Prescription Opioids Play Only Minor Role in Overdose Crisis

By Pat Anson, PNN Editor

The role of prescription opioids in the nation’s overdose crisis continues to shrink.

In a new study from the drug testing firm Millennium Health, researchers say multiple substances were found last year in nearly 93% of urine samples in which fentanyl was detected. That is not altogether surprising, as “polysubstance” use increased as fentanyl came to dominate the illicit drug supply, appearing in more and more street drugs such as heroin, cocaine and methamphetamine.

What is surprising is the minimal role that prescription opioids now play. In 2013, opioid pain medication was the most common substance found in fentanyl-positive drug tests in the United States, appearing in over 70% of urine samples.  A decade later, prescription opioids were detected in less than one in ten samples — ranking far behind methamphetamine, cannabis, cocaine and heroin.

In fact, you are about twice as likely to find two other medications -- benzodiazepines (15.8%) and gabapentin (13.3%) -- than you are prescription opioids (7.6%) in urine samples testing positive for fentanyl.

Substances Detected in Fentanyl-Positive Drug Tests (2023)

MILLEnNIUM HEALTH

Millennium based its findings on over 4.1 million urine drug tests (UDTs) collected from 2013 to 2023 and analyzed through mass spectrometry. Because many of those samples came from people being treated for a substance use disorder, they offer a clear insight into drug trends that are driving the overdose crisis.

Now in its “fourth wave,” Millennium says a tidal shift has occurred in the so-called opioid epidemic, with illicit drug users far more likely to use non-opioid substances like stimulants than prescription opioids.

“National, regional, and state-level UDT data all suggest that people who use fentanyl are now, intentionally or unintentionally, much more likely to also use methamphetamine and cocaine,” the report found. “The results of our analyses also reveal shifting patterns of opioid use among those who use fentanyl. More specifically, they showed progressive declines in prescription opioid use from 2015 to 2023.”

The declining role of prescription opioids can be traced back to the 2016 CDC opioid guideline and a multiyear campaign by the DEA to slash opioid production quotas, which has reduced the supply of oxycodone and hydrocodone by about two-thirds. There is little evidence either of those federal efforts reduced the number of overdoses. The CDC estimates there were over 111,000 drug deaths in the 12-month period ending in September 2023 — nearly double the number of fatal overdoses in 2016.

The growing use of stimulants such as methamphetamine makes it difficult for public health campaigns to address the problem. Unlike opioids, there are no FDA-approved medications for stimulant use disorder, leaving behavioral therapies and abstinence as the only “evidence-based” treatments for people with a stimulant problem.

“Stimulants are a serious national challenge emphasizing the need for continued progress on the national plan to address methamphetamine supply, use, and consequences,” Millennium said.

My Story: Why Is Everyone So Quiet About Rx Opioid Shortages?

By Kimberly Smith

I am a chronic pain patient in Florida with multiple modalities of pain: chronic intractable pain, pain from a sports injury, and pain from an autoimmune disease. To further complicate my situation, I also have a list of allergies and genetic mutations that leave me unable to take aspirin, NSAIDs, gabapentin, codeine, and morphine for pain relief.  

I have a background in medicine, pain management and hospice, so I’ve always been mindful of the spectrum of things that can go awry with opioids. I keep myself on a stable dose with the goal of just “dialing down” the pain enough so that I can function, while not relieving it entirely.  

Fifteen years ago, when public attitudes started turning against opioids, I was switched to a fentanyl transdermal patch because it was “less likely to be abused.” I had hoped to avoid using fentanyl until my final days, knowing that once you’re on fentanyl for an extended period, it’s a nightmare if you have to switch to anything else and potentially deadly if you suddenly stop.  

Starting in September, I started having trouble getting fentanyl patches at the CVS pharmacy I’ve been using for 30 years. Instead of the Mylan fentanyl patch that I’ve been using for 15 years, CVS only had a fentanyl patch that used a completely different type of adhesive mixture -- one that I absorb inconsistently and too quickly.

I had two absolutely frightening episodes using that patch where I couldn’t catch my breath.  I don’t think anyone would blame me for never wanting to try that brand again (Alvogen).

Now I call random pharmacies each month, trying to find the Mylan patch. The supply itself is dwindling and here I am needing one of the only two fentanyl patches still on the market. It’s insane and I’m constantly stressed, anxious and overwhelmed.  

Today, I called the CVS pharmacy about my second opioid, oxycodone 30mg, and was told this is the latest opioid that is only coming in sporadically. I’ve been having to use the oxycodone as a replacement for the periods when the pharmacies couldn’t source the fentanyl patch, so I no longer have any type of emergency supply (nor do I have the opportunity to build one up).

For me, this is the absolute end of the road for opioids. I lack the CYP enzyme to metabolize morphine and I have an additional mutation that affects the efficacy of the metabolic processes, so I require higher doses than “normal.”  

I’m in a terrible, terrible situation and I’m by no means alone.  I’m starting to dream about it every night.  My doctors and the pharmacy team who have been caring for me for decades are stressed and concerned, and all have made tremendous efforts to help. But without access to the two medications I need, their hands are tied.

One of my pharmacists searched the entire state for my meds for 9 weeks and couldn’t find any. I still have many friends who are pharmacists, pharmacy techs, doctors, nurse practitioners and physician assistants, and they’ve been telling me awful stories about how much time they spend trying to resolve the opioid shortages -- not to mention the emotional toll caused by listening to patients cry and panic about being left to endure horrible pain and withdrawal.  

I don’t understand why everyone is staying quiet about this problem, especially when the shortages affect the entire hospice system, oncology patients at cancer centers, anesthesia and twilight sleep procedures, emergency medicine, trauma medicine, surgical procedures, acute pain and, of course, chronic pain.  

Doctors and pharmacists have been responding to the shortage by moving their patients to other meds, which is exactly the harm that I suffered when I was taken off the Mylan patch. This further squeezes the availability of the meds that are available and pushes those patients out to make room for the patients who were on something else.  Even gabapentin is unavailable at many pharmacies.  This situation is dire and getting worse.

If politicians were smart, they would support legitimate patients and the relief of chronic pain by making immediate changes to provide opioids to those who need them. All of the patients who are suffering would absolutely cast their votes for anyone who relieved their misery and gave them their lives back.

Instead, the politicians just assume that pain patients don’t vote and write us off. This is incredibly shortsighted. We do vote - when we aren’t struggling with pain and forced withdrawal.

I’ve reached the point where I am legitimately scared about my future. The shortages will just grow worse and worse, unless and until sweeping, radical changes are made.  Most of us wouldn’t last two to three months without opioid medication, and some wouldn’t be able to endure just one.  

While I see endless reports about Biden and Trump in the mainstream media, there’s not a word about the opioid shortage crisis and the direct harm being visited upon legitimate patients. Diversion rates are low, overdoses are primarily caused by illicit fentanyl (a completely different substance than Rx fentanyl) and desperate patients feel forced to turn to the streets.

