Misperceptions about the ‘Opioid Epidemic’ Debunked

Misperceptions about the ‘Opioid Epidemic:’ Exploring the Facts – July 2019 – Pain Management Nursing

In this lengthy document, the authors meticulously prove that the ‘Opioid Epidemic’ is a complete fabrication, hyped by anti-opioid activists and spread into our society and even our medical system despite reams of evidence to the contrary from science and government data.

This thoroughly referenced article itemizes and thoroughly debunks the anti-opioid misperceptions (if not outright lies) that have swept through the medical profession and corrupted clear, logical thinking about the rising rate of illicit drug overdoses (not from prescribed opioids).

This is the most sensible document I’ve ever read about the so-called “opioid crisis”. Supported by numerous scientific references, it makes all the arguments we pain patient advocates have been making for years. 

You can print out the original document (link at top & at bottom of post) to take to any doctor who wrongly denies you the necessary opioid pain relief. If forced tapers have become policy for your doctor, ask them who made the policies and how you can get this information into their hands.

Finally, some clarity and documented facts on the current overdose crisis brought to you by the folks working in the trenches: nurses.

A plethora of statistics and claims exist concerning the rise in prescription opioid use and the increase in opioid-related deaths.

Eleven misperceptions were identified that underlie some of the growing national concern and backlash against opioid use.

Misperceptions include

• the number of opioid overdose deaths,
• the quality of government-sponsored data and guidelines,
• the impact of opioid dose escalation on overdose risk,
• postoperative opioid use associated with long-term use, and
• the link between prescription opioid use and heroin initiation.

Implications for research, practice and education include

• a call for improvement in data recording,
• unbiased and clear reporting of information, 
• a call for health care providers to ask critical questions when presented with data, and 
• a call for policymakers to avoid unnecessarily restrictive practices that are founded in fear and may cause unintended harm to patients in pain.

As concern broadens and emotional intensity rises, data that are quoted to raise awareness and determine causes of the opioid epidemic can become clouded and statistics can become confusing or conflated. The term epidemic itself can be misleading and emotionally charged as it suggests a widespread disease that is usually highly contagious

The risks in the charged atmosphere regarding overdose (OD) deaths involving opioids are multiple, including

• minimizing the cost and prevalence of the chronic pain crises affecting 23-25 million persons at a cost of up to $635 billion/year
• misunderstanding the overdose problem by data inaccuracies or oversimplifications; and
• designing solutions that are either ineffective or cause unintended harm in arbitrarily limiting access to opioids for chronic pain patients.

Opioids remain a necessary and effective agent for pain control and can be safely prescribed with judicious understanding of

• pharmacology (including opioids and other synergistic agents such as benzodiazepines) and
• factors contributing to risks with opioid use related to medical illnesses and mental health disorders (including substance use disorder [SUD]

Advocacy and safe practice require sifting through the volume of statistics cited about the opioid epidemic and discerning misunderstandings from well-founded fact.

Many current assumptions that are buoyed by statistics about prescription opioids are ill founded and can further fuel an already charged atmosphere and cloud the facts.

The purpose of this review is to investigate a number of common misperceptions pertaining to opioid use/misuse and ODs and replace them with facts and data.

This very long document then goes on to list the 11 main misperceptions which have been promoted by the anti-opioid zealots and proves, in great detail and with numerous scientific references, that these are simply unsubstantiated myths.

Misperception 1: Deaths Reported as “Prescription Opioid Deaths” Indicate That Prescribed Opioids Are the Direct Cause of Death

Fact: Prescription opioid-related deaths are deaths where prescription opioids are present at the time of death but may not be the cause of the death.

Deaths that are directly caused by prescription opioids are not the same as other similar terminologies such as “prescription opioid-related deaths” or “deaths involving prescription opioids.” The presence of an opioid may not be the cause of death but, unfortunately, if present will be listed as one or more of the causes of death

Thus a death might be caused from an OD of acetaminophen, but if there was hydrocodone detected, even in minor amounts and had been used according to the prescribed directions, it would also be classified as a prescription opioid death.

