The Fake Excuses Pharmacists Use to Avoid Filling Opioid Prescriptions

By Crystal Lindell

I still remember the first time a pharmacist lied to me about why they couldn’t fill my opioid prescription.

I went in to pick up my regularly scheduled morphine refill, and when I got to the counter, she told me that my insurance wouldn’t cover two prescription refills within the same calendar month. She claimed that the rule applied even if the refills were 30 days apart due to a month having 31 days. And, since the insurance wouldn’t cover it, they weren’t filling it.

At the time, it didn’t even occur to me that a pharmacist would blatantly lie to me about something like that. So I immediately walked away from the counter and pulled out my cell phone to call my insurance company.

I’m not going to lie, I had a whole rant ready to spew at them about this nonsensical rule.

As it turned out, my frustration was misplaced, because no such nonsensical rule existed. In fact, the representative told me no one from the pharmacy had attempted to even put the prescription through. If they had, the insurance company would have covered it.

When I went back to the pharmacy counter and relayed this information, the pharmacist shrugged and said it must have been a mistake. Then, she filled my prescription – which was indeed covered by insurance.  

It wouldn’t be the last time I would have to deal with a lying pharmacist.

Over the years I’ve realized that it’s common for pharmacists to throw up false hurdles when patients try to fill any type of controlled substance script. This includes opioids, but also stimulants like those prescribed for ADHD.

I’ve seen it happen many times to myself and loved ones. Their excuses seem to fall into three broad categories.

Claim #1: Insurance won’t cover the medication

This ties into my opening story here, but it’s also happened to me and my loved ones a number of other times.

For example, after my mom had a hip replacement surgery, the pharmacist tried to tell her that her insurance would only cover a specific number of pills, so they did not fill for the entire amount. My mom was too out of it to argue with them and just accepted the smaller amount – which is what the pharmacist was likely hoping would happen.

A related claim here is that the pharmacy can’t take cash payment for a controlled substance in cases where insurance is refusing to cover it. They never even offer the option in this circumstance, despite the fact that generic pain medications are relatively cheap, and many patients would be happy to pay cash if it meant getting their meds.

I can only speak to Illinois, but as someone who’s been living without health insurance since 2022, I can confirm that pharmacies here can definitely take cash for a controlled substance.

Claim #2: The pharmacy never received the prescription from your doctor

Just last week, one of my loved ones called his pharmacy when his pain medication was due to be refilled and the staff told him that they had not received the prescription. He asked them to check different computer files to see if they were missing it, because he was sure his doctor had sent it in.

The pharmacy staff insisted that they had not received it. It was a Saturday, so he was unable to get a hold of his doctor.

He called back on Sunday morning and they again claimed they had not received the prescription, but after he pushed them to look for it in different places they suddenly found it.

When he finally got the bottle, it said the prescription had been dated for that Saturday, meaning they had definitely lied about not receiving it the day before.  

Claim #3: The medication is completely out of stock

This is one that’s difficult to prove, but it happens so frequently that I have to assume that at least some of the time pharmacists are lying about being out of a medication. It’s an excuse they can give to avoid filling a prescription. 

Even if they aren’t lying about it, there’s nothing the patient can do to prove it. Opioids at many pharmacy chains are essentially being rationed due to opioid litigation settlements.

Beyond the direct lies, pharmacists use other tactics to make getting refills more uncomfortable and difficult. I assume that their hope is that it will deter patients from coming back.

For example, my current pharmacist will sometimes decide that he needs to discuss my opioid usage with me, and have a talk with me encouraging me to lower the dosage. It’s always an awkward and unwelcome conversation, and just the possibility of it happening makes me dread going in there every month.

My pharmacist has also tried to tell me that I needed a Narcan prescription to get another refill. The problem is I would have to pay cash for it, because I don’t currently have insurance. Thankfully, I convinced him that I already had Narcan at home – which was true. But I could see other patients giving up and leaving without their refill.  

The thought process among pharmacists seems to be that if they give pain patients enough hurdles to jump before they can get their opioid prescriptions, that some will just give up. That keeps more opioids out of patients’ hands.

I think pharmacists underestimate how much harm they cause when they straight up lie to patients. They see what they’re doing as protecting people from the supposed harms of opioids. But what they’re actually doing is eroding patient trust in them and medical professionals in general.

When pharmacists lie about being unable to fill prescriptions, it makes me wonder what else they are lying about. And it’s not a far leap to start questioning other medical information they provide.

I’m not sure what the solution is to all of this, other than to call out the behavior and to make more patients aware that it could be happening to them. People should know that they aren’t crazy, and that it’s okay to push back if you think the pharmacy is lying.

Maybe one day there will be more regulations in place to protect patients from being lied to by pharmacists. Or maybe pharmacists will be replaced by artificial intelligence programs – which may come with brand new problems that we haven’t even considered yet. 

Until then, my hope for you is that the next time you need to get a controlled substance prescription filled, the whole process goes so smoothly that it’s ready for pick up before you even get to the pharmacy.

Combining Opioids With a Cannabis-Based Medicine Doesn’t Add to Pain Relief

By Pat Anson

Combining a low dose of opioids with a cannabis-based medicine did not improve acute pain for people with arthritis, according to results of a small clinical study published in the journal Anesthesiology.

Animal studies have suggested that the two drugs might have a synergistic effect and provide better pain relief, but the study of 21 people with knee osteoarthritis found no added benefit. 

“Some patients believe combining cannabis with opioids can help with pain, and clinicians may recommend or prescribe it in states where cannabis is legal,” said lead author Katrina Hamilton, PhD, a Psychiatry Professor at Johns Hopkins School of Medicine. “Our study suggests that isn’t the case and patients may experience more side effects when the drugs are combined.”

There are some important caveats to the study that diminish its findings.

One is the design of the study and its small size – just 21 patients – who received placebo pills, hydromorphone alone, dronabinol alone, and a combination of hydromorphone and dronabinol. 

Participants received all four combinations prior to having pain induced by sticking their hands in cold water or having their skin rubbed with a “hot” capsaicin cream. That means the researchers were evaluating acute pain induced in a laboratory, not the chronic pain caused by arthritis.

