Over-Prescribing Did Not Cause the Opioid Crisis

Over-Prescribing Did Not Cause America’s Opioid Crisis – By Richard A. Lawhern, Ph.D. –  Mar 2019

A central assertion in many articles is that the crisis began with physicians over-prescribing to their patients in the 1990s and early 2000s, in an era of “Pain as the Fifth Vital Sign.”

Almost the entirety of present U.S. public policy on opioid pain relievers at Federal and State levels is founded upon this false claim.

Governments are engaged in a vast exercise in regulatory over-reach, seeking to “solve” our opioid crisis by restricting dose levels and duration of treatment for both acute and chronic pain.  

However, attribution of blame to doctors is flat-out wrong.

We need only look at the data.

Figure 2:  CDC Overdose Mortality vs. Prescribing Rates

In this real-world data drawn directly from the CDC Wonder database, each point shows the number of overdose-related deaths per hundred thousand population, versus the number of prescriptions written by any doctor, per hundred population.

Data are shown for 50 U.S. states plus DC. The data plot looks like a shotgun blast aimed at a barn door. There is no consistent upward trend here. There are instead wide variations from state to state. And there is certainly no correlation or cause-and-effect.

According to the prevailing mythology so widely shouted by anti-opioid advocates, we would expect higher rates of overdose deaths among populations that receive more opioid prescriptions. But this doesn’t happen, either.

Figure 3 shows us the rates of opioid prescription compiled by age group.

Figure 3:  Opioid Prescribing by Age

Rates of prescribing are highest for seniors by a factor of 300% when compared to young people. This is an expected result. Older people are much more often treated for chronic pain

As we see from Figure 4 below, the rate of opioid overdose deaths from all sources in people above age 51 is the lowest for any age group.

Likewise, that rate has been stable for 17 years, as overdose death rates among kids and young adults have sky-rocketed to levels now six times higher than in seniors

This chart was constructed by searching the CDC Wonder database by age (1 year intervals) and State, current as of December 2017, using the Drug/Alcohol Induced Causes selection in underlying cause of death and choosing “drug related.”

Figure 4:  Opioid Overdoses by Age, 1999 to 2016

A third contradiction to the prevailing policy narrative is that the demographics of opioid overdose death are very different from those of chronic pain patients prescribed opioids.

The typical new abuser of opioids is a young male who also abuses alcohol and has a history of unemployment, family stress or family substance abuse, and sometimes mental health problems. But the typical chronic pain patient (by a ratio of about 60/40) is a woman in her 40s or older

There is also strong evidence that policies restricting access to opioids have been completely ineffective in moderating our overdose crisis.

From a peak in 2010, opioid prescribing has steadily been driven downward by our hostile regulatory environment. That rate is now more than a third lower than in 2010.

However, overdose-related mortality has more than doubled, in large, part due to the emergence of illegally manufactured fentanyl into street markets.

Our Opioid Crisis Is Real

But the crisis is not one of over-prescribing except in a very narrow sense. Prescriptions partially unused by legitimate pain patients may find their way into family medicine closets where they may be later stolen by a family member or burglar.

Much larger volumes of “corporate diversion” can be traced to relatively few unscrupulous doctors operating pill mills.

Thus, our “opioid crisis” is an issue not of medical exposure to prescriptions, but of street drugs and unsafe storage and careless tracking of prescriptions distributed from manufacturers.

I hope you’ve commented on the @HHSGov Pain Management Best Practices Inter-Agency Task Force Document.

This is a critically important effort undertaken by the government to counter the horrific undertreatment of pain in America unleashed by the CDC.

https://www.federalregister.gov/documents/2018/12/31/2018-28403/request-for-public-comments-on-the-pain-management-best-practices-inter-agency-task-force-draft

For some encouragement, ideas, and useful tips, please see the previous post:

Just under 2 days left to comment on @HHSGov Pain Mgmt

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