It is important to recognize that the coding from the National Vital Statistics System (NVSS), which gathers data from death certificates in most states, does not actually reflect the cause of death, but the conditions that existed at the time of death.

Thus, when multiple opioids are present at the time of death, it is unknown which opioid caused the death or if the opioid contributed to the death at all.

To add to the confusion, the system of recording drug OD deaths involving specific opioid drugs and categories incurs duplicate recordings that can add to misperceptions of the problem. 

By recording the deaths in more than one opioid category, the reported statistics then can only accurately claim that the death “involved” opioids.

Thus an OD death caused by heroin with hydrocodone also detected would be considered a heroin OD death and a prescription opioid OD death.

This practice of recording deaths in more than one category adds confusion and can conflate the understanding of scope of the problem.

Misperception 2: The United States Is the Biggest Consumer of Opioids, Indicating Opioid Overprescribing Is Unchecked

Fact: The data supporting the idea that United States is the biggest consumer of opioids are misleading because they are taken out of context.

First, most other countries do not report data on prescription opioid use, so the statement that the United States is the largest global consumer of opioids cannot be substantiated

Second, according the World Health Organization, only 7.6% of the world’s population is calculated to have adequate access to opioids, with a staggering 80% of the world’s population living in areas with minimal or no access to opioids

Third, many other countries that have adequate access to opioids prefer other opioids over hydrocodone. In Europe, dihydrocodeine is preferred over hydrocodone and morphine

Without this broader context, the data are skewed and falsely supports the claim that health care providers (HCPs) in the United States overprescribe opioids based on the share of global opioid use.

Misperception 3: Prescription Opioid OD Deaths Continue to Escalate and Cause the Majority of Opioid-Related Deaths

Fact: Illicit opioids are primarily driving the current rise in opioid-related OD deaths, whereas prescription opioid OD deaths declined after 2011, with small rises since 2014.

The primary statistic of concern is the number of opioid OD deaths, which have undeniably increased over the last two decades.

Many governmental publications, such as those from the CDC and others, have outlined this rise in death rates and have called for action in decreasing the number of opioid prescriptions written.

However, less publicized and often overlooked is the fact that the number of opioid prescriptions and prescription opioid–related deaths hit a peak in 2011 at 16,917 OD deaths involving opioids, with declines during 2012-2014, when the numbers were recalculated to separate out synthetic opioids

Without synthetic opioids, which are primarily driven by illicitly manufactured fentanyl (IMF), OD deaths were 14,220 in 2012 and remained relatively stable in 2013.

The disparity between these numbers indicates that there were many more deaths related to synthetic opioids/IMF other than methadone

Although opioid-related deaths continue to rise nationwide at significant rates, it is now clear that this is primarily driven by stark increases in the use of IMF as well as heroin.

This fact, however, is still not often conveyed in published materials, leading to a continued unbalanced view of the role of prescription opioids in this public health challenge.

Another factor in understanding OD death rates is the lack of discernment between prescription and nonprescription opioid–related deaths.

This is illustrated in the commonly discussed statistic of the number of Americans dying every day from drug ODs, which can be quoted as dozens to hundreds.

1. SAMHSA states, “44 people die every day in the United States from overdose of prescription painkillers” (2017).
2. When the hyperlink of the source of the statement is activated, the reader is taken to the CDC website, which states, “91 Americans die every day from an opioid overdose” (CDC, 2016b).
3. Finally, the U.S. Attorney General has stated that “140 Americans on average now die from a drug overdose each day” (U.S. Department of Justice, 2017).

The reader is left wondering if it is indeed 44, 91, or 140 people dying from drug ODs every day.

A closer look does shed some light on this confusion. If the initial statistics are examined, we find that the drug categories referred to by the various publications and websites are not identical.

In comparing the three sources just given, we find that

1. SAMHSA (2017) cites 44 deaths/day from prescription opioids;
2. the CDC (2016b) cites 91 deaths/day from all opioid sources, including licit and illicit opioids; and
3. the U.S. Attorney General cites 140 deaths/day (U.S. Department of Justice, 2017) from drug ODs, which includes all prescription and nonprescription medications, as well as illicit drugs.