Second, dronabinol (Marinol) is not cannabis. Dronabinol is a synthetic version of THC, the active ingredient in cannabis. It is FDA-approved to treat nausea and vomiting in chemotherapy patients, and to improve appetite in AIDS patients. Dronabinol was never intended to provide pain relief and has little in common with the various forms of cannabis (edibles, smoking, vaping) used in the real world. 

Third, while hydromorphone is a potent opioid, the oral dose (2 mg) that was used is relatively low – about 10 morphine milligram equivalents (MME). The research team had previously conducted a similar study using 4mg of hydromorphone. That also produced little pain relief for participants, so it’s not surprising that 2mg didn’t help either, although researchers say the lower dose has a “better safety profile.” 

The researchers found that taking hydromorphone and dronabinol, either alone or in combination, did not provide significant relief from acute pain. The opioid alone reduced pain sensitivity, while dronabinol did not, but neither meaningfully reduced participants’ self-reported pain.

When the two drugs were combined, side effects such as drowsiness, dizziness and impaired thinking were stronger and more noticeable, but without added pain relief.

“Opioid and cannabinoid medications failed to produce robust analgesia in experimentally induced pain among patients with knee osteoarthritis. In contrast to preclinical studies, there was no evidence of synergistic analgesic effects by combining hydromorphone and dronabinol,” researchers concluded.

While the dose of hydromorphone was low, the 10mg dose of dronabinol that was used in the study is a hefty amount. Interestingly, participants reported more of a “high” sensation from the dronabinol than from hydromorphone. But again, dronabinol is a synthetic version of cannabis and has little in common with what most cannabis consumers use.    

“In the real world, people often use cannabis differently, including lower starting doses, using gradually stronger doses, which may affect both benefits and side effects,” said Hamilton, acknowledging the limits of her study. “More research is needed to better understand how cannabis affects pain when used in real-world settings.”

Medical Cannabis Significantly Reduced Use of Opioids and Other Rx Drugs

By Pat Anson 

A new survey of cannabis users in Germany found a significant reduction in their use of painkillers, sleep medications, anti-depressants and other prescription drugs after starting medical cannabis treatment.

Over 3,500 cannabis patients participated in the online survey, published by Bloomwell, which found an average 84.5% decrease in the use of medications overall. Over half of respondents (58.9%) said they stopped taking at least one medication completely.

The reduced consumption of prescription drugs led to a corresponding change in side effects. Over 60% of patients said they no longer had any medication-related side effects, while nearly 38% said their side effects were reduced. 

Less than 2% said their side effects remained the same or intensified after they started using medical cannabis.

“Cannabis is often portrayed as dangerous and addictive, even though the most severe side effects and addiction potential have only been proven with other prescription medications,” said Julian Wichmann, MD, co-founder and CEO of Bloomwell, one of the leading providers of medical cannabis in Europe.

The reduced use of prescription drugs was associated with major improvements in quality of life and productivity. Most patients reported better concentration (67.8%), more social interactions (61.9%), and fewer days of missed work (53.9%) after they started using medical cannabis.

“Patients benefit significantly when they are able to replace other prescription drugs with medical cannabis. The often completely absent side effects are also associated with a marked improvement in quality of life and work performance. This is likely the most important finding of our survey,” said Wichmann.

The steepest reduction in the use of a prescription drug class was for sleep medications; 93.6% were able to reduce their use of sleeping pills by at least half, and 75.5% were able to discontinue them completely. 

Patients who took the stimulant methylphenidate (Ritalin) reported an average reduction of 88.4% after starting medical cannabis, while 77.3% were able to discontinue it completely. 

Patients were able to reduce their use of opioids by an average of 83.9%, while 61% were able to completely discontinue opioids.

That finding mirrors those of other studies in the US and UK. 

A large 2022 survey of medical cannabis users in Florida found that those who have chronic pain were able to reduce or even stop their use of opioids. Patients reported less pain and better physical and social functioning once they started using medical cannabis. 

A recent survey of UK adults prescribed medical cannabis for anxiety, depression, insomnia, PTSD and other mental health conditions found that 97% said it improved their well-being and happiness, while 68% said it enabled them to work.

Germany first legalized medical cannabis in 2017, allowing patients with certain medical conditions to access it with a prescription. In 2024, the German Narcotics Act declassified cannabis as a narcotic and allowed adults to possess and cultivate limited amounts for recreational use.

According to Bloomwell, cannabis reforms in Germany have led to significant reductions in the price of cannabis flowers and an increase in cannabis prescriptions.  

Vertanical, a German pharmaceutical company, hopes to soon get regulatory approval in Europe and the UK for the first cannabis-based medicine for chronic pain. In clinical trials, the full spectrum cannabis extract provided better pain relief for low back pain in a head-to-head comparison with low doses of opioids.

Doctors More Likely to Use Negative Terms for Sickle Cell Patients

By Crystal Lindell

Sickle cell patients are more likely than other patients to have negative descriptions in their medical charts, such as “noncompliant” and “noncooperative,” according to a new study published in JAMA Network Open.

The results are concerning because prior research has shown that such descriptors make doctors less likely to aggressively treat pain, a common symptom of sickle cell disease. The genetic disorder causes red blood cells to form in a crescent or sickle shape, which creates painful blockages in blood vessels. About 100,000 Americans have sickle cell disease, primarily people of African or Hispanic descent.

Researchers at the University of Chicago used artificial intelligence to analyze electronic health records and clinician notes for over 18,000 adult patients. They looked for seven negative words in patient charts: aggressive, agitated, angry, nonadherent, noncompliant, noncooperative, and refuse.

The descriptive words for sickle cell patients were then compared to those of four other groups without sickle cell disease: Black patients, patients diagnosed with chronic pain, patients diagnosed with opioid use disorder (OUD), and non-Black patients. 

They found that patients with sickle cell disease had higher odds of having negative descriptions than Black patients, non-Black patients and patients with chronic pain, but had similar odds of negative descriptors as patients with opioid use disorder. Non-Black patients had the fewest negative descriptors than the other patient groups.

Black patients with sickle cell disease, chronic pain, and OUD had the highest frequency (19%) of negative descriptors in their medical notes.

The researchers said their findings suggest there is bias against patients with sickle cell disease, particularly when opioids are involved.

