Are Rx Opioids Scapegoats for the Opioid Crisis?

By Dr. Lynn Webster, PNN Columnist

The Washington Post recently published a series of stories about the volume of opioid medication distributed over the past several years in the United States. Over 76 billion pills were distributed from 2002 through 2012.

That sounds like a huge amount, but it is difficult to know what the number means. What is clear is that the stories are meant to suggest the number of pills is excessive and responsible for the rise in opioid overdose deaths. 

This presumed correlation is one reason for the recent lawsuits that have been filed against opioid manufacturers and distributors. It has also spawned policies that appear to have worsened, not prevented, overdoses.

Though the situation has been framed largely as a prescribing problem, the reasons for the drug crisis are many. While overprescribing has certainly been a factor, it is probably less important than other factors, such as joblessness, homelessness and despair, which are more challenging to address.

Let’s look at the data about the relationship between opioid prescriptions and overdose death rates. The number of opioid prescriptions in the United States peaked in 2012 and began a steady decline. By 2017, they reached a 15-year low.

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Despite the decline in the number of opioids prescribed, overdoses from all opioids – both legal and illegal -- continued to increase. Overdoses involving prescription opioids represent only about 25% of the total number of drug overdoses.  

Obviously, something more than the supply of prescription opioids is driving overdoses higher.

No Correlation Between Opioid Prescriptions and Overdoses

After winning a year-long court battle with the Justice Department, the Post and HD Media, publisher of the Charleston Gazette-Mail in West Virginia, were able to access data from the DEA’s Automation of Reports and Consolidated Orders System (ARCOS).

The information in the database shows that, between 2006 and 2012, West Virginia received the largest per capita amount of prescription opioids. The state also experienced the highest opioid-related death rate during that period. Is there a correlation?

Kentucky also had a high number of pills and a high death rate, but as Jacob Sullum recently reported in Reason, Kentucky’s death rate in 2017 was actually lower than Maryland’s and Utah’s, where prescription rates are substantially lower. He also pointed out that although Oregon’s prescription rate was among the highest in the country, the rate of deaths involving pain pills in Oregon was just 3.5 per 100,000, lower than the rates in most states. 

Sullum further showed that Kentucky, Nevada, Oklahoma, Oregon, South Carolina and Tennessee were among the 10 states with the highest per capita prescribed pills during the 2006-2012 period. But they were not the states with the highest overdose rates. 

In a separate analysis, the CDC and Agency for Healthcare Research Quality found no correlation -- not even a weak one -- between opioid prescribing rates and overdoses when comparing data from each state. 

In addition, the rate of opioid prescribing is highest nationally for people 55 years and older, but that age group has the lowest rate.  

This lack of correlation between opioid overdoses and the volume of prescribed opioids is consistent internationally. In 2016, England prescribed the most opioids and saw the most overdose deaths in its history. However, the drug responsible for many of those deaths was heroin, not prescription opioids. 

There is a raging opioid crisis in West Africa where, despite a low prescription rate, the number of overdoses has surged

In 2018, Scotland's drug overdose rate exceeded that of the United States -- largely because of heroin. There is no evidence of an overall increase in opioid prescribing in Scotland. 

No Simple Answers to the Opioid Crisis

It is clear that the data does not support a simple answer to the opioid crisis. Focusing all of our efforts on decreasing the supply of prescriptions will not solve the problem and is already creating unintended consequences.

In fact, cocaine and methamphetamine were involved in more overdose deaths in the U.S. in 2018 than prescription opioids. As the supply of prescription opioids has decreased due to the policies of the last few years, people have moved from prescription opioids to other illicit drugs.

The solution to the opioid crisis must be multi-pronged. Overprescribing played a role in causing the crisis, but sociological factors appear to have driven the demand. We must consider what prompts people to turn to drugs in despair. A recent study published in SSM-Population shows job loss bears a significant correlation to opioid-caused deaths.

In addition, in the Proceedings of the National Academy of Sciences, Princeton University economists Anne Case and Angus Deaton (recipient of the 2015 Nobel prize in economics) showed mortality from substance use was linked to declining economic opportunity and financial insecurity.

Solving the drug crisis will not be easy. However, the disenfranchised members of our most impoverished communities deserve viable solutions to their problems. It is crucial to understand the degree to which job loss and hopelessness contribute to the drug problem.

Reputable data proves that the volume of opioids prescribed is not solely, or even primarily, responsible for the opioid crisis. Let’s focus on what is responsible.

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Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth” and co-producer of the documentary, “It Hurts Until You Die.”

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Misleading CDC Study Links Prescription Opioids to Binge Drinking 

By Pat Anson, PNN Editor

A new study by the Centers for Disease Control and Prevention has found that over half of people who misuse prescription opioids also binge drink, increasing their risk of dying from an overdose.

“We are losing far too many Americans each day from overdoses,” CDC Director Robert Redfield, MD, said in a statement. “Combining alcohol and opioids can significantly increase the risk of overdoses and deaths.”

Binge drinking and misuse of opioid medication are never a good idea, whether done separately or in combination. Unfortunately, the CDC study is written in ways that mislead and further worsen the stigma associated with prescription opioid use. And it fails to acknowledge the role CDC itself has played in the growing use of alcohol for pain relief.

The study, published in the American Journal of Preventive Medicine, is based on survey of over 160,000 people who participated in the National Survey on Drug Use and Health from 2012 to 2014. After analyzing their answers, CDC researchers came to some sweeping conclusions about Americans getting high on pills and alcohol.

