Prevalent Misconceptions About Opioid Use Disorders in the United States Produce Failed Policy and Public Health Responses | Clinical Infectious Diseases | Oxford Academic – August 2019 – free full-text
The current opioid crisis in the United States has emerged from higher demand for and prescribing of opioids as chronic pain medication, leading to massive diversion into illicit markets.
This massive diversion is how so many millions of pills ended up on the streets, not from individuals stealing a handful of pills from grandma’s medicine cabinet.
This is an aspect of the “opioid crisis” that seems deliberately ignored. I suspect it’s because supposedly “legitimate” opioid dealers have been able to deflect investigations of their opioid supply chain dealings by pointing to the drama of “innocent kids” overdosing on prescription opioids (not prescribed to them).
A peculiar tragedy is that many health professionals prescribed opioids in a misguided response to legitimate concerns that pain was undertreated.
It’s a sad commentary on our society that a compassionate, effective response to pain is called “misguided”. That’s the real crisis, right there: a lack of compassion and rigid obedience to standards, no matter how cruel they may be in action.
The crisis grew not only from overprescribing, but also from other sources, including
- insufficient research into nonopioid pain management,
- ethical lapses in corporate marketing,
- historical stigmas directed against people who use drugs, and
- failures to deploy evidence-based therapies for opioid addiction and
- [failures] to comprehend the limitations of supply-side regulatory approaches.
Restricting opioid prescribing perversely accelerated narco-trafficking of heroin and fentanyl with consequent increases in opioid overdose mortality.
The DEA throughout its history has repeatedly fueled the same deadly black-market profits with its predictable and ineffective response to every prescription drug that became a drug of abuse. In one era after another their attempts to restrict the supply increased the incentives for illicit and much more dealy versions:
- barbiturates (angel dust, PCP),
- amphetamines (crack cocaine),
- opioids (heroin laced with illicit fentanyl),
- benzodiazepines (counterfeit pills laced with illicit fentanyl), and
- amphetamines again (powders laced with illicit fentanyl).
This viewpoint explores the origins of the crisis and directions needed for effective mitigation.
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.
The full paper then covers what they call the first and second crisis:
- The first crisis: 1865–1913
- The second crisis: 1960–1975
- The third crisis: 1995–TODAY
I’m more interested in the most recent of these:
The misconception unique to this current third crisis is the role played by legal and highly regulated opioid medications. Natural opiates had for millennia been a useful tool to treat many kinds of pain and were refined for medical use in the 19th century.
Since then, health providers have had a growing array of options for pain relief beginning with morphine, then a variety of semisynthetic opiate derivatives, and later, as pharmacology and pharmaceutical science grew more sophisticated, a wide range of fully synthetic opioids.
A review of the origins of the third crisis that began 30 years ago reveals efforts to shift American health systems toward “patient-centered” medical care, including better management of pain.
This is stated as though it were a “bad” thing when it is the only correct ethical choice: our medical care *should* be patient-centered, whether for pain or any other ailment because patients are individuals that differ widely from the “average patient” more often than not.
This was seen as a way to
- improve recovery after surgery or trauma,
For acute pain, opioids are by far the most effective drug; that’s why they are used for trauma like car accidents, organ transplants, or gunshot wounds.
Even in these virulent anti-opioid times, no medical professional has yet suggested such cases be treated with Tylenol or NSAIDs instead of opioids.
- reduce suffering among the terminally ill, and
Is a reduction of suffering only necessary for those who are about to die? What about those who have the same pain, but will still be living with it for years to come?
- allow people with chronic pain a higher quality of life.
All 3 conditions seemed to justify the increased use of opioids.
Why don’t these conditions still justify the use of opioids?
No other drug is as effective as opioids for achieving these 3 goals.
…the effectiveness of opioids for treating most kinds of chronic pain—musculoskeletal, neurological, or autoimmune—has been insufficiently studied.
Thousands of years after opioids started being used by humans for pain relief, it seems a bit odd that there’s been “insufficient study”.
On the other hand, rigorously random, double-blind, prospective, long-term studies of opioids for chronic pain might be considered unethical because some trial participants with significant pain would be treated with placebos or a less-effective non-opioid medication.
A previous study (“Krebs Study”), found a novel way to avoid this ethical problem: when a subject’s assigned non-opioid medication protocol wasn’t relieving their pain enough (which doctors are now instructed to ignore), researchers provided them with “rescue” medication.
It verifies everything we’ve been saying about opioids that this pain reliever of last resort was an opioid (Tramadol, a weak opioid, but an opioid nonetheless).
If opioids are really so ineffective for long-term chronic pain, then why would opioids be used as “rescue medication” for people who weren’t getting enough pain relief?
The Automation of Reports and Consolidated Orders System (ARCOS) is used by the US Drug Enforcement Administration to track opioids and some other controlled substances from manufacturing to retail distribution.