“Although patients with sickle cell disease routinely use opioid medications to manage their chronic pain, the vast majority do not have an opioid use disorder,”  said senior author Monica Peek, MD, a Professor for Health Justice at University of Chicago Medicine. 

“It is a testament to the strength of their character that they do their best to live full lives while managing debilitating pain with the minimum amount of medication. And yet, within health professions and society as a whole, there is a persistent bias that stereotypes these patients primarily as ‘drug-seekers’ rather than regular people managing a chronic disease.”

The bias and stigma have real life consequences: If a doctor or nurse sees negative descriptors in a patient’s chart, they are less likely to effectively treat their pain.

When it comes to terms like “noncompliant,” the issue can be a bit of a chicken-egg situation — it’s difficult to know what came first. 

Prior research has shown that patients with sickle cell disease who experience discrimination in health care are less likely to follow physician recommendations. These same patients may then be labeled as “noncompliant,” which could perpetuate discriminatory behavior against them. 

The researchers said that clinicians should work to understand why a patient may not want to take a medication or has trouble adhering to treatment, and then adjust their treatment plan to support the patients from there. And they should avoid using negative terms in patient charts.

Researchers Say Opioid Risk Tool Has ‘Too Many False Alarms’

By Pat Anson

The use of artificial intelligence (AI) continues to grow in healthcare, with patient health data and behavior increasingly being used to assess whether a patient is at risk of an illness or chronic health condition.

NarxCare and Epic, for example, scan electronic health records and prescription drug databases to create Opioid Risk Scores (ORS) for patients, which are then shared with healthcare providers to flag patients at risk of opioid misuse or an overdose. Patients deemed to be at high risk may not be able to get a prescription for opioids or they may be abandoned as “too risky.”

But a new study – the first of its kind – suggests that using opioid risk scores to predict patient outcomes is flawed, with unacceptably high rates of false positives.   

The study, recently published in the Journal of General Internal Medicine, looked at Epic’s opioid risk scores for over 700,000 U.S. patients being treated by primary care providers. The vast majority of patients (99.6%) were classified as low risk, with only 0.4% considered at high risk of an overdose or OUD.

It’s reassuring to see so many patients deemed low risk. But how accurate is the risk score in predicting patient outcomes? 

Of the 702,099 patients deemed low risk, only 2,177 went on to have an overdose or OUD diagnosis within the next 12 months. That means the system correctly predicted outcomes 99.7% of the time.

Conversely, of the 2,665 patients deemed high risk, only 185 later had an overdose or OUD diagnosis. That means Epic’s scoring system correctly predicted outcomes only about 7% of the time. 

Researchers say the false positive rate of 92.2% in the high risk category means that Epic’s ORS “produces too many false alarms” and is of little value to providers.  

“In this study, most high-risk patients were false positives, and most who developed OUD or overdosed were false negatives. Because these outcomes are rare, achieving adequate PPV (the proportion of cases that are accurate) is challenging. The ORS’s misclassification could undermine its external validity, leading to misallocated resources and missed interventions,” wrote lead author Stephanie Hooker, PhD, a Research Investigator at HealthPartners Institute.

“Missed interventions” in this case could mean a patient being denied opioid medication or being referred to addiction treatment, when neither move is justified.

On the flip side, Epic’s 99.7% success rate in identifying low risk patients also isn’t foolproof. 

Of the 2,362 patients who experienced an overdose or OUD diagnosis, Epic’s system flagged only 185 of them as high risk — which suggests that over two thousand were incorrectly labeled as “low risk.”

Maybe the lesson here is that “low risk” doesn’t mean no risk, and “high risk” doesn’t provide any certainty either.  

Pain management expert Dr. Lynn Webster says no opioid risk score — whether Epic’s or NarxCare’s – should be viewed as authoritative by doctors and pharmacists in making clinical decisions.     

“Both tools can be harmful if used punitively. The NarxCare scores have shown that overestimated risk may lead to forced tapering, abandonment, or other punitive responses, which could paradoxically increase overdose risk. With Epic, the harm is a bit different: the score can both stigmatize flagged patients and falsely reassure clinicians about the much larger group labeled low risk,” said Webster, a Senior Fellow at the Center for U.S. Policy (CUSP).

In 2023, CUSP petitioned the FDA to take Narxcare’s ORS software off the market as an unproven and misbranded medical device. The FDA rejected the petition on procedural grounds. 

In the case of Epic’s ORS, Webster says it is a mistake to count OUDs and overdoses in the same prediction model because they are distinct events. Someone can overdose without having OUD, while someone can have OUD without ever experiencing an overdose.   

“Opioid risk tools will always struggle to predict overdose death risk because overdoses can occur in patients who have no opioid use disorder and no aberrant drug-related behavior,” Webster told PNN. “Some patients overdose even when they take their medications exactly as prescribed. Overdose can also occur because of comorbid medical conditions or other factors unrelated to OUD.”

As flawed as they might be, Epic and NarxCare are already embedded in the U.S. healthcare system. Data on over 190 million patients has been collected by Epic’s MyChart software, while NarxCare is used by Walmart, Rite Aid, CVS and other major pharmacy chains to analyze patient risk.

“Whether the score comes from NarxCare or Epic, the core danger is the same: once a proprietary risk label is embedded in the chart, it can take on a false authority that changes how patients are treated,” says Webster.

Co-Prescribing of Opioids and Gabapentinoids Grows Despite Warnings

By Pat Anson

In 2019, the FDA warned that serious breathing problems can occur in patients who take gabapentinoids with opioids or other medications that suppress the central nervous system. The agency said elderly patients and those with pre-existing lung problems were at highest risk of respiratory depression, which can lead to a fatal overdose.

Those warnings went unheeded by many doctors, according to a new study that found the co-prescribing of gabapentinoids to patients on long-term opioid therapy increased over the past decade, rising from 47% in 2015 to 58.7% in 2023.

Gabapentinoids are a class of nerve medication originally developed to prevent seizures, but are widely prescribed off-label to treat pain. They include gabapentin (Neurontin) and pregabalin (Lyrica), as well as generic versions of the drugs.

