The Wrong Opioid War
/By Roger Chriss, Columnist
The opioid crisis continues to worsen, with rising rates of addiction and overdose deaths. The 2016 CDC opioid prescribing guidelines and earlier state guidelines in Washington and Oregon have not helped. Government interventions, from increased physician surveillance to reduced opioid manufacturing quotas by the DEA, are not working.
And the reason is simple: they are fighting the wrong opioid war.
The American Society of Addiction Medicine (ASAM) reports that opioid addiction rates have doubled in the past decade to the current estimate of 2 million opioid addicts and another 500,000 heroin addicts.
It’s a myth that prescription painkillers are the leading cause of addiction. According to the National Institute of Drug Abuse (NIDA), “use of most drugs other than marijuana has stabilized over the past decade or has declined."
As can be seen in the chart below, overall prescription drug abuse was virtually flat between 2002 and 2013, the most recent year data is available. Significant increases were seen for marijuana, starting in 2007 with state-level legalization, and for illicit drugs like heroin.
NATIONAL INSTITUTE OF DRUG ABUSE
“Although heroin use in the general population is rather low, the numbers of people starting to use heroin have been steadily rising since 2007. This may be due in part to a shift from abuse of prescription pain relievers to heroin as a readily available, cheaper alternative,” says NIDA Director Nora Volkow, MD.
If opioid addiction were starting with medical opioids prescribed to adults for acute pain or persistent pain disorders, we’d be seeing a rise in prescription drug abuse and addiction, with a high percentage of addicts found among people on opioid therapy. But in fact this is not happening.
So the question becomes: When does opioid addiction start?
At a very young age, usually. There were over 2.8 million new users of illicit drugs in 2013, according to NIDA, or about 7,800 new users per day. Over half (54%) of these new users were under 18 years of age.
The National Center on Addiction and Substance Abuse reports that 90% of all drug addiction starts in the teens. Other studies tell us that opioid medications are rarely the first drug young people misuse, and that early signs of addiction start with alcohol, marijuana and tobacco use.
Further, Pain Medicine News reports that research at Boston Children’s Hospital found that “if a patient reaches the age of 25 years without misuse, the odds of that patient ever becoming an opioid misuser are much lower.” Thus, opioid abuse almost always starts during adolescence, a time when medical treatment with opioids is rare.
According to NIDA, 6.5 million Americans aged 12 or older used prescription drugs non-medically in 2013. The source of these drugs is usually not a doctor or a drug seeking patient. Doctor shopping is rare, occurring in about 1 out of 143 patients. And according to ASAM, “most adolescents who misuse prescription pain relievers are given them for free by a friend or relative.”
The medical use of opioid drugs for persistent pain disorders is conspicuous by its absence. That is because pain patients are a statistically insignificant part of the opioid crisis. As Maia Szalavitz reported in Scientific American, “regulatory efforts will fail unless we acknowledge that the problem is actually driven by illicit—not medical—drug use.”
Federal agencies and state governments by and large have not recognized this. And we are witnessing the consequences. The CDC reports that overdose deaths for heroin and illicit fentanyl have been rising rapidly since 2010, while overdose deaths involving commonly prescribed opioids have been almost flat.
Moreover, a significant percentage of the overdose deaths are suicides. The CDC classified 10% of the overdose deaths in 2015 as suicides. Florida’s Medical Examiners Commission came up with even more startling numbers, classifying 20% of the state’s oxycodone deaths and 31% of its hydrocodone deaths as suicides.
"Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides," says Dr. Maria Oquendo, President of the American Psychiatric Association.
The opioid crisis is about illicit drug use. Policies that fail to recognize that fact will end up fighting the wrong war, with consequences that are becoming all too common.
Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.
Roger is a technical consultant in Washington state, where he specializes in mathematics and research.
The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.
