Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts | Pain Medicine | Oxford Academic – Mark Edmund Rose, BS, MA – Dec 2017
Sharp increases in opioid prescriptions, and associated increases in overdose deaths in the 2000s, evoked widespread calls to change perceptions of opioid analgesics. Medical literature discussions of opioid analgesics began emphasizing patient and public health hazards.
Repetitive exposure to this [mis-]information may influence physician assumptions.
This is a huge problem for us, and a sad commentary on the state of medicine in the U.S. when doctors are influenced more by media-hype and biased research than their patients’ lived experiences.
While highly consequential to patients with pain whose function and quality of life may benefit from opioid analgesics, current assumptions about prescription opioid analgesics, including their role in the ongoing opioid overdose epidemic, have not been scrutinized.
It’s pathetic how the medical industry has steamrolled over pain patients. I blame it on the financial sharks who have taken over the practice of medicine.
These money-grubbing sociopaths (yes, many CEO’s are sociopaths) don’t recognize they’re being led on by PROPaganda. This leads them to mandate media-hyped, politically-fueled “medical policy” restricting opioids to patients with legitimate and serious pain – as if that would make even the smallest difference in overdose deaths from street drugs.
By ignoring patient outcomes, such standard restrictions go completely against the correct practice of medicine and understanding of science, which tells us that individual patients respond very differently to the same opioids.
Methods
Information was obtained by searching PubMed, governmental agency websites, and conference proceedings.
Results
Opioid analgesic prescribing and associated overdose deaths both peaked around 2011 and are in long-term decline; the sharp overdose increase recorded in 2014 was driven by illicit fentanyl and heroin.
Nonmethadone prescription opioid analgesic deaths, in the absence of co-ingested benzodiazepines, alcohol, or other central nervous system/respiratory depressants, are infrequent.
Within five years of initial prescription opioid misuse, 3.6% initiate heroin use. The United States consumes 80% of the world opioid supply, but opioid access is nonexistent for 80% and severely restricted for 4.1% of the global population.
Conclusions
Many current assumptions about opioid analgesics are ill-founded.
Illicit fentanyl and heroin, not opioid prescribing, now fuel the current opioid overdose epidemic.
Hello, hello, is anyone in charge listening?
Apparently not.
National discussion has often neglected the potentially devastating effects of uncontrolled chronic pain.
Any concern over patient outcomes seems to have fallen out of fashion, as all the folks in medical management (and politics) race to most drastically limit opioid prescriptions, which have become the stand-in measure for success in fighting the contrived “opioid crisis”.
See my posts on the folly of such surrogate outcomes.
Opioid analgesic prescribing and related overdoses are in decline, at great cost to patients with pain who have benefited or may benefit from, but cannot access, opioid analgesic therapy.
Introduction
Opioid analgesics remain the most effective drug class for controlling severe pain, but carry potential for adverse effects, misuse, and overdose
Every person writhing and screaming after horrific accidents or invasive surgeries understands this, and yet some doctors now insist on giving IV Tylenol.
While highly consequential to patients whose quality of life and function benefit from opioid analgesia, current assumptions about opioid analgesic prescribing have not been scrutinized
Therefore, these assumptions were examined for validity. Data were obtained from multiple public, including governmental, sources, as described below.
Background
The important role of opioid analgesics is broadly accepted in acute pain, cancer pain, and palliative/end-of-life care, but opioid use in chronic noncancer pain is controversial, and this debate is polarized.
One would think this would depend on the patient, as does the rest of our medical care.
Propagation by the CDC of one-sided information on opioid analgesic prescribing fueled sensationalized portrayals of opioid analgesics, prescribers, and patients.
These portrayals promoted stigma and misperceptions of opioid analgesics in health care and lay populations, with far-reaching consequences.
Public statements, such as those by the CDC leadership that “prescription opioids…are no less addictive than heroin” have not been helpful..
When exposed to misinformation and/or covert threats by drug enforcement or regulatory bodies, physicians change their opioid prescribing patterns through increased subanalgesic dosing, tapering patients off opioids, refusing to prescribe opioids or even to see patients with pain complaints.
This “crisis” has shaken my faith in medical professionals (and their know-nothing managers).
I used to think doctors were well-educated and knew more about my body than the media and self-appointed experts, but when I see how media hype has infiltrated my medical care, swaying the minds of educated doctors who should know better, I’ve begun to realize they aren’t as smart as I thought they were (as a group).
