Though the subject here is opioid addiction, I’m amazed and delighted to find this publication for medical professionals repudiating the assumed link between opioid prescribing and addiction.
The current opioid crisis is the third one observed in the United States. This latest trend is, however, the result of unusual factors and has had some unique effects.
Knee-jerk reactions to restrictions on opioid prescriptions have resulted in an increase in the narco-trafficking of heroin and fentanyl, and as the consumption of opioids shifted from oral intake to injections, hepatitis B and C and HIV infections have increased.
“The unintended effect [of limiting supply] has opened many communities to narco-trafficking. New markets for heroin have emerged to take the place of ‘pill mills’ and other sources for diverted pharmaceuticals,” explained the article’s authors.
“We believe that the new, cartel-supplied black markets for heroin/fentanyl have produced more dire consequences than if misuse of pharmaceuticals had continued.”
Then comes the sentence that’s truly revolutionary in such a publication, whose intended audience is medical professionals:
Researchers note that despite a documented doubling of opioid analgesic use from 2000 to 2010, they cannot find evidence that prescribing opioids for chronic pain is the principal driver of rising addiction rates in adults.
After years and years of regurgitating the latest carefully manipulated study damning opioids and adding to the anti-opioid rhetoric, this is the first reference I’ve seen to the fact that there was never any evidence that prescribed opioids are the “principal driver of rising addiction rates.”
The article states this truth as though it weren’t of particular significance, whereas I see it as a monumental about-face on this publication’s long-established anti-opioid stance.
OUD develops in only a small percentage of adults who are prescribed opioids for acute pain.
The article points out that in studies of extremely large numbers of people prescribed opioids, only a tiny fraction become addicted:
In a large study of 640,000 opioid-naive patients in which chronic opioid use was examined one year after surgery for 11 surgical conditions, the prevalence was found to range from 0.12% for cesarean section deliveries to 1.4% for total knee replacement surgeries.
In another study in which chronic opioid use was examined in approximately 18 million people with acute pain who had not undergone surgery and had never taken opioids, only 0.14% of those who were prescribed opioids were found to still use the medications a year later.
This is followed by a long list of more reasonable policy proposals for dealing with OUD when it does happen, mostly due to illicit opioids and not prescriptions:
Recommendations From Researchers
Researchers recommend several measures to stem the opioid crisis:
- Relax the regulations outlined in the Drug Abuse Treatment Act of 2000, in particular, those pertaining to requirements for physicians wishing to prescribe buprenorphine (ie, length of training course, number of patients treated).
- Omit or limit the quantity of opioids prescribed to young people and monitor the substance use patterns of patients who were initially treated with opioids to manage acute pain (eg, from injury or surgery).
- Conduct additional research to investigate the nature of factors that may predispose to OUD.
- Screen older patients for previous nonmedical use of opioids and substance use disorders before prescribing them opioids.
- Remove the stigma associated with OUD by recognizing this disorder as a treatable chronic disease with a favorable prognosis.
- Develop services complementary to OUD treatment to help patients develop appropriate life skills.
- Expand overdose prevention programs and community-based distribution of naloxone.
- Conduct research for the development of nonopioid medications and nonpharmacologic alternatives for the management of chronic musculoskeletal, neurologic, and autoimmune pain.
- Expand paid medical leave, reduce copays, and improve access to nonpharmaceutical approaches.
If more workers were given paid “sick days” or medical leaves, they might not have to use large doses of opioids to reduce the pain enough to do their jobs.
When people are living paycheck to paycheck, they can’t afford to take any unpaid time off and will do whatever is necessary to do their jobs, even if those jobs require strenuous physical labor or, at the other end of the spectrum, endless hours motionless and glued to a computer screen.
With paid time off, they could stay home and recover at least somewhat. They could nurse their injuries in order to heal and not just swallow pills to kill the pain and keep going to work.
Although the treatment of OUD with opioid agonists is endorsed by
- the World Health Organization,
- the American Medical Association,
- the National Institute on Drug Abuse,
- the Office of National Drug Control Policy, and
- the Centers for Disease Control and Prevention,
fewer than half of substance abuse treatment facilities offer patients these options.
stigma associated with drug addiction has created a climate in which abstinence is valued over effective treatment,” noted the article’s authors.
“Often this preference is centered on an ethical argument that agonist therapy is merely replacing one drug with another.”
Although research studies have identified an array of effective treatment interventions for OUD, these have not widely been taken into account by policymakers when crafting related regulations.
Engaging policymakers may help bridge the gap between evidence and policy.
We have been trying to do exactly this, but have not been able to make much headway.
Politicians know that most of their constituents have no knowledge about pain, opioids, and addiction besides what they see or hear in the horrific examples of opioid overdoses that generate click-bait headlines.
These constituents want their leaders to clamp down on those “evil opioid heroin pills that immediately cause addiction” – at least as long as they aren’t suffering pain themselves.
- Heimer R, Hawk K, Vermund SH. Prevalent misconceptions about opioid use disorders in the United States produce failed policy and public health responses. Clin Infect Dis. 2019;69:546-551.
- Miclette MA, Leff JA, Cuan I, et al. Closing the gaps in opioid use disorder research, policy and practice: conference proceedings. Addict Sci Clin Pract. 2018;13(1):22.
Here are the critical sentences from the 2nd scientific paper above: Closing the gaps in opioid use disorder research, policy and practice: conference proceedings.
At the national and local levels, the sometimes-lurid stories and more serious, probing, evidence-based investigations have failed to promote and disseminate evidence-based actions.
These failures are, we believe, rooted in a set of prevailing misconceptions that holds
- that the crisis was driven primarily by financial gain sought by corrupt pharmaceutical manufacturers abetted by duped or corrupt medical personnel,
- that treating patients suffering from chronic pain with opioids is a fundamental driver of addiction,
- that addiction itself is an individual moral failure, and
- that abstinence-based recovery is the most desirable treatment for those suffering from OUD.
These oversimplified explanations need critical examination and historical context that recognizes that we are now in the third critical period of expanding OUD.
Finally, we’re seeing the awakening we’ve been waiting for when the persistent and fact-free PROPaganda is overtaken (and hopefully eventually annihilated) by reality.