toward deadlier drugs.

Toward a Truer narrative

In a September 2018 analysis of CDC data going back to the 1970s, Jalal et al found that “death rates from drug overdoses in the U.S. have been on an exponential growth curve that began at least 15 years before the mid-1990s surge in opioid prescribing

Summing up these findings, NBC News correspondent Maggie Fox observed that the overdose crisis “started before the availability of synthetic opioids, and may have only a little to do with the prescribing habits of doctors or the pushy habits of drug makers”

Americans increasingly have been engaging in the nonmedical use of licit and illicit drugs since the late 1970s. Some of this drug use may represent self-medication in response to anxiety, depression, alienation, and despair.

However, policymakers and the media tend to favor simple explanations and solutions for complex problems, and the opioid overprescribing narrative is no exception

However, policymakers and the media tend to favor simple explanations and solutions for complex problems, and the opioid overprescribing narrative is no exception

It’s easier to track overdoses than rates of misery and despair, so guess which one is counted.

Harmful effects of the standard narrative

Opioid-related deaths continue to rise even as many patients in chronic pain have seen their medication dosages involuntarily reduced or cutoff altogether. Some, in desperation, have sought relief from the black market or even in suicide

Health care providers have criticized the imposition of prescription limitations as a misinterpretation of the opioid prescribing guidelines published by the CDC in 2016, and some have criticized the guidelines themselves as lacking a firm empirical basis.

…a diverse group of pain and addiction specialists who signed a November 2018 letter in Pain Medicine that describes “nonconsensual tapering policies” as a “large-scale humanitarian issue.”

Conclusion

The current overdose crisis is rooted in the intersection of long-term psychosocial and cultural trends with the lucrative opportunities offered by drug prohibition.

I’m surprised to see such language, bordering on political opinion, in a scientific journal.

I happen to agree with the authors’ assessment, but it feels vaguely unsettling to read an unsupported (and almost tangential) implication that the “lucrative opportunities offered by drug prohibition”.

Ending drug prohibition will not curb the growing tendency to use drugs nonmedically. However, it will potentially reduce the resulting harm.

Health care in general, and pain and addiction management in particular, are nuanced undertakings

Current public policies aimed at reducing opioid-related deaths ignore such nuance in favor of ham-handed, empirically dubious, and demonstrably harmful dictates