ARCOS data documented a doubling of opioid analgesic use, measured in milligrams per 100 people, from 2000 to 2010
Despite this large increase in opioid prescribing for chronic pain, we believe that this alone is not the cause of increased rates of OUD that occurred concurrently with increasing prescribing.
Our work, exploring the life histories of adults with co-occurring chronic pain and OUD, has failed to find a trajectory in which opioid prescribing for chronic pain preceded the development of OUD in individuals experiencing chronic pain.
In 2 separate studies conducted 10 years apart, experimentation and nonmedical opioid use preceded the onset of chronic pain for 80% of adult participants.
This should not be surprising, since
- experimentation is a feature of adolescence and early adulthood whereas
- chronic pain appears toward middle and older age.
This, then, is the second prevailing misconception: that the prescribing of opioids for chronic pain is the principal cause of rising addiction rates in adults during the third opioid crisis.
Only a small percentage of adults progress to OUD after being prescribed opioids after an episode of acute pain.
Studies of opioid prescribing for acute pain from conditions as diverse as surgery, burns, or sickle cell disease found that progression to OUD was rare, <3% for all 3 conditions.
A more recent, large study explored chronic opioid use 1 year after surgery for 11 surgical conditions covering 640000 opioid-naive patients. …prevalence of ongoing opioid use ranged from 0.12% for cesarean delivery to 1.4% for total knee replacement
Shifts in Opioid Availablility
The current crisis has its roots in the expansion of opioid prescribing and their diversion to illicit markets, but has been worsened more recently by supply-side efforts to limit opioid availability.
Multiple attempts to crack down on unethical pharmaceutical marketing practices and on large-volume prescribers or wholesalers whose practices have been deemed criminal or suspect have not reduced rates of new OUD diagnoses.
Opioid Use Disorder as a Disease
The third prevailing misconception views addiction as a moral failure, and has its roots, as described above, in the 2 previous opioid crises. This completely discounts the preponderance of evidence demonstrating the genetic and neurobiological basis of the disease of addiction
…the etiology of OUD is multifactorial; corporate malfeasance is only part of the explanation of the massive opioid use expansion in this third crisis.
A major goal of clinical medicine is promoting patients’ well-being, and if this requires prescribing exogenous opioids for acute pain and palliative care, such prescribing may be indicated.
Rather than blame the crisis on the moral failures of those who succumb to OUD and exploiters of market forces, it is time to identify and change the social and economic structures that created the conditions conducive to the expansion of opioid misuse.
the fourth prevailing misconception: that the ultimate goal of treatment for OUD is abstinence from any opioid use.
Abstinence-based “recovery” models are based on the false notion that OUD can be treated like an acute ailment. One recovers from influenza or a broken arm, but not from a chronic disease that recurs if treatment stops.
Opioid use disorder is much more like hypertension or diabetes; it can be effectively managed but is rarely cured, though abstinence is possible for some after many years.
Acceptance of this fact is rendered difficult because the organ system compromised by opioid use disorder is the brain. We like to believe that we have control over our brain, but much of our experience should disabuse us of this notion. Once continued opioid misuse has altered brain chemistry and neural pathways, the chances of restoring the brain’s original homeostasis are slim.
The paragraph above explains the inevitable circular logic used to accuse someone of addiction and in need of recovery:
Because you use a substance that changes your brain, your faulty thinking makes you believe you’re not addicted when you actually are (as determined by “us”).
studies going back a century reveal that failure rates for abstinence-based approaches to managing OUD are exceedingly high; recidivism rates of >90% within 6 months support neurobiology observations
Along with recidivism, there is compelling evidence for heightened rates of opioid overdose deaths in the wake of relapse as a result of reduced tolerance, which can occur in days to weeks. This is certainly true following periods of enforced abstinence in the criminal justice system. The rates of fatal overdose in the first few weeks following release are 5–10 times higher than at any other time in an individual’s life
In contrast, opioid agonist–based treatment sharply reduces overdosemortality. The preponderance of evidence, based on studies in the United States and abroad, supports additional health and social benefits and cost-effectiveness of agonist medications (methadone or buprenorphine)
What can be done?
This all begs the question of primary prevention of opioid misuse.
Why has the desire for the euphoric and pain-dulling effects of opioids increased in so many places in the United States during this third crisis? The answers are complex and most likely not easily remediated because they lie in social and economic transformations over the last 3 decades.
Large numbers of young and middle-aged people are unemployed or underemployed, adrift without adequate social support, and seeking escape within the context of an eroded social safety net.
Until these problems are addressed, we must mitigate the immediate problems of often-untreated OUD, relapse, and overdose.
This is only the first part of this free article. You can read the rest of the free full-text paper at Prevalent Misconceptions About Opioid Use Disorders in the United States Produce Failed Policy and Public Health Responses
This is the full article referred to in another recent post:
No evidence Rx opioids caused “Opioid Crisis” – Clinical Pain Advisor – Aug 2019