Isn’t this a violation of the spirit of our Constitution?  It is certainly cruel and unusual punishment. We who follow the law and contribute to society are being cruelly punished for the bad behavior of others -- behavior which is basically a lapse of morals and mental health issues, which cannot be legislated away. We need to change the media narrative and shame the politicians and policy makers who created this mess.  

Do you have a “My Story” to share?

Pain News Network invites other readers to share their experiences about living with pain and treating it.

Send your stories to editor@painnewsnetwork.org.

Lack of Education Is Fueling Overdose Crisis

By Pat Anson, PNN Editor

Anti-opioid activists have long claimed that excessive prescribing of opioids over a decade ago created an “epidemic of addiction” that lingers to this day. Once hooked on prescription opioids, patients turned to stronger and more lethal drugs — like heroin and illicit fentanyl — sending the overdose rate to record levels.

A large new study debunks that theory, showing that socioeconomic factors – particularly lack of education -- play a hidden but central role in the overdose crisis.

"The analysis shows that the opioid crisis increasingly has become a crisis involving Americans without any college education," said lead author David Powell, PhD, a senior economist at RAND, a nonprofit research organization. "The study suggests large and growing education disparities within all racial and ethnic groups --- disparities that have accelerated since the beginning of the COVID-19 pandemic."

Powell looked at data from the National Vital Statistics System from 2000 to 2021, and identified over 912,000 fatal overdoses for which there was education information on the people who died.

His findings, published in JAMA Health Forum, show that overdose deaths increased sharply among Americans without a college education and nearly doubled in recent years for those who don’t have a high school diploma. The findings are notable because they came during a period when per capita consumption of prescription opioids plummeted, sinking to levels last seen in 2000.

For people with no college education, the overdose death rate increased from 12 deaths per 100,000 individuals in 2000 to 82 deaths per 100,000 in 2021. That rate is sharply higher than Americans who have some college education. In 2000, their overdose rate was 4.6 deaths per 100,000 people, which rose to 18.6 deaths per 100,000 in 2021.

Trends in Overdose Deaths by Educational Attainment

JAMA HEALTH FORUM

Powell is not the first researcher to link socioeconomic factors to overdose deaths. The so-called “deaths of despair” were first reported in 2015 by Princeton researchers Angus Deaton and Anne Case, who found that economic, social and emotional stress were major factors in the reduced life expectancy of middle-aged white Americans, who increasingly turned to substance abuse to dull their physical and emotional pain.

Education plays a significant role in socioeconomic status. People without college degrees are more likely to have blue-collar jobs requiring manual labor, which raise the risk of work-related injuries and conditions such as arthritis. One recent study found that people who did not finish high school in West Virginia, Arkansas and Alabama were three times more likely to have joint pain compared to those with bachelor degrees in California, Nevada and Utah.

“Overall, the analysis suggests that the opioid crisis has increasingly become a crisis disproportionately impacting those without any college education. Research is needed to understand the driving forces behind this gradient, such as isolating the independent roles of differences in income, employment, family composition, health care access, and other factors,” said Powell.

“Overdose death rates grew during the COVID-19 pandemic, and the education gradient increased further, although it is unclear what role the pandemic had relative to changes in fentanyl penetration in illicit drug markets and other factors.”

Powell says education merits further attention in understanding how and why the opioid crisis continues to intensify and lower U.S. life-expectancy.

Stimulants Involved in Growing Number of Fentanyl Overdoses

By Pat Anson, PNN Editor

The number of drug deaths involving both fentanyl and stimulants has soared in recent years, according to a new UCLA study that highlights the complex and changing nature of the U.S. overdose crisis.

Stimulants such as cocaine and methamphetamine are now involved in nearly a third of fentanyl-related overdoses, the most of any other drug class. Fentanyl is a synthetic opioid up to 100 times more potent than morphine and 50 times as potent as heroin.

In 2010, researchers say there were only 235 fatal overdoses in the U.S. involving illicit fentanyl and stimulants. In 2021, there were 34,429 drug deaths linked to fentanyl and stimulants, a 14,550% increase in a little over a decade.

"We're now seeing that the use of fentanyl together with stimulants is rapidly becoming the dominant force in the US overdose crisis," said lead author Joseph Friedman, PhD, an addiction researcher at the David Geffen School of Medicine at UCLA. "Fentanyl has ushered in a polysubstance overdose crisis, meaning that people are mixing fentanyl with other drugs, like stimulants, but also countless other synthetic substances. This poses many health risks and new challenges for health care providers.

“We have data and medical expertise about treating opioid use disorders, but comparatively little experience with the combination of opioids and stimulants together, or opioids mixed with other drugs. This makes it hard to stabilize people medically who are withdrawing from polysubstance use."

People who overdose on stimulants and other non-opioid substances mixed with fentanyl may not be as responsive to naloxone, which only works as an antidote to opioids.

The study findings, published in the journal Addiction, highlight the four “waves” of the overdose crisis, which began with an increase in deaths from prescription opioids (Wave 1) in the early 2000s, followed by a rise in heroin deaths (Wave 2) in 2010, and fentanyl-related overdoses in 2013 (Wave 3). The fourth wave — overdoses from fentanyl and stimulants — began in 2015 and continues to escalate.

The Four Waves of Overdose Crisis

SOURCE: ADDICTION

Since cocaine, methamphetamine and other stimulants are not opioids, the findings undercut the long-held theory that the overdose crisis started with prescription opioids and is still being fueled by people addicted to them. Deaths involving prescription opioids and heroin have been in decline for several years.

Researchers found that fentanyl/stimulant deaths disproportionately affect African Americans and Native Americans. There are also geographical patterns to fentanyl/stimulant use. In the northeast US, fentanyl is usually combined with cocaine, while in the south and western US, fentanyl is most commonly found with methamphetamine.

"We suspect this pattern reflects the rising availability of, and preference for, low-cost, high-purity methamphetamine throughout the US, and the fact that the Northeast has a well-entrenched pattern of illicit cocaine use that has so far resisted the complete takeover by methamphetamine seen elsewhere in the country," Friedman said.

In addition to its low cost, drug users say methamphetamine helps prolong fentanyl’s “high” and delays the onset of withdrawal symptoms.  

Counterfeit pills laced with fentanyl – which are frequently made to look like oxycodone or alprazolam (Xanax) – represent about a quarter of all illicit fentanyl seizures. Researchers say it is difficult to track deaths involving counterfeit pills because they are often mistaken for legitimate medication, so the data is not completely reliable.

In its most recent update on the overdose crisis, the CDC estimates there were a record 111,355 drug deaths in the 12-month period ending April 2023 -- about a thousand more deaths than the year before. Fentanyl and its analogues were involved in nearly 70% of the overdoses, stimulants were linked to about a third of them, and cocaine was involved in about a quarter of the drug deaths.