Misperception 4: More People Die from Prescription OD Deaths Than from Motor Vehicle Accidents

Fact: Prescription OD deaths continue to be fewer than motor vehicle accidents (MVAs), even though all opioid OD deaths have exceeded MVAs.

In addition to separate sources reporting varying death statistics, a confusing mismatch of statistical categories can often be found in the same paragraph of a document.

Often a topic begins discussing ALL drug ODs, because the higher number is typically the most attention grabbing, and then proceeds to specifically discuss opioid ODs.

prescription opioid deaths excluding synthetic (largely IMF) opioids have continued to drop by increasing margins from 48.2% fewer than MVA deaths in 2014 to 58% fewer than MVA deaths in 2017 (Table 2)

Misperception 5: The Long-Term Use of Opioids Is Not Supported by Evidence for Either Benefit or Safety

Fact: Although there many studies showing opioid effectiveness in short-term trials (<12 weeks), there are very few randomized controlled trials (RCTs) conducted for 1 year or more on opioid AND nonopioid analgesics as a result of multiple limiting factors.

This misperception is misleading in multiple ways. It is true that there are few RCTs examining the risks and benefits of opioid therapy extending up to 1 year or more compared with a different opioid or with placebo. However, there are equally few long-term RCTs of nonopioid analgesics beyond 12 weeks duration of study (Rose, 2018).

According to Rose (2018), long-term studies are less common because they face a number of obstacles such as ethical concerns, industry reluctance to conduct trials of that length, and high patient dropout rates. Ethical concerns center around withholding effective treatment over extended periods from patients in pain, particularly with placebo-controlled trials.

It’s ironic that they won’t allow research studies to withhold effective pain medication, but they are doing exactly that by government edict.

The lack of response to a “one-size-fits-all” prescriptive protocol likely underestimates study responses of efficacy and may overestimate the incidence of side effects and toxicity incurred with a rigid protocol (Nadeau, 2015).

Additionally, it is posited that response to opioids in chronic pain is often not in a normal distribution of the bell-shaped curve, but in fact can occur in a bimodal distribution of significant or minimal effectiveness of opioids (Häuser & Tölle, 2015). When these bimodal responses are averaged, a moderate or fair response to long-term opioids is often reported (Häuser & Tölle, 2015).

Misperception 6: The Statistics Published by the CDC Are Always of the Highest Quality and Should Be Used Without Question

Fact: Some data published by the CDC are based on less-than-high-quality data and can be misleading and lack transparency in how it is calculated.

As referenced in Misperception 3, the prescription opioid OD numbers may be inaccurately inflated in publications before 2013-2014 because of IMF counted as prescription fentanyl.

Since 2013, synthetic opioids, which include fentanyl and tramadol, have been tallied separately, which lowers the prescription OD numbers (Seth et al., 2018).

Although agreeing to this separate tally, the CDC initially cautioned that this may underestimate prescription OD deaths by overlooking prescription fentanyl deaths (Seth et al., 2018).

Later, O’Donnell, Halpin, Mattson, Goldberger, and Gladden (2017) reported that in only a small percentage of fentanyl deaths was there any evidence of prescription fentanyl use at the time of death (transdermal use versus injection).

The CDC does, however, acknowledge an ongoing inaccuracy in death data collection that may falsely raise the prescription opioid death rates in that heroin degrades rather quickly into its primary metabolite of morphine (O’Donnell et al., 2017). The presence of the morphine as a heroin metabolite may result in the misclassification of some heroin deaths as prescription opioid deaths.