Not only did co-prescribing with gabapentinoids increase, but the age of patients on long-term opioids also rose, from 52.5 years in 2015 to 60.5 in 2023. Nearly half of those patients (48.7%) are on Medicare. 

“Because older adults are at higher risk of adverse events from polypharmacy, the increased rates of coprescribing, particularly with gabapentinoids, raises additional safety concerns,”  said Thuy Nguyen, PhD, Assistant Professor of Health Management and Policy at the University of Michigan’s School of Public Health.

Nguyen and her colleagues' findings, published in a JAMA research letter, also document a steady decline in long-term opioid use, which coincides with federal and state guidelines that were imposed to limit opioid prescriptions.  

Between 2015 and 2023, the number of U.S. patients on long-term opioid therapy for at least 90 days fell from 5.6 million to about 4.2 million — a 24.3% decrease. 

At the same time, the average daily dose of opioids also declined, from 47.9 morphine milligram equivalents (MME) in 2015 to 38.6 MME in 2023 – which is in line with CDC guidelines that recommend caution when doses exceed 50 MME.

Researchers think more work is needed to reduce opioid use and to find alternative ways to relieve pain.

“With almost 5 million Americans on long-term prescription opioids for chronic pain, and likely millions more who are taking shorter courses of prescription opioids for acute pain, most clinicians are likely to care for someone using prescription opioids for pain, highlighting the pressing importance for investing in better treatment models for pain,” said senior author Pooja Lagisetty, MD, Associate Professor of Internal Medicine at the University of Michigan Medical School.

In addition to gabapentinoids, researchers tracked overlapping prescriptions for other controlled substances. They found that co-prescribing of long-term opioids with benzodiazepines declined from 43.8% in 2015 to 33.5% in 2023; while co-prescribing for stimulants rose from 5.9% to 6.7%.

In short, polypharmacy is relatively common with patients on long-term opioids, despite the known risks of combining certain drugs. 

Common side effects from gabapentin include brain fog, dizziness, weight gain, headache, fatigue, and anxiety. The drug has also been linked to a higher risk of dementia.

Those side effects may lead to a “prescribing cascade,” in which doctors mistakenly prescribe unnecessary medications to patients that cause even more side effects – never suspecting that gabapentin was the cause and they should consider discontinuing the drug.

In 2024, gabapentin was the fifth most prescribed drug in the U.S., with prescriptions nearly tripling since 2010. The number of patients prescribed gabapentin reached 15.5 million in 2024.

The off-label prescribing of gabapentin is legal and, in some cases, appropriate. But it has reached extreme levels, with studies estimating gabapentin is prescribed off-label up to 95% of the time. 

Iran War Creates ‘Perfect Storm’ for Drug Shortages

By Pat Anson

The Iran war has disrupted the global supply chain so much that it could worsen shortages and raise prices of painkillers and other commonly used medications, according to experts. 

In addition to supplying much of the world with oil and natural gas, the Middle East serves as a crucial transportation hub for pharmaceutical companies. Ships and planes are being rerouted to avoid the region, which creates delays and higher shipping costs. 

“If the instability really persists, you’ll probably see lead times, transportation costs that can impact direct items that we need for our medicines, including the key starting materials into active pharmaceutical ingredients,” Gerren McHam, vice president of external affairs at the API Innovation Center, told The Hill.  

Even before the war, the UK was dealing with shortages of aspirin and co-codomal, a combination of paracetamol and codeine. Other drugs in short supply include those used to treat arthritis, diabetes, epilepsy and cancer.

The UK is reportedly “a few weeks away” from running out of some generic medicines. Like the United States, the UK relies heavily on generic pharmaceuticals produced in India.

“It’s the perfect storm. We have the conflict in the Gulf that caused the strait of Hormuz to shut down, and India is known as the pharmacy of the world. They produce a lot of the generic drugs and APIs (active pharmaceutical ingredients). With the geopolitical situation, it’s harder and harder to get those out,” said David Weeks, director of supply chain risk management at Moody’s. 

Before the war, Canada was also dealing with shortages of drugs used to treat pain and arthritis, according to a new report from the Canadian Arthritis Patient Alliance (CAPA). 

CAPA interviewed arthritis sufferers and their caregivers, who reported “profound disruptions to their physical and mental well-being” due to shortages of pain relievers such as Percocet, hydromorphone, Tylenol 3 and acetaminophen, as well as anti-inflammatory drugs and biologics used to treat arthritis. 

Patients and caregivers said they often had to make multiple trips to pharmacies before finding one that had their medications in stock.

“What happens to people who don’t have someone to support them through this? Would they just be waiting in the pharmacy while in immense pain - I would hate for my mom to be stuck in a situation like this on her own,” one caregiver told CAPA.

One bright spot is that shortages of oxycodone and acetaminophen with codeine that began last summer in Canada have largely ended. The drugs are now “generally available in pharmacies,” according to Health Canada.

The Iran war so far has had little immediate impact on pain patients in the U.S. – who have already been dealing with persistent shortages of opioid medication for several years. 

The American Society of Health-System Pharmacists (ASHP) continues to report shortages of oxycodone-acetaminophen tablets, oxycodone immediate release tablets, hydrocodone-acetaminophen tablets and morphine immediate release tablets; as well as injectable opioids used in surgery and emergency medicine. 

A new study published in JAMA Health Forum highlights how vulnerable the U.S. pharmaceutical industry is to global supply chain disruptions. 

Researchers at Yale University looked at stimulant shortages in 2022 and 2023, when many  patients with attention-deficit/hyperactivity disorder (ADHD) had difficulty filling their prescriptions. 

Although the limited supply was often blamed on increased demand and tight DEA production quotas, researchers say the more likely cause was a “historically unprecedented” decrease in US imports of amphetamine and other chemicals used to make stimulants. The shortfall in imports led to sudden production cutbacks by several stimulant manufacturers.

“Supply chain disruptions can occur in many places in the supply chain. However, descriptive evidence indicates that the most recent ADHD drug shortage may be associated with a disruption in the sourcing of raw ingredients from abroad,” researchers reported..

“More broadly, this economic evaluation reframes the discussion of ADHD medication shortages beyond DEA quotas, highlighting the vulnerability of US pharmaceutical manufacturing to international supply chain disruptions.” 