CDC Report ‘Likely Underestimated’ Deaths Linked to Counterfeit Drugs

By Pat Anson, PNN Editor

A new report from the Centers for Disease Control and Prevention found that fatal overdoses in the U.S. from counterfeit medication more than doubled in recent years, with 93% of those deaths involving illicit fentanyl.

Deaths from counterfeit pills rose from 2% of all overdoses in the third quarter of 2019 to 4.7% of drug deaths in the last quarter of 2021, according to the CDC’s Morbidity and Mortality Weekly Report (MMWR). The overdose rate from fake medication was three times higher in western U.S. states (14.7%). 

However, due the unreliability of death certificates, witnesses and coroner investigations, as well as other flaws in the study’s methodology, the MMWR report acknowledges that the number of deaths involving counterfeit medication is “likely underestimated.”

CDC researchers only looked at overdose data from 34 states and the District of Columbia, identifying 2,437 deaths linked to counterfeit pills during the 30-month study period.

Nearly 106,700 people in the U.S. died from drug overdoses in 2021, so if the 4.7% death rate was applied to that year alone, that would suggest there were over 5,000 deaths nationwide involving counterfeit medication.

Even that estimate is probably on the low end, because CDC researchers focused on counterfeit pills made to look like oxycodone and the anti-anxiety drug alprazolam (Xanax).

While “Mexican Oxy” – blue tablets that look like 30mg oxycodone – are favored by counterfeiters, fake pills are also designed to look like Vicodin, Norco, Adderall, and many other medications. Deaths from those pills were not counted.  

Importantly, whether a death was even linked to fake medication “depended largely on scene or witness evidence of pill use” and other anecdotal evidence, rather than toxicology tests on the pills or the actual people who died.

And while pills are obviously designed to be taken orally, the MMWR report only includes “noningestion routes of drug use,” such as smoking, snorting or injection, which require the pills to be ground into powder or liquefied. CDC researchers considered data on the oral ingestion of counterfeit pills so unreliable, “that information is not presented” in the report.

Many of these details on the study’s strange methodology are buried in the footnotes of the MMWR report, which a casual reader could easily miss. 

Not surprisingly, given the limitations on data, smoking was found to have an outsized role in overdose deaths. According to the MMWR, nearly 40% of the deaths linked to counterfeit medication involved smoking – a misleading statistic, given the study’s flaws. But that didn’t stop researchers from drawing conclusions or recommending “safer smoking practices.”

“The higher percentage of deaths with evidence of drug use by smoking might reflect recent general shifts from injecting drugs to smoking them in western states or could be specific to counterfeit pill use methods,” wrote lead author Julie O’Donnell, PhD, an epidemiologist at the CDC’s National Center for Injury Prevention and Control.

“Harm reduction services that expand outreach to persons using drugs by methods other than injection, such as smoking, and provide education about safer smoking practices and risks related to smoking, might be most successful at addressing diverse drug use patterns.”

There’s a safer way to smoke illicit fentanyl?

This is the CDC’s first MMWR report to look exclusively at deaths caused by fake pills, a public health crisis that the agency has been slow to acknowledge. The DEA started warning about a “fentanyl crisis” as far back as 2016, a time when the CDC was preoccupied with its guideline to reduce opioid prescribing.

There were major flaws in CDC research even back then. The agency eventually admitted that thousands of overdose deaths linked to illicit fentanyl and other street drugs were misclassified as deaths caused by prescription opioids. Some deaths that involved more than one drug were counted multiple times.

America’s Biggest Fear: Fentanyl and Opioid Addiction

By Pat Anson, PNN Editor

The fentanyl crisis is the biggest public health problem in the US, according to two new surveys that highlight Americans’ growing fears about opioid addiction and the toxicity of street drugs.

The first survey, conducted by Axios-Ipsos, found that opioids and fentanyl have surpassed Covid-19, firearms, obesity and cancer as the nation’s #1 public health threat. Over one in four Americans (26%) ranked opioids and fentanyl first, replacing gun violence as the top threat to public health.  

Top U.S. Public Health Threats

Fentanyl is a synthetic opioid that is 100 times more potent than morphine. It has been used safely for decades as an analgesic during surgery and to treat severe pain, but in recent years illicit versions of fentanyl have come to dominate the black market, where they are used in counterfeit medication or mixed with substances like heroin. Most fatal overdoses in the U.S. involve illicit fentanyl, not prescription opioids.

The Axios-Ipsos survey found that about four in ten adults (44%) are aware that U.S. overdose deaths reached a record high last year. Americans who live in rural areas, which have some of the highest overdose rates, are even more familiar (51%) with the rising number of drug deaths. 

Over half the respondents (51%) said they cared a lot about overdoses and think the government should be doing more to reduce drug deaths (79%). Most also believe that government does not make the health and well-being of citizens a priority (62%).  

While most Americans trust the health information they get from federal agencies like the CDC (64%) and FDA (62%), there is more trust placed in health information from personal doctors (89%) and family members/close friends (75%). 

Other key findings about respondents’ drug use in the last three months:

• 26% used a pain medication for which they had a prescription or knew someone who did

• 3% used a pain medication for which they did not have a prescription or knew someone who did

• 20% used cannabis or knew someone who did

• 2% used hallucinogenic drugs or new someone who did

• 2% used “other illegal drugs” or knew someone who did

“Pain medication” was not defined in the survey questions, so the responses may include some non-opioid analgesics.

The recently updated Axios-Ipsos American Health Index is based on a nationally representative sample of 1,162 adults, who were surveyed on a wide array of health topics from August 11-14.

Most Families Impacted by Addiction

The second survey, conducted by the non-profit KFF, asked a representative sample of 1,327 adults online and over the phone in July about a variety of drug and substance use issues.

Two-thirds of respondents said either they or a family member were addicted to alcohol or drugs, experienced homelessness due to addiction, or had a drug overdose resulting in hospitalization or death.  

Nearly three in ten (29%) said they or someone in their family were addicted to opioids, either prescription opioids or illicit ones like fentanyl and heroin. Opioid addiction was most common among rural residents (42%) and White adults (33%). Among those who experienced addiction firsthand, most said it had a negative impact on their family’s relationships and finances. 

Only 5% felt they themselves might be addicted to opioid painkillers, far less than those who believe they might be addicted to alcohol (13%). 

Fear about addiction is common. Over half (51%) of adults are worried that someone in their family will experience a substance use disorder and one-third (32%) are worried that someone in their family will overdose on opioids.  

About four in ten adults (39%) are worried that someone in their family will unintentionally consume illicit fentanyl, a fear that looms largest in rural areas (48%). 

SOURCE: KFF

Nearly three in ten respondents (29%) said they had been prescribed opioid pain medication in the past five years. Of those, most said their doctors had warned them about the risks of opioid addiction and dependence (57%), side effects from opioids (69%), other ways to manage pain (60%), and about keeping their medications in a safe place (58%).  