It is worth noting that the 2016 CDC guidelines themselves have been criticized for inappropriately categorizing their recommendations as grade A, which is defined as the highest standard of evidence and usually requires RCT data. According to some critics, the CDC guidelines were based on case studies and expert opinion, which does not typically qualify for grade A ratings

Another factor pertaining to data reliability pertains to information recorded by NVSS. When analyzing data, the CDC relies on the NVSS to record the toxicology of opioids listed on death certificates. In collecting data pertaining to opioid-related OD deaths, the CDC reports that only 20 states have consistent and high-quality reporting

Variations in identifying specific drugs involved in OD deaths on the state death certificates also affect the accuracy of data and makes comparison between states difficult

Misperception 7: Opioid Prescribing Continues to Increase and Decreasing Opioid Prescribing Will Decrease the Overdose Death Rate

Fact: Overall opioid prescribing has been in multiyear decline beginning in 2012, with modest increase in 2016. There is a nonlinear relationship between opioid prescribing rates and opioid death rates.

A factor often cited as contributing to the rapid rise in opioid OD deaths is an increase in the number of opioids being prescribed. Although there has been an undeniable increase in the number of opioid prescriptions written in the last two decades, recent years have actually seen decreases in opioid prescriptions (Aitken & Kleinrock, 2018; CDC, 2018c). Nonetheless, many publications continue to cite data that are difficult to compare and that lead the reader to believe that opioid prescriptions continue to soar.

Often dates of comparison vary and varying measurement units are used, making the trend unclear and almost impossible to compare.

Despite documented decreases in opioid prescriptions and lowered opioid amounts prescribed, the OD death rate as a result of all opioids continues to rise sharply (NIDA, 2018), indicating that simply lowering prescription opioids available to patients does not solve the rising opioid-related death rate, which is largely driven by illicit opioids.

The CDC continues to imply a linear relationship between opioid prescribing and OD deaths involving prescription opioids (CDC, 2018c).

I don’t understand why the CDC is so persistent in trying to hide the true causes of overdoses (multiple illicit drugs) when the truth will only become more clear as time goes on.

The overdose rate keeps climbing, fueled by other drugs (not Rx opioids) and prescriptions of opioids will keep falling, irrevocably severing any possible connection between prescribing and overdoses.

There will be a lot of people left looking stupid when reality finally overtakes their ridiculous anti-opioid zealotry.

Misperception 8: High Doses of Prescription Opioids Based on Morphine Milligram Equivalents per Day Significantly Raise the Risk of OD, and Dose Limits Are Necessary to Lower OD Events

Fact: Opioid ODs can occur at any dose and are influenced by multiple factors, not just dose alone.

Even though increased risk with increased opioid dose seems to be widely accepted, the studies exploring the risks have significant flaws and limitations that are not often discussed.

Specifically,

1. coexisting risk factors beyond opioid dose are often ignored, and the
2. morphine milligram equivalent (MME) per day concept is uncritically accepted as an accurate and valid tool (Shaw & Fudin, 2013).

Interestingly, despite the fact that many studies suggest a linear relationship between opioid dose and OD mortality, Dasgupta et al. (2016) state that fatal and nonfatal opioid ODs are rare in clinical trials even in “higher’’ dose ranges.

Additionally, many of the studies suggesting the relationship between opioid dose and OD events are difficult to compare as data is unclear whether deaths included illicit opioids, intentional suicide events, or opioid-naive individuals.

One foundational problem in risk determination is that there is no standard accepted definition of high-dose opioid therapy. In a review for the National Institutes of Health (NIH), Chou et al. (2015) notes both 100 MME and 200 MME identified in studies as the high-dose link with risk.

The CDC guidelines advise avoiding ≥90 MME/day (Dowell et al., 2016). Dasgupta et al. (2016) suggest that the tendency for studies to assign 100 MME/day or thereabouts as the threshold for increased risk may be related more to a natural preference for the number than on clear scientific data.

Nonetheless, specific dose thresholds marking where increased risk begins are unclear because of inconsistency between studies in dose ranges examined and varying risk calculations.

Although all the studies identified some increase in OD risk with increased opioid dose, in the study of more than 2 million patients by Dasgupta et al. (2016), there was no distinct risk threshold in dosing—meaning there is no clear “safe dose” or “unsafe dose.”