U.S. Overdose Deaths Down Significantly

By Pat Anson

The number of fatal drug overdoses fell sharply in the U.S. in 2024, led by a significant decline in deaths involving illicit fentanyl, according to a new analysis.

Over 79,000 Americans lost their lives to a drug overdose in 2024, compared to 105,000 in 2023, a 24.5% decline in one year. Over 54,000 of the deaths in 2024 involved an opioid of some kind. 

The analysis by KFF further demonstrates the declining role of prescription opioids in the nation’s drug crisis. Prescribed opioids are now involved in about one in seven (13.6%) drug overdoses. 

In 2024, 10,851 Americans died from an overdose involving a natural or semi-synthethic prescription opioid, compared to 47,735 deaths involving synthetic opioids, mostly illicit fentanyl. 

Deaths from prescription opioids peaked at 17,029 in 2017 and have steadily declined.

U.S. Opioid Overdose Deaths 2004-2024

SOURCE: KFF

“Since the opioid epidemic was declared a public health emergency in 2017, it has claimed more than half a million lives. While the epidemic was initially driven by prescription opioids and heroin, it has evolved in recent years, to be dominated by illicit synthetic fentanyl — a substance significantly more potent than morphine,” KFF said. “Provisional CDC data suggest opioid deaths have continued to decline through 2025.”

The KFF analysis also looked at deaths involving alcohol, suicide and firearms.

In 2024, 48,824 American lives were lost to suicide, down slightly from the previous year. Firearms accounted for 57% of those deaths. There were 46,714 “alcohol-induced” deaths in 2024 caused by health conditions attributed to excessive alcohol use, about the same number of fentanyl overdoses.

Those deaths greatly outnumber fatal overdoses involving prescription opioids.

U.S. Deaths in 2024

Source: KFF

As PNN has reported, a recent study ranked alcohol as the 5th most harmful drug In the United States, behind illicit fentanyl, methamphetamine, crack and heroin. Prescription opioids ranked as the 7th most harmful drug in the U.S.

The analysis not only looked at the direct harm to drug users, but the indirect harm to families, communities and society at large caused by excessive drug use.

A panel of experts said the analysis shows how misdirected U.S. drug policy is, which is focused on crime and punitive measures to stop drug use, rather than public health measures to address substance use disorders. Criminalizing drug use may also be making the drug crisis worse, by taking legal drugs away from people who benefit from them.   

“All drugs have benefits to people who use them at least initially, and some may have ongoing benefits. For legal drugs, there may be social benefits like employment in related industries and taxation to fund public services,” wrote lead author Michael Broman, PhD, an Assistant Professor at The Ohio State University College of Social Work.

“Redirecting resources towards harm reduction may reduce social harms by reducing the economic cost of policing and surveilling people who use drugs. Concurrently, PWUD (people who use drugs) could remain contributing members of their families and communities.”

Every Chronic Pain Patient Should Have Their Hormone Levels Tested

By Dr. Forest Tennant

Periodic hormone panel testing should be a standard procedure in chronic pain care. Why? Some specific hormones are essential for pain control and others for healing and restoration of damaged tissues. 

Unfortunately, both chronic pain and opioid medications can suppress hormones, which the body needs for pain control and tissue healing. Nerve receptors in the brain that control pain, such as the opioid/endorphin, dopamine, GABA, and serotonin receptors, use hormones as energizers – the same way gas is needed to fuel your car. 

One of the first signs that your hormone levels are deficient — and that you’re running out of gas —- is when your pain relief medication seems to be losing its effectiveness. If that is the case, hormone panel testing should be performed and hormone replacement may be necessary. 

Six hormones that you should test for:

• Pregnenolone

• Progesterone

• Dehydroepiandrosterone (DHEA)

• Estradiol

• Testosterone

• Cortisol

Opioids can suppress all of these hormones. Long-acting opioids like oxycodone, morphine, methadone, fentanyl patches, and intrathecal opioids are the worst.

Short-acting opioids like hydrocodone and hydromorphone are less disruptive, because they do not constantly remain in the blood, so they give the pituitary and other hormone-producing glands time to recover. 

Long-acting opioids constantly suppress the pituitary and other glands. Consequently, any person who takes a long-acting opioid needs hormone panel testing at least every 6 months. All deficiencies must be replenished.

Hormone Therapies

Given the importance of hormone testing and hormone replacement therapy, I recently published a new book, “Hormone Therapies in Chronic Pain Care.”

I wrote the book because I strongly believe it is time to incorporate hormonal therapies into the care of essentially every chronic pain patient.  

Despite an imperfect pain care system that admittedly has some supply, regulation, and financial issues, modern pain management has achieved great success.  

Recently developed medications, physical therapies, and surgical procedures have brought pain relief and recovery to millions around the world.  Hormones can and will build on this foundation. 

The book is designed to help both medical practitioners and patients identify hormone therapies that can improve their current treatment. You can’t control pain or acquire healing and restoration with deficient hormone levels.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about his research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its research bulletins here.   

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section. 

Tapering Plan Led by Pharmacists Shows No Benefit for Seniors

By Crystal Lindell

If pharmacists helped taper elderly patients off opioids and benzodiazepines, would that reduce their risk of falling?

Turns out, the answer is no. Having pharmacists get involved in a senior’s treatment plan doesn’t significantly reduce fall risk or prescriptions for the medications, according to research recently published in JAMA..

Falling is a significant risk factor for seniors, because their bones fracture more easily and it takes longer for them to recover. Medications that impair balance – such as opioids and anti-anxiety drugs – raise the risk of falling, especially in seniors who take them concurrently. 

Researchers at the University of North Carolina School of Medicine recruited 15 primary care clinics to participate in the study. Nearly 2,100 patients at the clinics met the study criteria, which was being over the age of 65 and having a long-term prescription for opioids and/or benzodiazepines. 

Over 95% of the patients on opioids had chronic pain and about a third of them had a fall in the past year..

Pharmacists for about half the patients were encouraged to “deprescribe” them, when appropriate, by recommending a voluntary taper plan to their doctors  The other patients received usual care from their doctors, without any tapering recommendations, and served as a control group.