While fears about addiction to opioid pain medication are common, it doesn’t happen nearly as often as many people believe. A recent study in Australia found that 92% of patients prescribed opioids for the first time never progressed to long-term use. Less than 3% became persistent users or needed higher doses — and they were mostly seniors with chronic health problems.

Neither the KFF or Axios-Ipsos polls asked respondents about growing shortages of opioid pain medication or how the reduced supply was impacting legitimate pain patients.   

‘Unintended Victims’

The patient side of the story was shared this week in an opinion video by The New York Times. Video producers Vishakha Darbha, Lucy King and Adam Westbrook spoke with chronic pain patients who are the “unintended victims” of the national crackdown on opioid prescribing.

“America’s doctors have been put in a difficult position. But it doesn’t need to be this way. It is possible to stop overprescribing yet ensure that pain sufferers get the relief they deserve. The patients in our video have one message: Listen to us,” the producers said.

CDC Study Shows Oxycodone Plays Minor Role in Overdose Crisis

By Pat Anson, PNN Editor

A new study by the CDC highlights the sharply rising death toll in the U.S. caused by illicit fentanyl, while at the same time revealing the minor role played by oxycodone in the nation’s overdose crisis.

The study, released this week by the CDC’s National Center for Health Statistics, looked at overdose death rates from 2016 to 2021. Deaths involving fentanyl more than tripled during that period, rising from 5.7 deaths per 100,000 people in 2016 to 21.6 deaths per 100,000 in 2021. Drug deaths involving methamphetamine and cocaine also rose sharply, while fatal overdoses involving heroin declined.

And what about oxycodone, the most commonly prescribed opioid pain medication? It turns out oxycodone has always played a relatively minor role in the overdose crisis, although regulators and public health officials said otherwise in a concerted campaign against all prescription opioids.

“Overprescribing opioids – largely for chronic pain – is a key driver of America’s drug overdose epidemic,” then-CDC director Dr. Thomas Frieden said in a 2016 news release.

But the facts don’t support Frieden’s claim. In 2016, the year the CDC released its controversial opioid prescribing guideline, there were only 1.9 deaths per 100,000 people that involved oxycodone. By 2021, the rate had fallen 21% to 1.5 deaths -- well below the death rates of fentanyl, methamphetamine, cocaine and heroin.   

Drug Overdose Deaths in U.S. (2016-2021)

SOURCE: CDC

CDC researchers used an unusual method to conduct this study. Instead of relying on medical ICD-10 codes in death certificates, which lump drugs together into broad categories, the CDC used a “literal text” analysis.

“To address the limitations of ICD–10- coded mortality data, the National Center for Health Statistics has developed a method that searches the literal text of death certificates to identify mentions of specific drugs and other substances involved in the death. Death certificate literal text is the written information provided by the medical certifier, usually a medical examiner or coroner for drug overdose deaths, that describes the causes, manner, and circumstances contributing to the death,” the researchers explained.

Flawed Data

The literal text method is not foolproof, but it’s an improvement over the ICD-10 codes, which the CDC admitted in 2018 “significantly inflate” the number of deaths involving prescription opioids — flawed data that Frieden used to make his “key driver” of the epidemic claim in 2016.

How inflated were the overdose numbers back then?  Using the old ICD-10 method, which counted illicit fentanyl as a prescription opioid, Frieden’s CDC estimated that nearly 32,500 Americans died from overdoses of opioid medication in 2016. The death toll was later revised downward to about 17,000 overdoses after the CDC came clean about its flawed methodology.

Patient advocate Richard “Red” Lawhern has long been suspicious of CDC data, including studies that use literal text analysis.  

“CDC suggests an incidence of drug overdose deaths ‘involving’ oxycodone at only 1.5 per 100,000.  But they neatly avoid telling us that such a rate is so low that it confounds the non-uniformity of reporting from county to county, creating such statistical noise that the contribution of this agent (oxycodone) to overdose mortality is too small to accurately measure or report,” Lawhern said.  

Another problem is the qualifications of county coroners and medical examiners varies. Some are elected to their positions without any medical training or experience. The death certificates they fill out usually don’t say if a prescription drug was obtained legally or illicitly, or what specific drug or combination of substances caused the death. That is determined later by a toxicology test. As a result, a drug may be “involved” in a death and be listed on the death certificate, but have little or nothing to do with someone’s demise.

“It is startling that CDC has so consistently and deliberately conspired to disguise the fact that oxycodone really isn't significant in drug overdose mortality, and probably never has been,” Lawhern told PNN. 

Of course, every death is a tragedy in some way, regardless of the cause or substance involved. The graphic below helps bring oxycodone’s role into more context – comparing the five leading causes of death in 2021 to those involving fentanyl, oxycodone and the other drugs.

SOURCE: CDC

Despite the minor role played by oxycodone in 2021 deaths, efforts continue to restrict its availability. This year the Drug Enforcement Administration reduced the supply of oxycodone for the seventh consecutive year. Since their peak in 2013, DEA production quotas for oxycodone have fallen by 65 percent. The tightened supply has resulted in recent reports of oxycodone shortages and patients unable to get their prescriptions filled.

The DEA justifies the cuts by saying it is concerned about diversion and abuse, but the agency’s own data shows that less than one percent of legally prescribed oxycodone (0.3%) is diverted to someone it was not intended for.

DEA Warns About Fentanyl As It Draws Criticism for Crackdown on Doctors

By Pat Anson, PNN Editor

The Drug Enforcement Administration has issued another public warning about the growing risk of counterfeit opioids and other medications made with illicit fentanyl. Over two-thirds of the drug deaths in the U.S. involve synthetic opioids like fentanyl, which is 50 to 100 times more potent that morphine.

Last year the DEA seized over 50 million counterfeit pills laced with fentanyl and more than 10,000 pounds of fentanyl powder. The seizures represent more than 379 million potentially deadly doses of fentanyl, according to the DEA, enough to kill every man, woman and child in the United States.

Over 56,000 American deaths last year involved fentanyl, nearly the number that died in the Vietnam War, and the crisis appears to be escalating. In 2021, a DEA laboratory analysis estimated that 4 out of 10 counterfeit pills laced with fentanyl contained a potentially lethal dose. The DEA now estimates that six out of ten fake pills contain a deadly dose of fentanyl. Just two milligrams of fentanyl, enough to fit on the tip of a pencil, is considered a potentially lethal dose.

“More than half of the fentanyl-laced fake prescription pills being trafficked in communities across the country now contain a potentially deadly dose of fentanyl. This marks a dramatic increase – from four out of ten to six out of ten – in the number of pills that can kill,” DEA Administrator Anne Milgram said in a public safety alert. “Never take a pill that wasn’t prescribed directly to you. Never take a pill from a friend. Never take a pill bought on social media. Just one pill is dangerous and one pill can kill.”