Underlying any discussion of opioid dose and risk is the question of reliability of the concept of MME/day itself.

First, there is no universally accepted method to calculate MME/day and often wide variations exist. One survey of 319 HCPs (pharmacists, physicians, nurse practitioners, and physician assistants) reported a variation of ±124 mg for fentanyl patch MME/day conversion and ±166 mg variation in methadone MME/day (Shaw & Fudin, 2013). Further, a survey of eight online opioid conversion tools discovered a –55% to +242% variation between the tools (Shaw & Fudin, 2013).

Such wide variations can, in themselves, exceed many of the opioid dose limits recommended by various guidelines, such as the 90 mg MME/day limit cited by the CDC.

Besides wide variations in methodology, opioid equianalgesic tables are largely derived from single-dose studies, observational studies, and expert opinion (Fudin, Pratt Cleary, & Schatman, 2016) making it of questionable reliability as a foundation on which to build practice guidelines.

Therefore considering

1. the observational and expert opinion basis of MME/day;
2. the large variations in MME/day calculations;
3. the lack of a proven and clear dose risk threshold; and
4. the lack of inclusion of patient variabilities in most guidelines,

an arbitrary number on which to limit opioid prescribing is a flawed approach to safety.

Misperception 9: The Current Rise in Fatal Opioid ODs Confirms That Drugs in the Opioid Category Are Inherently Lethal and Therefore Should Be Limited or Avoided

Fact: Prescription opioids when taken as directed and without other central nervous system depressants are generally safe.

Despite the publicized rising numbers of prescription opioid ODs, the overdose rate of patients using prescribed opioids as directed is amazingly low, even when the OD numbers include patients taking other central nervous system (CNS) depressant medications.

Zedler et al. (2015) analyzed 1,877,841 patients and found 817 OD events (including serious respiratory depression), which is a rate of only 0.04%.

The rate drops further when looking exclusively at fatal events, with Dasgupta et al. (2016) finding an OD death rate of 0.022% per year in a study evaluating 2,182,374 patients prescribed opioids.

These number were similar in older studies of patients prescribed opioids, with Dunn et al. (2010) finding a 0.5% OD rate (fatal and nonfatal) and Gomes et al. (2011) recording 0.08% of fatal prescription opioid ODs. In an NIH analysis of opioid safety and harms, Chou et al. (2015) record a prescription OD rate of 0.256% for serious and nonserious events (Table 6).

The aggregate numbers indicate that the risk of all OD events from prescription opioids tends to be low, with fatal ODs even lower.

When OD deaths do occur, they tend to involve multiple drugs.

According to Jones, Logan, Gladden, and Bohm (2015), most heroin users also use at least three other drugs, most commonly alcohol, marijuana, cocaine, and opioid pain medications. In 2016, 80% of synthetic opioid OD deaths involved another drug or alcohol (Jones, Einstein, & Compton, 2018).

There are some clinical indications for simultaneously prescribing opioids and other CNS depressants (Babalonis & Walsh, 2015).

It is not the inherent lethality of the opioid alone that is to be considered—whether licit or illicit—but the combination of drugs that appears to significantly escalate the risk of OD.

Misperception 10: Prescription Opioids Used Postoperatively Often Lead to Long-Term Opioid Use and Potential Addiction

Fact: A small percentage of patients use opioids long-term postoperatively, and this is influenced by multiple risk factors and chronic postoperative pain.

Every year more than 10 million Americans have surgery as inpatients (Steiner, Karaca, Moore, Imshaug, & Pickens, 2017) and postoperative opioids are typically prescribed, particularly after major surgery (Hill, Stucke, Billmeier, Kelly, & Barth Jr, 2017).

There is a growing body of literature claiming a link between postoperative opioid use as the initiating event in precipitating long-term opioid use and potential SUD (Hah et al., 2017, Lanzillotta et al., 2018).