Luckily, there are always exceptions, but finding them is a matter of luck and location. Especially now that “doctor shopping” is considered a “red flag” (after years of being told we should “shop around” for our medical care) we can no longer seek out better medical care elsewhere.
The improvement of prescribing patterns is best achieved through presentation of comprehensive and balanced information.
Why This Matters: Consequences of Uncontrolled Chronic Pain
The negative impact of severe chronic pain is hard to overstate.
A pioneer in pain research observed that prolonged uncontrolled pain can destroy the quality of life, the will to live, and drive some patients to suicide.
Psychosocial consequences of unmanaged pain can be severe, with adverse psychological (impaired cognitive function, pathologic anxiety/depression, suicidal ideation, despair, hopelessness) and social/interpersonal (relationship disruption, loss of employment/financial ruin) outcomes.
Assumptions Informing the Current Opioid Debate: Fallacies or Facts?
Safety is the foundation of opioid analgesic prescribing and a basic principle of good medical practice, but misinformation has influenced current assumptions of opioid analgesic prescribing safety, risk, and efficacy.
Misperception: Prescription opioid analgesic overdose (OD) deaths soared in 2014 and continue to increase.
Fact: Fatal prescription opioid analgesic ODs have steadily declined since 2011; in contrast to earlier reports [63–66], the 2014 increase was not due to prescription opioid analgesics [67,68].
The CDC classifies opioids as:
1) natural (morphine, codeine) and semisynthetic (oxycodone, hydrocodone) opioid analgesics;
2) methadone;
3) nonmethadone synthetic opioid analgesics (fentanyl, tramadol); and
4) illicit opioids (heroin).Groups 1–3 can be combined as opioid analgesics or prescription opioids, distinct from illicit opioids.
The cited reference, the Wide-Ranging Online Data for Epidemiologic Research (WONDER) database, is a public-access CDC database. Other CDC releases show differing figures. Recent opioid analgesic overdose figures by the CDC are inconsistent; these are presented in Table 1:
Disparate opioid overdose fatality data published by the CDC
Evaluated Opioids 2015 2014 2013 Opioid analgesics n/a 18,893 [63–65] 16,235 [64,65] Opioid analgesics minus fentanyl*,† [13] n/a ∼14,000 693 fewer than 2014 Prescription opioids [66] ∼22,000 ∼19,000 n/a Prescription opioids minus fentanyl*,† [66] More than 15,000 443 fewer than 2015 n/a Natural and semisynthetics‡ [67,68] 12,727 12,159 n/a Natural, semisynthetics,‡ methadone [67,68] 16,028 15,559 n/a Fentanyl* [67,68] 9,580 5,544 n/a Heroin [67,68] 12,989 10,574 n/a Fentanyl* plus heroin [67,68] 22,569 16,118 n/a
Evaluated Opioids 2015 2014 2013 Opioid analgesics n/a 18,893 [63–65] 16,235 [64,65] Opioid analgesics minus fentanyl*,† [13] n/a ∼14,000 693 fewer than 2014 Prescription opioids [66] ∼22,000 ∼19,000 n/a Prescription opioids minus fentanyl*,† [66] More than 15,000 443 fewer than 2015 n/a Natural and semisynthetics‡ [67,68] 12,727 12,159 n/a Natural, semisynthetics,‡ methadone [67,68] 16,028 15,559 n/a Fentanyl* [67,68] 9,580 5,544 n/a Heroin [67,68] 12,989 10,574 n/a Fentanyl* plus heroin [67,68] 22,569 16,118 n/a
CDC = Centers for Disease Control and Prevention.
*Illicit fentanyl, phrased in the cited reference as “non-methadone synthetic opioids.”
†Removed to eliminate deaths involving illicit opioids.
‡Semisynthetic opioid analgesics.Discussion
This paper examined the factual basis supporting or refuting common assumptions about opioid analgesic prescribing.
Publically available data on opioid analgesic prescribing show long-term decline and corresponding decline in ODs.
When taken as prescribed and not combined with sedatives and/or alcohol, fatal OD is infrequent.
Population-wide, misusing prescription opioid analgesics infrequently leads to heroin use.
Importantly, recent data show a fundamental shift in the “opioid overdose epidemic” away from prescription opioid analgesics and toward illicit opioids (heroin and fentanyl).
Lobbying by advocates of opioid prescribing restrictions may contribute to proposals advocating blanket restrictions on access to opioid analgesics regardless of individual patient need.
Some advocates are motivated by the tragedy of losing a loved one to prescription opioid toxicity or OUD that began during opioid analgesic therapy. One can appreciate the pain they experienced and their desire to spare others the fate of their relative.