In an effort to bring more public attention to the fentanyl crisis, the DEA launched its One Pill Can Kill campaign, which highlights the similarities between real medications like oxycodone and alprazolam and their fake counterparts. The counterfeit pills are mass produced by drug traffickers in the U.S. and Mexico, using chemicals largely sourced from China.

Backlash Against DEA

As the DEA grapples with the fentanyl crisis, it’s coming under growing criticism about its efforts to reduce the supply of legal prescription opioids. Recent articles in USA Today, The New York Times, Los Angeles Times and VICE News – many based on stories that first appeared on PNN – suggest that the mainstream media is slowly coming to recognize the harm caused to pain patients by the DEA’s enforcement actions against doctors who prescribe opioids.

“Law enforcement agencies, especially the Drug Enforcement Administration, are out of control, with the DEA routinely caught releasing ‘safety plans’ for the patients of arrested physicians that simply direct pain patients to the nearest emergency room,” wrote Peter Pischke, a disabled freelance journalist, in a USA Today op/ed.

“American medicine and law enforcement continue to fight the last war. Policymakers still operate under the assumption that too many opioids are being prescribed. Overdose deaths — including those among adolescents — are now overwhelmingly caused by street fentanyl, not prescription medications,” Maia Szalavitz wrote in The New York Times.

The backlash against the DEA produced a backlash of its own in Newsweek, in an op/ed by a former deputy chief of staff at the DEA. Rather than doing fewer enforcement actions against doctors, Jim Crotty believes there should be more.

“With the U.S. drug crisis reaching unprecedented levels, and many opioid use disorders starting with prescription drugs, now is not the time to increase their availability,” wrote Crotty, who said the recent deaths of patients who lost access to opioids when their doctor’s license was suspended do not justify a change in DEA policy.

“These isolated incidents, however tragic, should not be used to upend otherwise sound drug policies designed to protect the American public from drug addiction and abuse,” said Crotty. “The U.S. is making slow but steady progress in rolling back the opioid crisis, but there is much work to be done. The threat of prescription opioids still looms large and requires continued vigilance from DEA and its partners to protect Americans' health and safety. We should be asking them to do more, not less.”

Crotty said over 13,000 Americans have died from overdoses involving prescription opioids in the last 12 months – a fraction of the number dying from fentanyl -- and repeated the old saw about the U.S. being “the world's largest consumer of prescription opioids.” That may have been true a decade ago, but no longer is. The U.S. now ranks 8th in per capita opioid consumption, behind Canada, Australia and several European countries

Fentanyl Linked to 94% of Overdose Deaths in Massachusetts

By Pat Anson, PNN Editor

There’s good and bad news in the latest report on overdose deaths in Massachusetts. State health officials say drug deaths were down slightly in the first nine months of 2022, compared to the same period last year. But deaths involving fentanyl – most likely illicit fentanyl -- rose to 94% of opioid-related overdoses, a record high.

Massachusetts was one of the first states in the U.S. to expand the use of toxicology tests to look for the presence of certain drugs involved in opioid overdoses, instead of just relying on death certificates and coroner reports. That makes its overdose data more accurate.

In the first nine months of 2022, there were 1,340 confirmed opioid-related overdose deaths in Massachusetts, and officials expect that to reach about 1,696 deaths by the end of the year. That’s 25 fewer deaths than in 2021, a decrease of 1.5 percent.

Nationally, drug overdose deaths also appear to be slowing. The CDC estimates there were 107,735 U.S. overdose deaths in the 12-month period ending in July 2022, down from over 110,000 deaths in the 12-month period that ended in March, 2022. Illicit fentanyl, a synthetic opioid about 50 to 100 times more potent than morphine, is involved in the vast majority of those deaths.

Deaths in Massachusetts involving a fentanyl have been rising for over a decade, from nearly 42% of opioid-related overdoses in 2014 to 94% this year. Over that same period, deaths involving prescription opioids such as oxycodone and hydrocodone have steadily declined from about 35% to 11% of overdoses in 2022.

More people are now dying in Massachusetts after ingesting fentanyl, cocaine, alcohol or benzodiazepines such as Xanax than from pain medication. Deaths linked to opioid medication fell by 30% in just one year, which coincides with a steep decline in prescriptions in Massachusetts over the past decade.   

Drugs Involved in Massachusetts Opioid-Related Overdose Deaths

Massachusetts Department of Public Health

“Every life lost to opioid overdose is its own tragedy,” Public Health Commissioner Margret Cooke said in a statement. “With this report, we are encouraged by the decrease, however modest, in opioid-related overdose deaths in Massachusetts so far this year. We will continue to build on our data-driven and equity-based public health approach as we address the impacts of the opioid epidemic and the COVID-19 pandemic, especially among vulnerable populations.”

Health officials say the illicit drug supply in Massachusetts is “heavily contaminated” with illicit fentanyl, which is frequently used in the manufacture of counterfeit medication sold on the street.

Pharmaceutical fentanyl is used as a surgical analgesic and in patches and lozenges to treat severe pain, but only small amounts are diverted for abuse. The DEA estimates that only 0.01% of prescription fentanyl is diverted for use by someone it was not intended for.

It's important to note that the presence of a drug found in a toxicology screen doesn’t mean it was the cause of someone’s death. Multiples substances are frequently involved in opioid overdoses, and the official cause of death is a clinical decision made by coroners and medical examiners.

Toxicology tests alone also don’t reveal if a prescribed drug was intended for the decedent, or if it was bought, stolen or borrowed by them. An earlier study of drug deaths in Massachusetts found that only 1.3% of overdose victims had a prescription for the opioid medication involved in their deaths.

The vast majority of patients prescribed opioids use them responsibly and don’t go doctor shopping. The Massachusetts Department of Public Health estimates that only 0.6% of patients who were prescribed an opioid this year had an “activity of concern,” such as getting prescriptions from multiple providers or having them filled at multiple pharmacies.

Can Fentanyl Be Made Safer?

By Pat Anson, PNN Editor

Illicit fentanyl has been public health enemy #1 in the United States since 2016, when the DEA first declared there was a "fentanyl crisis" and warned that overdose deaths would increase due to the growing trade in street drugs laced with the potent synthetic opioid. That prediction sadly came true, as illicit fentanyl is now involved in about 71,000 U.S. overdose deaths a year. 

A team of scientists says it can reverse that trend by using sodium to make fentanyl far less dangerous, yet still effective in treating pain. 

“In its current form, fentanyl is like a weapon of mass destruction,” says Vsevolod Katritch, PhD, a computational biologist at the USC Michelson Center for Convergent Bioscience. “Our new collaborative work suggests that we could redesign the drug in such a way that we convert this frequent overdose killer to a much more benign but still effective analgesic.”