The number of patients affected varies considerably from a high of 13% of opioid-naive patients after hand surgeries (Johnson et al., 2016) to a low of 1.41% of total knee arthroplasty patients and 0.6% for total hip arthroplasty patients—all reporting opioid use after 90 days postoperatively (Lanzillotta et al., 2018, Sun et al., 2016).

One initial problem that may cause variation in outcomes is the lack of standard definition of “long term,” with some studies counting prescriptions filled >90 days postoperatively (Brummett et al., 2017) and others counting prescriptions filled 150 or 180 days postoperatively (Carroll et al., 2012, Goesling et al., 2016).

Further confusion is noted in studies that mix data from nonoperative chronic opioid use with data from postoperative use.

I’m shocked to learn that even Stanford University is “cooking” the data to show that opioids are dangerous:

One study out of Stanford University and funded by the NIH (Hah et al., 2017) inserts into the same sentence describing increased risk of long-term opioid use after outpatient surgery that “60% of people receiving 90 days of continuous opioid therapy remain on opioid years later” (p. 1735).

Examining the source of the 60% number (Martin et al., 2011) reveals it was from a 2000-2005 study examining discontinuation rates of chronic opioid recipients.

The inclusion of these data in a discussion of postoperative opioid use clouds the issue by mixing data not clearly applicable to the population examined in the study.

Standford scientists are too smart not to know that they are comparing the numbers involved in different situations. I’m sad to discover that deliberate lies are being promulgated by this (previously) respected university.

An additional issue leading to misunderstandings is the lack of separate analysis of low-risk versus high-risk patients related to factors that may lead to long-term use. Without this distinction, the overall risk may be inflated as a result of inclusion of high-risk patients. Factors influencing prolonged postoperative opioid use fall into two major categories: preoperative opioid use and mental health comorbidities (including BZD/psychoactive prescriptions and SUD history).

Misperception 11: Prescription Opioid Use Often Leads to Heroin Initiation
Fact: Prescription opioid use infrequently leads to heroin initiation.

Martins et al. (2017) note that adults using prescription opioids as directed from a prescriber have a low risk of developing SUDs compared with those engaging in nonmedical pain reliever use (NMPRU).

This 2015 broader definition of nonmedical use of prescription opioids includes behaviors that could be considered relatively minor infractions to serious misuse, but without any differentiation of risk associated with this range of behaviors.

It is worth noting that physical pain relief was reported as the main reason for engaging in NMPRU for 62.6 % of people in 2017 (SAMHSA, 2018)

Some statistics that are used to describe prescription opioids as a risk factor for heroin initiation are alarming but can be misleading, incomplete, or outdated.

Another alarming claim published by the CDC states that people with substance abuse or dependence on opioid pain relievers in the past year are 40 times more likely to initiate heroin use (Jones et al., 2015).

In essence, this is a switch from one opioid addiction/SUD to a different opioid substance, but not a new SUD.

Most people with SUD use multiple substances, with 96% of heroin users reporting at least one other drug used and 61% reporting at least three other drugs used (Jones et al., 2015).

Incomplete data published on government websites may lead to a partisan view.

Cicero et al. (2014) are often cited as reporting that 75% of heroin users start with prescription opioids as part of a rising trend since the 1960s. Although the NIH website quotes this study, the website neglects to report that the same study noted a downward trend from 2010-2013, with approximately 63% of heroin users initially using prescription opioids—a 12% drop from the peak number noted.

Until updates are available, researchers and writers publishing current claims using old numbers need to be more transparent to their readers regarding when the cited data were collected and any counterpoint data that are available.

Implications for Practice, Research, and Education

The well-informed HCPs must sort through statistics that are misleading or conflated, provoking confusion and misgivings about the use of opioids.

We are not denying that inappropriate prescribing may be a problem in some HCP practices but are reaffirming that opioids are an important tool in providing pain relief to patients.

HCPs need not fear the statistics reported on prescription opioid misuse and OD but prescribe opioids judiciously and responsibly. HCPs need to ensure that the patient with pain is thoroughly assessed, managed, educated, and evaluated during follow-up (St Marie, Arnstein, & Zimmer, 2018)

Glaring gaps in the gathering and reporting of statistics are apparent.