A year later, doctors followed the pharmacists’ advice by tapering 21.4% of patients off of opioids. But that was only slightly more than the control group, which saw opioids discontinued for 19.9% of patients. The tapering rates for benzodiazepines were similar and “not statistically significant."

Notably, there was little difference in falls between the two groups, which were essentially “unchanged” by the tapering.

In other words, having a pharmacist make tapering recommendations to doctors had very little, if any, impact. Tapering occurred in both groups, whether a pharmacist was involved or not.

“Although reductions occurred in both groups, the intervention did not significantly reduce prescribing or falls at 1 year. Still, pharmacist recommendations were feasible to implement and accepted more often than rejected, indicating general practitioner receptiveness,” researchers concluded. “These results suggest that a consultant pharmacist–led intervention is feasible to implement in primary care clinics.”

Note the word, "feasible" rather than "effective." Sure, it can be done, but that doesn't mean it should be done.

I would guess that the program did not reduce prescriptions for opioids and benzodiazepines anymore than the control group because prescribing had already been reduced. At the start of the study, the average daily dose of opioids was 23.6 morphine milligram equivalents (MME), which is a low to moderate dose.

Given how much these medications are already being restricted, few patients are getting opioids or benzos if they don’t desperately need them – not even seniors.

Beyond that, I think it’s really important to take a step back when looking at research like this and consider the patient’s perspective. 

How were the tapering plans presented to patients? Were they asked to weigh the pros and cons? Did they have a voice in their treatment?  

I suspect if they were given the option of staying on a medication or reducing their fall risk, many seniors would choose to stay on the medication. 

Unfortunately, the study authors seem to take the wrong lesson from the research, at least in my opinion. Although their study failed to prove much of anything, they concluded there should be “more intensive or sustained deprescribing strategies.”

There are a lot of studies looking at ways to reduce opioid prescriptions — I suspect because those are the easiest to fund — and I’m honestly glad this one failed. 

The biggest problem many seniors face today is that they cannot get access to effective pain and anxiety treatment. If anything, researchers should be working to address that problem, rather than making it worse.

Instead of working on blanket reductions for these types of medications, I wish they would look at finding alternatives that actually work.

If you lost a loved to suicide after a change in their prescription pain medication, please consider participating in a survey to help researchers learn more about these tragic situations. Click here or on the banner below for more information.

Opioids Effective for Many Acute Pain Conditions

By Pat Anson

As pharmaceutical companies scramble to develop new non-opioid treatments for pain, a large new review found that opioid analgesics are effective for many acute pain conditions and come with little risk.

Led by researchers at the University of Sydney, the study looked at 59 clinical studies for dozens of short-term acute pain conditions.

They found “high-certainty” evidence that opioids were effective in treating abdominal pain, postpartum pain and dental pain; “moderate-certainty” evidence that they relieve pain from sciatica, post-operative pain and ten other acute conditions; and “low-certainty” evidence that they work on nine other short-term pain conditions.

There was no high quality evidence that opioids are ineffective for acute pain, but there was moderate and low quality evidence that they provide little relief for some acute conditions, such as pain from minimally invasive surgeries.

Adverse events were limited to vomiting and nausea, with no serious events like overdose, death, or addiction reported in any of the 59 studies.

“This paper is best understood as a broad evidence map, not a simple yes/no verdict on opioids for acute pain. It shows that opioids have helped in some acute pain conditions, but benefits are mixed, often modest, and vary by condition and timepoint,” said Lynn Webster, MD, a pain management expert and Senior Fellow at the Center for U.S. Policy, who was not involved in the study.

“The authors did not find a significant increase in serious adverse events in these short-term trials, but they also emphasize that harms reporting was incomplete.”

In short, opioids work for many acute pain conditions, depending on the dose, and pose no serious risk of harm, at least over the short-term.

“There was no high certainty evidence showing that opioids were not efficacious,” researchers reported in the journal Drugs. “There was no significant increased risk of serious adverse events in any review.”  

‘Opioids Aren’t Effective’ 

But that is not how the study was portrayed in a University of Sydney press release, which warned in a headline that “opioids aren’t effective for many acute pain conditions.”

The release quoted one author as saying opioids work “only slightly better than a placebo” and are not worth the risk.

“Our review found that they did not provide large or lasting pain relief compared with placebo for the vast majority of acute pain conditions, with pain relief typically lasting only a few hours,” said lead author Christina Abdel Shaheed, PhD, an Associate Professor in the School of Public Health at the University of Sydney. 

“By showing that the benefits are generally small, short-lived, absent for many common conditions, and sometimes harmful, our research challenges the widely held belief that opioids are the most effective ‘go-to’ option for acute pain.”

Shaheed and several of her co-authors have participated in other studies that take a dim view of opioids. One is a controversial 2023 trial, known as the OPAL study, which found that low doses of oxycodone work no better than a placebo in relieving acute back or neck pain. 

“Opioids should not be recommended for acute back and neck pain, full stop,” said Christine Lin, PhD. a Professor of Public Health at the University of Sydney, who was the lead investigator of the OPAL study and a co-author of the new study. 

Critics complained the OPAL study’s conclusions were too broad, not supported by evidence, and “misplaced and dangerous.”  In reply, Lin agreed that they may have gone too far and that their findings “might not be generalizable to all patients.”

Dr. Webster takes a similar view of the new study, saying it would be wrong to draw conclusions about the effectiveness or harm caused by opioids, given the low quality of most studies that were reviewed.

“The paper is best viewed as a map of evidence gaps and variable-quality evidence, not a final word,” Webster told PNN. “Most of the underlying reviews were rated critically low quality, so the paper is very useful for mapping what we know and what we still don’t know. Broad conclusions about opioid efficacy would be inappropriate.” 

One of the co-authors of the new study is Jane Ballantyne, MD, a former President and current Vice-President of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group. Ballantyne reported no conflicts of interest, although in the past she has acknowledged serving as a paid expert witness in opioid litigation cases.

Can Fentanyl Be ‘Rewired’ to Make It Safer?

By Pat Anson

Scientists at Scripps Research have found a way to change fentanyl’s molecular structure to reduce the risk of overdosing, while at the same time preserving its pain-relieving properties. 

The findings, published in the ACS Medicinal Chemistry Letters, suggest that next-generation synthetic opioids could have less risk of addiction, respiratory depression, and death. 