Katritch and colleagues at Washington University in St. Louis and Stanford University have published a study in the journal Nature demonstrating that chemically linking sodium to fentanyl can alter the way fentanyl binds to opioid receptors in the brain. In tests on laboratory mice, the modified drug was still an effective pain reliever, but didn’t have as many risky side effects. 

“We are desperately looking for ways to maintain the analgesic effects of opioids, while avoiding dangerous side effects such as addiction and respiratory distress that too often lead to death. Our research is still in its early stages, but we’re excited about its potential for leading to safer pain-relieving drugs,” Susruta Majumdar, PhD, an associate professor of anesthesiology at Washington University, said in a statement.,.

In modifying fentanyl with sodium, researchers developed a variation of the drug that still binds to mu-opioid receptors -- known as G-protein coupled receptors -- but also engages with a sodium ion binding site. That alters the pathway through which fentanyl reduces pain, making it possible for the drug to maintain most of its analgesic effects while also reducing the risk of respiratory depression leading to an overdose.

“The idea that the sodium ion, something we find in table salt, could modulate the activity of G-protein coupled receptors, such as these opioid receptors, is not new, but our group appears to be the first to successfully alter the chemistry of fentanyl so that it interacts with the sodium site on the receptor,” says Majumdar, who believes the same technique can be used in other medications, including other opioids, to make them safer.  

“Almost one-third of all drugs currently on the market — from blood pressure drugs to diabetes drugs to analgesics like fentanyl — bind to various G-protein coupled receptors, so it may be possible to make many drugs more effective, and to limit their side effects, by altering how they bind with such receptors.”

Researchers say further study is needed to prove that their altered version of fentanyl will work in humans, but they believe they've found a way to potentially improve its safety and those of other painkillers.

The research appears promising and may someday benefit pain patients, but it overlooks a simple fact: most of the fentanyl that is killing people is illicitly produced. And the clandestine labs, drug cartels, pill pressers and drug dealers responsible for the vast majority of overdoses will have no interest in adding sodium to their counterfeit pills and other fentanyl-laced drugs to make them safer.

The Nature study also perpetuates some longstanding myths about the overdose crisis, calling fentanyl and other prescription opioids a "major public health concern due to their adverse side effects."

But as pain management expert Dr. Lynn Webster pointed out in a 2019 PNN column, calling fentanyl a "weapon of mass destruction" is a bit of an overreach. Fentanyl has been legally used for decades -- safely and effectively -- as a surgical analgesic, and in transdermal patches and lozenges intended for patients with severe pain from cancer and other intractable pain conditions.

"Each of these new uses of fentanyl exposed millions of Americans to the drug without evidence of an inordinate degree of harm if it was used as directed," Webster wrote. "The opioid crisis is now largely driven by nonpharmaceutical fentanyl and fentanyl analogs, not prescription fentanyl."

Few pain patients who use fentanyl as directed become addicted or overdose, although many do become dependent on the drug to continue working, perform simple household chores, maintain personal hygiene, and have some quality of life. Modifying prescription fentanyl with sodium to make it safer might benefit some of those patients, but it will likely have no effect on the fentanyl crisis or prevent many overdoses.

Drug Tests Show Pain Patients on Opioids Less Likely to Use Illicit Drugs

By Pat Anson, PNN Editor

In an effort to reduce soaring rates of drug abuse and overdoses, many physicians have taken their pain patients off opioids and switched them to “safer” non-opioid drugs like pregabalin, gabapentin and duloxetine. Others have encouraged their patients to try non-pharmacological treatments, such as acupuncture, massage and meditation.

That strategy may be backfiring, according to a large new study by Millennium Health, which found that pain patients prescribed opioids are significantly less likely to use illicit drugs than pain patients not getting opioids.

The drug testing firm analyzed urine drug samples from 2019 to 2021 for nearly 55,000 patients being treated by U.S. pain management specialists. About 80% of the patients were prescribed an opioid like oxycodone or hydrocodone, while the other 20% were not prescribed opioids.

Millennium researchers say detectable levels of illicit fentanyl, heroin, methamphetamine and cocaine were far more likely to be found in the urine of non-opioid patients than those who were prescribed opioids. For example, illicit fentanyl was detected in 2.21% of the patients not getting an opioid, compared to 1.169% of those who were. The findings were similar for heroin, methamphetamine and cocaine.

“In all cases, we found that the population that was not prescribed an opioid was significantly more likely to be positive for an illicit drug than those patients who were prescribed opioids,” said lead author Penn Whitley, Director of Bioinformatics at Millennium. “(There was) a 40 to 60 percent increase in the likelihood of being positive if you were not prescribed an opioid.”

Illicit Drug Use By Pain Patients

MILLENNIUM HEALTH

What do the findings mean? Are pain patients getting ineffective non-opioid therapies so desperate for relief that they’re turning to illicit drugs? That’s possible, but the study doesn’t address that specifically.

Another possibility is that patients on opioids are simply being more cautious and careful about their drug use. Opioid prescribing in the U.S. has fallen by 48% over the past five years, with many patients being forcibly tapered or abandoned by doctors who feel pressured to reduce their prescribing.  

“Unfortunately, a lot of people with chronic pain have learned that it’s a bit tenuous, that their doctors are feeling pressure, and if they want to maintain their access (to opioids), they need their PDMP (Prescription Drug Monitoring Program) and their drug tests to look the way they need to look, so their doctor can feel comfortable continuing to prescribe,” said co-author Steven Passik, PhD, VP of Scientific Affairs and Head of Clinical Data Programs at Millennium. “I do think they realize that they’re on a treatment and that access to it is not guaranteed.”   

Preliminary findings from the study were released today at PainWeek, an annual conference for pain management providers. The findings mirror those from another Millennium study earlier this year, which found that pain patients have lower rates of illicit drug use than patients being treated by other providers.     

“If your main way of protecting people in pain from getting involved in substance abuse is to limit their access to opioids, there’s at least a hint here that’s not the right approach,” Passik told PNN. “It’s not a definitive statement by any stretch of the imagination, but it’s an approach to patient safety that leaves a bit to be desired.”  

Another recent study at the University of Texas also found that restricting access to opioids is “not a panacea” and may even lead to more overdoses.  Researchers found that in states that mandated PDMP use, opioid prescribing decreased as intended, but heroin overdose deaths rose 50 percent.

“Past research has shown that when facing restricted access to addictive substances, individuals simply seek out alternatives rather than limiting consumption,” said lead author Tongil Kim, PhD, an assistant professor of marketing at University of Texas at Dallas. “In our case, we measured overdose deaths as a proxy and found a substantial increase, suggesting that the policy unintentionally spurred greater substitution.”

DEA Warns of ‘Rainbow Fentanyl’ Targeting Kids

By Pat Anson, PNN Editor

At first glance, they look like candy. Brightly-colored tablets in shades of pink, purple, yellow and green. Not unlike a bag of Skittles or a bowl of Fruit Loops.