It is difficult to generalize findings when the reporting of opioid-related deaths is marginal at best in almost one third of states. Including the presence of specific drugs on death certificates is a needed standard that is not consistently applied.

Further research needs to validate the 2016 CDC guidelines because recommendations were categorized as grade A, which usually requires RCTs as opposed to case studies and expert opinions that were used to design the guidelines.

Additionally, the guidelines were written for primary care providers, but many states and some agencies have developed or are considering laws and policies based on the guidelines with the broader application outside of primary care (Facher, 2018; Rosenberg, Bilka, Wilson, & Spevak, 2018).

Specifically, more recent data are needed regarding the initiation of heroin with and without prior prescription opioid misuse because much of the existing data linking opioid misuse to heroin initiation are more than 5 years old.

Finally, there is a need for improved reporting of data from all sources.

All claims should be substantiated with research with clearly cited sources, particularly in a highly charged subject such as opioid OD.

Balanced reporting of statistics is needed, particularly in government publications and websites intended for public consumption.

Data also need to be presented without sensationalism that provokes fear rather than objective analysis.

Educators at the academic and practice levels need to emphasize unbiased translation of evidence into practice.

Lastly, HCPs need basic skills in interpreting and understanding research statistics.

The ability to think critically and raise questions about the validity and application of data is necessary to support balanced and unbiased application of research into practice.

Academic and continuing education in these basic skill sets is largely lacking and should be improved on in HCP prelicensure and postlicensure educational offerings.

Conclusions

In the current backlash against prescription opioid use, facts are sometimes colored by fear and underlying bias contributes to many misunderstandings.

This is stated as though it were unintentional, but the actions of the anti-opioid zealots are clearly intended.

To help correct such misunderstandings, data must be presented to HCPs and to the public in factual and nonsensationalized ways, such as clearly separating prescription opioids from other opioids and drugs.

Data also should not be cherry-picked to support a particular viewpoint

Oversimplifications of complex issues must be avoided, such as

• asserting a simple linear correlation between prescription opioid-related deaths and the volume of opioid prescriptions written;
• positioning a high risk for overdose based on opioid dose alone without weighing concurrent medical comorbidities and synergistic medications such as BZDs;
• attributing a definite cause of death to prescription opioids when multiple drugs, licit and illicit, are present; and
• linking long-term postoperative opioid use to opioid exposure alone without accounting for additional factors such as psychiatric comorbidities and chronic postoperative pain

Further, misunderstanding SUD/addiction as merely a disease of exposure to a substance needs to be challenged and corrected to include a complex intersection of individual social and physical vulnerability at the time of substance exposure.

The primary concern regarding the misuse of opioids is focused on patients with noncancer pain, with the twin goals of adequate pain relief and safe use of prescribed opioids.

These two goals are not mutually exclusive but are often set in opposition, creating a sense of controversy in pitting safety against pain relief.

The better and more effective approach is to pursue both goals by increasing the margin of safety for patients and society while preserving access to opioid therapy (Von Korff, Kolodny, Deyo, & Chou, 2011).

In order to design effective solutions and prevent unintended harm, it is crucial to base policy and practice changes on accurate understandings of the complexity of factors, while identifying and correcting the misunderstandings of these factors.

We call on the government, both local and federal, to improve the quality of its data collection and presentation to dispel misunderstandings and avoid arbitrary solutions.

To restrict prescribed opioids for those suffering acute and chronic pain who demonstrate benefit and safe use is to cause needless harm and would likely do little to stem the tide of illicit opioid use as the current driver of overdoses.

In this current climate of concern surrounding prescription opioids, the health care provider must now be a well-informed advocate for safe and appropriate inclusion of opioids

Finally, a clear-eyed response to the absurdities about currently hyped “information” about opioids.

I’ve excepted almost all of this incredible document, which you can find in full at Misperceptions about the ‘Opioid Epidemic:’ Exploring the Facts. There, you will also find links to all the references and tables listed throughout.