Fentanyl has been used safely and effectively for over 50 years as a surgical analgesic, and by patients with severe pain from cancer and other intractable pain conditions. Only in the past decade has illicit fentanyl emerged as a potent and deadly street drug that fueled the U.S. overdose crisis.

That has given fentanyl a bad name – and led to efforts to “rewire” fentanyl and other opioids to make them safer, but still effective as pain relievers.

“For decades, the pharmaceutical industry has been constrained by the assumption that major structural changes to opioids would eliminate their analgesic properties,” says senior author Kim Janda, PhD, Professor of Chemistry at the Skaggs Institute For Chemical Biology. 

“Our research has identified a different possibility—that fundamental structural redesign can preserve pain relief while improving safety.”

Janda and his colleagues used a medicinal chemistry strategy known as “bioisosteric replacement,” a method used to redesign molecules to have different effects than the original molecules. 

To engineer the change in fentanyl, scientists replaced the central ring structure of fentanyl molecules with an entirely different one called “2-azaspiro[3.3]heptane.” The new compound doesn’t bind as much to nerve receptors in the brain that regulate breathing. 

When the redesigned fentanyl was tested on laboratory mice, the team arrived at a dose that remained effective as an analgesic, while the mice “appeared normal with no indication of distress or signs of acute toxicity.” 

Slowed breathing in the mice occurred only at very high doses and was temporary, with breathing returning to normal within 25-30 minutes. The new analog has a short half-life of about 27 minutes – the amount of time it takes for the liver to metabolize and break down the drug. Other medicines have a long half-life of several hours or even days — which makes them potentially more toxic.

“Finding ways to preserve the analgesic properties of the synthetic opioids without encumbering the perils of respiratory depression could help derisk the toxicity associated with synthetic opioid use while providing a new conduit for pain management,” says Janda.

The research appears promising and may someday benefit pain patients, but it overlooks the fact that illicit fentanyl is involved in most overdoses. The drug cartels and street dealers that sell it will have little interest in changing the chemical structure of illicit fentanyl to make it safer.

Can Long-Term Opioid Use Be Predicted Before Surgery?

By Pat Anson

Patients on Medicaid and those who have a history of anxiety, mood disorders, or benzodiazepine use are significantly more likely to use opioids long-term after surgery, according to a new analysis.

The study, published in the journal Pain Medicine, could provoke fresh debate over whether opioid addiction can be predicted, and whether risk assessments unfairly stigmatize patients and affect how they are treated.

“Identifying who is at risk before the first incision is made is a critical step in combatting the opioid crisis,” said lead author Yoonjae Lee, DNP, a second-year PhD student at the University of Pennsylvania’s School of Nursing..

“Our findings provide a roadmap for clinicians to implement targeted interventions, ensuring that high-risk patients receive enhanced monitoring and alternative pain management strategies.”

Lee and her colleagues analyzed data from 27 clinical studies to see what raises the risk of patients new to opioids becoming long-term users after surgery. 

They found that “opioid-naïve” patients with Medicaid coverage and those with a history of taking benzodiazepine anti-anxiety medication had 77% higher odds of developing new persistent opioid use (NPOU). 

Patients with a history of depression or other mood disorders had 24% higher odds, while those with anxiety had a 17% higher risk of persistent opioid use.

Based on these findings, researchers say every patient should be screened before surgery for the risk of long-term opioid use, so that changes can be made in their treatment.

“Minimizing the development of NPOU requires a thorough preoperative medication review, as our findings indicated that certain drugs including antidepressants, muscle relaxants, anticonvulsants, and sedatives are linked to a higher risk of NPOU. Among these risk factors, preoperative benzodiazepine use stands out as the strongest,” researchers concluded.

“With respect to clinical implications, clinicians should adopt a comprehensive and individualized approach to assessing and managing these predictive factors in each surgical patient, given the complex interaction of multiple factors affecting the development of NPOU. Although insurance status cannot be changed, mood disorders, anxiety, and benzodiazepine use can be modified preoperatively.” 

The idea of pre-screening surgery patients is similar to female patients being screened for potential opioid misuse through a questionnaire called the Opioid Risk Tool. In some cases, the questionnaire has been used as an excuse to deny opioids to women who have a history of childhood sexual abuse.

Penn Nursing researchers may have an exaggerated notion of just how common long-term opioid use is after surgery. They cited a study claiming that “up to 65% of patients” continue to use opioids 90 days after surgery, a “significant postoperative complication” that leads to higher healthcare costs, as well as opioid misuse, diversion, overdose and addiction.

That’s a misleading reference to a 2024 analysis, which found that 2% to 65% of surgery patients are at risk of long term opioid use. That assessment is based on a review of over 30 clinical studies, which came up with a wide range of estimates on the risk of persistent opioid use. The Penn Nursing study only cited the higher 65% estimate, while ignoring the lower ones. 

Other studies have found that surgery patients rarely misuse opioids or become long-term users. A large 2018 Harvard Medical School study found that only 0.6% of patients had signs of opioid misuse after surgery.

A large 2016 study in Canada put the risk of long-term opioid use after one year at only 0.4% of surgery patients. “Our study thus provides reassurance that the individual risk of long-term opioid use in opioid-naive surgical patients is low,” researchers reported.

Neither the Canadian or Harvard study were included in the Penn Nursing analysis because researchers didn’t include studies conducted prior to 2019.

It’s fairly common for patients to need pain management for months after surgery. Post-operative pain becomes chronic in about 10% to 50% of surgery patients, depending on the type and invasiveness of the surgery. That’s why opioids and other analgesics are essential in post-op care. 

UK researchers say “great efforts must be made to provide effective post-operative pain relief for a long enough period” to prevent acute post-op pain from becoming chronic.

The Penn Nursing study was funded by the National Institutes of Health.

The Most Dangerous Drug in Canada Is Not Prescription Opioids

By Pat Anson

The most dangerous drug in Canada doesn’t require a prescription. You can’t smoke, vape, snort, or inject it. It doesn’t come in a pill, patch or edible.

It’s responsible for as many as 18-thousand deaths every year in Canada and can result in a lifetime of addiction. It ruins marriages, families, friendships and careers, and costs society about $20 billion a year in added healthcare expenses and lost productivity.