But they’re not sweet treats. They’re the latest version of “Mexican Oxy” – counterfeit oxycodone pills laced with fentanyl, stamped with an “M” on one side and “30” on the other. Typically blue in color – like authentic oxycodone – the pills increasingly come in a variety of colors, what law enforcement agencies call “rainbow fentanyl.”

In recent weeks, rainbow fentanyl has been found in 18 states, including an August 17 bust at the Arizona border with Mexico, where over 15,000 of the colorful pills were found strapped to a smuggler’s leg.

It was the second consecutive day rainbow fentanyl was intercepted at the port of Nogales, a possible sign that drug cartels are targeting younger users.

“Rainbow fentanyl — fentanyl pills and powder that come in a variety of bright colors, shapes, and sizes — is a deliberate effort by drug traffickers to drive addiction amongst kids and young adults,” DEA Administrator Anne Milgram said in a statement that warns of the “alarming emerging trend.”

HOMELAND SECURITY IMAGE

The DEA says rainbow fentanyl is being seized in multiple forms, including blocks that resemble the chalk a child might use to color a sidewalk. A recent drug raid in Portland, Oregon turned up several powdered blocks of rainbow fentanyl, along with meth, heroin, hundreds of fentanyl pills and a small armory of guns.

“Deputies are particularly concerned about rainbow fentanyl getting into the hands of young adults or children, who mistake the drug for something else, such as candy or a toy, or those who may be willing to try the drug due to its playful coloring. The powdered fentanyl found during this investigation resembles the color and consistency of sidewalk chalk,” the Multnomah County Sheriff’s Office said in a statement.

“We are seeing more powdered fentanyl that is dyed in various colors. The strength can vary but is typically stronger than pressed pills,” said Kelsi Junge, Harm Reduction Supervisor for Multnomah County.

Some colors are believed to be more potent than others, a claim that has not been confirmed by DEA laboratory tests.  

No matter the color or shape, rainbow fentanyl is dangerous. Fentanyl is a synthetic opioid that is 50 times more potent than heroin and 100 times more potent than morphine. Just two milligrams of fentanyl, similar in size to 10-15 grains of salt, is considered a lethal dose. 

Because illicit fentanyl is cooked up in makeshift laboratories by amateur chemists, the potency of the pills or powder varies considerably.

MULTNOMAH COUNTY SHERIFF

The DEA says most of the illicit fentanyl in the United States is supplied by two Mexican drug cartels, the Sinaloa and Jalisco New Generation cartels, although there is no shortage of Americans willing to transport the drugs or turn them into tablets with pill presses.

“The men and women of the DEA are relentlessly working to stop the trafficking of rainbow fentanyl and defeat the Mexican drug cartels that are responsible for the vast majority of the fentanyl that is being trafficked in the United States,” said Milgram.

Fentanyl is a potent analgesic that is prescribed legally for severe pain, but it is illicit fentanyl and its analogues that are responsible for the vast majority of drug deaths. According to the CDC, over 107,000 Americans died of drug overdoses in 2021, with two-thirds of the deaths linked to fentanyl.

Overdose Deaths Double for Teenagers Amid Fentanyl Surge

By Pat Anson, PNN Editor

Drug deaths among U.S. teenagers have risen sharply in the last two years, according to a new study that found the number of fatal overdoses doubled for adolescents aged 14 to 18 years.

In 2019, there were 492 drug deaths among adolescents. In 2021, there were an estimated 1,146 fatal overdoses, a 133% increase.

The vast majority of adolescent drug deaths last year involved illicit fentanyl (77%), followed by benzodiazepines (13%), methamphetamines (10%) and cocaine (7%). Less than 6% of the overdoses among teens involved a prescription opioid.

The study findings, reported in the journal JAMA, reflect what is happening in the overall U.S. population, with drug overdoses rising to record levels. They also mark the reversal of a decade long trend of fewer overdose deaths among teens, which coincided with declining rates of illicit drug use.

Researchers say adolescents may be unaware or naive about the risks posed by fentanyl, a synthetic opioid up to 100 times more potent than morphine and 50 times stronger than heroin. In a prescription, fentanyl plays a valuable role in treating severe pain, but as a street drug it can be deadly

“Beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls,” lead author Joseph Friedman, MPH, University of California, Los Angeles, reported in the journal JAMA.

“In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency. Since 2015, fentanyls have been increasingly added to counterfeit pills resembling prescription opioids, benzodiazepines, and other drugs, which adolescents may not identify as dangerous and which may be playing a key role in these shifts.”

U.S. Adolescent Overdose Deaths

SOURCE: jama

Friedman and his colleagues found the highest overdose rates among Native American, Alaska Native and Latino adolescents, reflecting what they called a “wider pattern of increasing racial and ethnic inequalities” in drug deaths.

Fentanyl is even killing kids who have not reached their teenage years. In California, a boy was recently arrested and charged with murder in the death of 12-year-old Dalilah Guerrero. The 16-year-old suspect allegedly sold a counterfeit pill made with fentanyl to the girl, who overdosed after crushing and snorting the tablet at a party in San Jose.

The spike in adolescent drug deaths comes even as substance abuse by teens fell to record lows. An annual survey by the University of Michigan found significant declines in all types of drug use by adolescents in 2021, with the use of prescription opioids falling to the lowest level in nearly two decades.    

DEA Warns of Fentanyl Mass Overdoses

Public health experts and law enforcement agencies are growing increasingly alarmed by the rising number of fentanyl overdoses. Last week, the DEA warned of a nationwide spike in fentanyl-related mass overdose events, in which three or more overdoses occur in the same location.

In the past three months, at least seven mass overdoses were reported in Florida, Texas, Colorado, Nebraska, Missouri and Washington, DC, resulting in 29 deaths. Three people died in a hotel room in Cortez, Colorado after ingesting what that they thought were 30mg oxycodone pills, but were actually counterfeit pills containing fentanyl.

“Tragic events like these are being driven by fentanyl. Fentanyl is highly-addictive, found in all 50 states, and drug traffickers are increasingly mixing it with other types of drugs — in powder and pill form — in an effort to drive addiction and attract repeat buyers,” DEA Administrator Anne Milgram said in a letter to federal, state and local law enforcement agencies. 

“We recommend that the members of your offices assume that all drugs encountered during enforcement activities now contain fentanyl. Given fentanyl’s extreme toxicity and the increases we are seeing in the distribution of polydrug substances containing fentanyl, please take all the precautions you would take when handling fentanyl whenever you interdict any illicit substance.”

A recent study by the National Institute of Drug Abuse estimated that over 9.6 million counterfeit pills containing fentanyl were seized by U.S. law enforcement agencies last year.