However, unidimensional solutions to complex public health issues often yield undesired consequences.
Suicide by patients with chronic pain unable to access, or cut off from, opioid pain relief may come to rival fatal prescription opioid analgesic overdoses
Opioid analgesic prescribing has received greater media attention than other drug classes or prescribing patterns linked to highly concerning outcomes
Many unsafe opioid prescribing practices and overdose risk factors have been identified over the past two decades, yet until new analgesics enter clinical use, and there are few alternatives to opioids for controlling severe pain, and none that are widely available.
The National Pain Strategy recommends that pain management in our health care system be improved by pain education of patients and pain training of clinicians [121].
When prescribed judiciously with careful attention to possible comorbid psychiatric, substance use, or medical disorders and potential adverse drug interactions [4], morbidity and mortality associated with prescription opioid analgesics, including overdosage, can be reduced, and in fact have steadily declined since peaking in 2011.
In contrast, the recent upsurge in opioid-related deaths is attributable to the illicit opioids fentanyl and heroin.
This pattern of overdose fatality is unlikely to respond to regulation of access to medically prescribed opioid analgesics.
EDS and Chronic Pain News & Info 
This nation has gone fact free. They allowed the topic of opioids to be used for marketing, and from day one this has been profitable. Each and every intervention they have done, led to even more deaths. Instead of researching why this was happening, or collecting clear meaningful data, the regulatory agencies, the DEA and even the NIH, decided to run another narrative.
My state has been in a unique position, they had a heroin problem since the 1990s. They also set up a PDMP in 2011. They chose to ignore the facts here, and terrify people about “prescription drugs.” This led to even more deaths, despair, crime, children in foster homes, and people without healthcare. Of course they are still ignoring all of it. They conflated pain patients with craven drug addicts for a reason and media even reported on “addicted infants.” Each and every newspaper article on this topic was misinformation. They even allowed people to get medical marijuana for opioid addiction, of course only 7 people took them up on it.
They are not counting the suicides, and the deaths that appear to be accidents either. A number of people are dying now from fentanyl, laced fake pills. Those drug dealing cartel people are good marketers, they are even putting fentanyl in crystal meth and cocaine, leading to more deaths. People who need surgery or dental care, are now avoiding it, they already know their pain will not be treated.
At least we know that many of these deaths would have been avoided, if we had Medicare For All or Universal Healthcare. We can see how the corruption at our regulatory agencies led to more deaths. We see how they turned a public health problem into marketing opportunity as people suffered and died. We saw unscrupulous and self serving people make a name for themselves and a lot of money, repeating lies and false narratives as more people died.
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Kaiser Health News had some interesting tid bits today, https://khn.org/morning-breakout/fda-failed-to-properly-police-program-meant-to-curb-opioid-epidemic-at-height-of-crisis-new-documents-show/
None of this was accidental, the FDA was protecting the industry not American lives. Now almost 10 years out, the lies, propaganda and denial continue, as even more Americans die.
https://thehill.com/policy/healthcare/476260-fda-cant-prove-effectiveness-of-opioid-safety-strategy-analysis-finds
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These days, some guy’s “hunch” is getting turned into public policy and never evaluated again. That’s to make sure they can’t be proven wrong about their crazy ideas.
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Exactly Zyp!
They are making policy based on beliefs and stuff they heard in the media. I was just on the NPR Page, https://www.npr.org/sections/health-shots/2020/01/02/782654754/effort-to-control-opioids-in-an-er-leaves-some-sickle-cell-patients-in-pain
They clearly state that “Sickle Cell patients are not driving the addiction crisis. Then scroll down to the previous articles, where teens “need more pain” to prevent pain, a brisk walk is all that is needed, “Meditation reduces chronic pain by 75%” and an assortment of misreported articles about pain. Most of the articles read more like content marketing than anything scientific. We can see a similar pattern at the other media sites.
Of course allowing and encouraging patients to suffer and endure torture, to prevent opioid addiction, has not had any effect on the deaths or addiction rates. There was another piece here, https://www.theatlantic.com/health/archive/2020/01/what-caused-opioid-epidemic/604330/ An article that draws a correlation between economic factors and deaths of despair. The addiction industry, and the rest of the profiteers avoid these factors, as if they do not exist. It was just easier to blame sick people, they are a convenient target for scapegoating.
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I read that NPR article too and was absolutely horrified. There’s even a quote from some butthead doctor claiming he didn’t realize how giving these suffering people proper pain relief was “causing” addiction. That makes me see red!
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