Yet it is readily available in most stores and can be purchased by anyone over the age of 19. In some provinces, the age limit is 18.

By now you’ve probably guessed that I’m talking about alcohol.

A new report by the Centre for Addiction and Mental Health (CAMH) found that alcohol causes more harm in Canada overall than any other drug — ranking well above tobacco, illicit fentanyl, cocaine, cannabis, methamphetamine and, yes, prescription opioids.

CAMH put together a diverse panel of 20 experts in public health, epidemiology, addiction, criminology, psychology and public policy to assess the short and long-term impact of 16 commonly used psychoactive drugs. In addition to the direct “harm to users” – such as addiction and overdose – they evaluated the indirect “harm to others” – families, communities and society at large.

“This is the first time this approach has been used to assess drug harms in Canada, and it gives us a much more complete picture than we had before,” said Jean-François Crépault, Senior Policy Advisor at CAMH and lead author of the study published in the Journal of Psychopharmacology. 

“When we look at harm to people who use drugs and harm to others together, alcohol clearly stands out. Our findings highlight a major gap between the harms linked to alcohol and the way it is currently regulated in Canada.”

Based on a ranking system of 0 to 100, with zero meaning no harm and 100 being the most harmful, alcohol was given a score of 79, followed by tobacco (45) and non-prescription opioids (33). The latter category includes illicit fentanyl, xylazine, and other opioid-based street drugs.

Cocaine (19), methamphetamine (19), cannabis (15) and crack (10) are next, with “prescription opioids” (8) ranked as the eighth most harmful drug category.

Even that ranking is a bit misleading, as it includes morphine, oxycodone and other pharmaceutical opioids that are diverted and used without a prescription – which probably should be counted as non-prescription opioids.

Prescription opioids were ranked so low in terms of harm, they barely beat out ENDs (7), an acronym for electronic nicotine delivery systems, more commonly known as vapes or e-cigarettes.

Most Harmful Drugs in Canada

JOURNAL OF PSYCHOPHARMACOLOGY

The finding that alcohol causes the most harm aligns with previous studies in the United Kingdom, the European Union, Australia and New Zealand.

In the United States, a recent study that used a slightly different methodology ranked alcohol as the 5th most harmful drug, behind illicit fentanyl, methamphetamine, crack and heroin. Prescription opioids ranked as the 7th most harmful drug in the U.S.

Experts say these studies point to a clear need for government drug policies to better align with the actual harm that a specific drug causes – and not be based on laws, guidelines, class action lawsuits, or whatever drug hysteria is popular at the moment. 

Despite all the harm it causes, no one talks about banning alcohol, yet natural leaf kratom and the kratom extract 7-OH are being demonized as “gas station heroin” and “legal morphine” that should be banned. Never mind that there is little solid evidence they are dangerous when used appropriately. Neither substance made the “harmful” list in Canada, United States, or anywhere else.

“The key message here is that harm is not just about what a drug does to the body,” said Crépault. “How a drug is regulated shapes who uses it, how it is used, and how much harm it causes. Evidence-based policy can significantly reduce harm, and governments have a real opportunity to use regulation to protect public health.”

CDC Opioid Guideline Raised Cost of Pain Care

By Pat Anson

The CDC’s 2016 opioid prescribing guideline not only had disastrous consequences for many pain patients, but raised the cost of treating them in primary care practices, according to a new analysis.

Researchers at the University of Wisconsin-Madison studied the budget impact of four different strategies used at primary care clinics to comply with the guideline, which strongly encouraged doctors to reduce opioid prescribing. 

The strategies primarily relied on prescriber education, evaluations and auditing to see if the clinics were successful in reducing the use of opioids. Whether patient safety and pain relief improved were not part of the study.

The cost per clinic for implementing the strategies ranged from $4,416 to $8,358, with prescriber education being the cheapest approach. However, while education alone cost less upfront, the clinics that used it had the largest increases in downstream expenses, such as greater use of urine drug tests (UDTs), treatment agreements, and depression screening. That made it the most costly approach overall.       

The 2016 guideline recommended that doctors limit daily opioid doses to no more than 90 morphine milligram equivalents (MMEs), conduct regular drug testing of patients, and have patients sign “pain contracts” promising to follow their doctor’s treatment plan.

The CDC’s recommendations were not only costly and burdensome to providers, according to researchers, but resulted in “no significant decrease” in MME for patients on long-term opioid therapy. Patients on opioid therapy for less than 3 months saw their doses decline by 6%. 

“In summary, from 2016 to 2022, no evidence emerged showing that UDTs were effective in improving long-term outcomes such as decreased overdoses or better pain management,” wrote lead author Andrew Quanbeck, PhD, an Associate Professor in the University of Wisconsin's Department of Family Medicine and Community Health.

“Over time, treatment agreements and UDTs have emerged as low-value care that imposes significant costs for primary care physicians and patients. Results suggest that health systems have an opportunity to shift focus from costly surveillance tools to inexpensive, holistic screening for pain, function, and quality of life and careful initiation of opioids for new patients.”  

The study, published in the Annals of Family Medicine, is one of the few to analyze the long-term impact of the original CDC guideline.  

It’s important to note that the CDC updated its guideline in 2022 to give more “flexibility” to doctors prescribing opioids. However, many of the agency’s 2016 recommendations were so stringently adopted by states, healthcare systems, insurers, and even law enforcement agencies that they remain unchanged – even though there were many reports of patients being harmed by them.

“It is clear that the CDC Guideline has harmed many patients,” the American Medical Association wrote in a 2020 letter to the CDC. “In many cases, health insurance plans and pharmacy benefit managers have used the 2016 CDC Guidelines to justify inappropriate one-size-fits-all restrictions on opioid analgesics while also maintaining restricted access to other therapies for pain.”

The Food and Drug Administration also warned the CDC guideline was causing “serious harm” to patients, including forced tapers, uncontrolled pain, psychological distress and suicide.    

In a 2022 PNN survey of over 2,500 patients and providers, nearly 85% said the CDC should not have created guidelines for opioid prescribing and pain treatment. Over 93% said the guidelines made the quality of pain care in the United States worse.