9.6 Million Counterfeit Pills Made with Fentanyl Seized in 2021

By Pat Anson, PNN Editor

Seven years after the Drug Enforcement Administration issued its first nationwide alert about the emergence of illicit fentanyl in street drugs, the fentanyl crisis continues to escalate and overdose deaths keep rising.

A new study by the National Institute of Drug Abuse (NIDA) estimates that 2,416 kilograms (5,326 pounds) of illicit fentanyl powder were seized by U.S. law enforcement agencies in the last three months of 2021. According to a DEA estimate of fentanyl’s lethality, that’s enough to kill 1.2 billion people.  

That’s not the worst part, according to researchers. The number of counterfeit pills made with fentanyl is also growing and now make up about 29% of all seizures. Over 9.6 million counterfeit pills were seized by law enforcement last year.

“An increase in illicit pills containing fentanyl points to a new and increasingly dangerous period in the United States,” NIDA Director Nora Volkow, MD, said in a statement. “Pills are often taken or snorted by people who are more naïve to drug use, and who have lower tolerances. When a pill is contaminated with fentanyl, as is now often the case, poisoning can easily occur.”

In the last quarter of 2021, over two million counterfeit pills laced with fentanyl were seized – a 4,850% increase from the same period in 2018.

Counterfeit pills are particularly worrisome because they are easy to manufacture, transport and sell -- and most people who buy them have no idea if they’re getting a potentially lethal dose of fentanyl. Counterfeit pills known on the street as “Mexican Oxy” or “M30” look nearly identical to 30mg oxycodone pills.

Because fentanyl is up to 100 times more potent than morphine and 50 times more potent than heroin, it doesn’t take much to kill someone. The DEA estimates that nearly half of counterfeit pills contain at least 2mg of illicit fentanyl, a potentially lethal dose.

“What is particularly concerning is that fentanyl is now often pressed into counterfeit pills which resemble oxycodone (e.g., blue “M30″ pills), hydrocodone, or benzodiazepines such as alprazolam. This is alarming because a large portion of people who misuse psychoactive prescription pills such as opioids or benzodiazepines obtain them from nonmedical sources, thus increasing the likelihood of users unintentionally ingesting fentanyl through counterfeit pills,” lead author Joseph Palamar, PhD, a drug epidemiologist at NYU’s Grossman School of Medicine, reported in the journal Drug and Alcohol Dependence.

Illicit fentanyl was first detected in cocaine, heroin and other U.S. street drugs in 2014. Two years later, counterfeit pills made with fentanyl also began appearing, around the same time the CDC released a guideline that discourages doctors from prescribing opioids for chronic pain.

Faced with pressure from Congress to crackdown on painkillers, the DEA began reducing the legal supply of opioids in 2017. The agency has reduced opioid production quotas for five consecutive years, cutting the supply of hydrocodone and oxycodone in half.

In 2021, the DEA quietly acknowledged that drug cartels were actively targeting pain sufferers as potential customers.  A DEA report said nearly two-thirds of people who misused pain medication “identified relieving pain as the main purpose” of their drug use.

Cutting back on legal opioid medication has clearly backfired. The CDC recently reported that over 105,000 Americans died of drug overdoses in the 12-month period ending October 2021, a record number. About two-thirds of those deaths involved synthetic opioids such as fentanyl.

The risks of fentanyl and counterfeit pills should be well-known by now, but Palamar and his colleagues say a surprising number of people are oblivious to the danger. They cited a recent study of nightclub attendees – a group at high risk of illicit substance use – which found that only half were aware that pills obtained from family, friends or dealers may be counterfeit versions made with fentanyl.

“Public education about the risk of non-pharmacy-sourced pills containing fentanyl needs to be more widespread,” they wrote. “These findings suggest that a substantial portion of people who use illegal drugs appear to be aware that non-pharmacy-sourced pills can contain fentanyl, but less experienced people who may be at risk for use require more education.”

Should the CDC guideline be changed to make it easier for doctors to prescribe opioids? Let us know what you think by taking PNN’s survey on the revised CDC guideline. Click here to get started.

Pain Patients Have Low Rates of Illicit Drug Use

By Pat Anson, PNN Editor

Anti-opioid activists have long claimed that opioid medication is a gateway drug to heroin and other street drugs. That myth is so ingrained in the medical community that many pain patients are discriminated against by doctors and pharmacists, who suspect they are abusing their medication or using illicit drugs.

But a large new study by Millennium Health pokes a hole in that myth, finding that patients being treated in pain management practices are far less likely to use heroin, fentanyl, cocaine and methamphetamine than other patients.

The drug testing firm analyzed the lab results of two million urine tests from 2015 to 2021 – nearly 600,000 coming from pain patients -- and found that patients seeing primary care physicians, behavioral health doctors (psychiatrists and psychologists), or getting substance use disorder (SUD) treatment were significantly more likely to test positive for street drugs than patients of pain management providers.

SOURCE: MILLENNIUM HEALTH

“That’s one of the reasons why we decided to put this out there in the public domain, because it’s important. Because clearly there are differences across these groups,” said Eric Dawson, PharmD, Vice President of Clinical Affairs at Millennium Health.

For example, the positivity rate for fentanyl in urine samples is about 2% for pain management patients – a level that remained stable throughout the 6-year study period.

But Millennium found that for primary care and behavioral health patients, the positivity rate for fentanyl has ticked up to about 5 percent.

In patients getting SUD treatment, the positivity rate has skyrocketed to about 17 percent, no doubt a reflection of the growing presence of illicit fentanyl in street drugs.

Positivity rates for methamphetamine are also rising for most patients – but not for pain patients – while cocaine use has remained relatively flat. Positivity rates for heroin have declined steadily for all patients since 2015, according to Millennium.

“Generally speaking, the pain population that’s treated with opioids is an older population and uses illicit drugs at a very low rate,” said Steven Passik, PhD, VP of Scientific Affairs and Head of Clinical Data Programs at Millennium.

“Not only are they low, they remain low,” says Dawson. “So many of the other groups, over time their positivity rates are increasing. The pain population started low and remains low. And that says they are different than the other groups.”

What makes the findings even more striking is that they include the first two years of the covid pandemic, a time when stress, isolation and depression led many people to abuse drugs.

“But that did not happen in the pain patients. You can actually see that,” says Passik, who believes regular drug testing makes pain management patients less likely to take risks that might affect their healthcare. He thinks the Millennium study should be reviewed by both providers and policymakers to get a better understanding of people in pain.

“There isn’t that much data like this out there. I think it’s unique and very positive about this population. And I think that should be factored in when people are talking about access to opioids,” Passik told PNN.

In addition to fentanyl, heroin and other street drugs, the Millennium study also looked at positivity rates for marijuana, which have soared in recent years due to the legalization of medical and recreational cannabis in many states. By the end of 2021, the positivity rate for cannabis had reached nearly 32 percent for most patients. But, like the other drugs, cannabis use remained relatively low for pain patients.