“Prescription opioids were responsible for approximately 17,000 deaths in the U.S. in 2016. One in five prescription opioid deaths also involve alcohol,” wrote lead author Marissa Ether, PhD, CDC Division of Population Health.

“More than half of the 4.2 million people who misused prescription opioids during 20122014 were binge drinkers, and binge drinkers had nearly twice the odds of misusing prescription opioids, compared with nondrinkers.”

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The statement that prescription opioids “were responsible” for 17,000 deaths is misleading because it is based on data from death certificates and coroner reports that only indicate the medications were present or “involved” in overdoses. Other substances may have played a role or perhaps even caused those 17,000 deaths.

In 2016, over twice as many fatal overdoses involved heroin and illicit fentanyl, but CDC researchers “did not consider the use of illicit opioids” for their binge drinking study. Apparently, street drug users are teetotalers who do not drink.

And who were the binge drinkers who misused prescription opioids? They were recreational users of opioid medication who did not take the drugs for pain relief. “Misuse” in the study was defined as “use without a prescription or use only for the experience or feeling it causes.”

To be clear, pain patients with legitimate opioid prescriptions that are used appropriately were not included in the study. These patients are actually less likely to be binge drinkers — defined as four or more drinks by a woman, or five or more drinks by a man — and they are warned repeatedly not to mix their medications with alcohol. Including them would have significantly changed the study findings.

Patients Using Alcohol for Pain Relief

Perhaps the biggest oversight by CDC researchers is the 2012-2014 time frame chosen for their study – which is well before the agency released its controversial 2016 opioid prescribing guideline.

One of the key findings from a recent PNN survey of nearly 6,000 patients is that the guideline has limited their access to prescription opioids so severely that some are turning to alcohol for pain relief. Nearly one out of five patients surveyed said they had used alcohol for pain relief since the guideline came out.

“It has caused many pain patients to be cut off their pain medication,” one patient told us. “After losing my meds 16 months ago, I just started using alcohol and I never used alcohol. I don't like alcohol, but what are my options?” 

“Since my doctor stopped prescribing even my small amount of opioids I deal with days where I can’t even get out of bed because I hurt so much and I’m stuck turning to alcohol, excessive amounts of acetaminophen and NSAIDs,” another patient said. 

“The CDC guidelines are killing people,” one woman wrote. “My fiancé has been refused even the most mild stenosis treatment because he admitted using alcohol to treat his pain when he has no other treatment. He's mildly suicidal as well. We have two young kids.” 

“I lost a good friend to suicide because she was not able to get pain medications to relieve her pain and it was too much for her to handle,” a patient said. “Sadly, she is not the only one. I'm hearing about more and more. I'm also hearing about people turning towards alcohol.” 

“All they are doing is pushing chronic pain patients to find relief in other ways such as alcohol, illicit drugs or harming themselves to get the pain relief they do desperately seek,” wrote another patient. 

In other words, alcohol use is acceptable to the CDC — as long as it is not combined with prescribed opioid medication. This is your nation’s health protection agency at work.

The Prescription Opioid Crisis Is Over

By Roger Chriss, PNN Columnist

In a very real sense, the prescription opioid crisis is over. But it didn’t end and we didn’t win. Instead, it has evolved into a broader drug overdose crisis. Opioids are still a factor, but so is almost every other class of drug, whether prescribed or sourced on the street.

The main players in the crisis now are illicit fentanyl, cocaine and methamphetamine. The vast majority of fatal overdoses include a mixture of these drugs, with alcohol and cannabis often present, and assigning any one as the sole cause of death is becoming tricky.

Connecticut Magazine recently reported on rising fentanyl overdoses in that state. According to the Office of the Chief Medical Examiner, fentanyl deaths in Connecticut spiked from 14 in 2012 to 760 in 2018. Fentanyl was involved in 75% of all overdoses last year, often in combination with other drugs

Meanwhile, overdoses involving the most widely prescribed opioid — oxycodone — fell to just 62 deaths, the lowest in years. Only about 6% of the overdoses in Connecticut were linked to oxycodone.

Similar trends can be seen nationwide, mostly east of the Mississippi. Opioids still play a major role in drug deaths, with the CDC reporting that about 68% of 70,200 drug overdose deaths in 2017 involving an opioid. But more than half of these deaths involved fentanyl and other synthetic opioids obtained on the black market.

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According to the National Institute on Drug Abuse, overdoses involving prescription opioids or heroin have plateaued, while overdoses involving methamphetamine, cocaine and benzodiazepines have risen sharply.

In other words, deaths attributable to prescription opioids alone are in decline. Deaths attributable to fentanyl are spiking, and deaths involving most other drug class are rising rapidly. The CDC estimates that there are now more overdoses involving cocaine than prescription opioids or heroin.

Moreover, the crisis is evolving fast. At the American College of Medical Toxicology’s 2019 annual meeting, featured speaker Keith Humphreys, PhD, remarked that “Fentanyl was invented in the sixties. To get to 10,000 deaths took 50 years. To get to 20,000 took 12 months.”

In fact, provisional estimates from the CDC for 2018 suggest we have reached 30,000 fentanyl deaths. And state-level data show few signs of improvements for 2019.

Worryingly, methamphetamine use is resurgent. And cocaine is “making a deadly return.”  Illicit drugs are also being mixed together in novel ways, with “fentanyl speedballs” – a mixture of fentanyl with cocaine or meth – being one example.

Drug Strategies ‘Need to Evolve’

The over-emphasis on prescription opioids in the overdose crisis has led to an under-appreciation of these broader drug trends. Researchers are seeing a need for this to change.

“The rise in deaths involving cocaine and psychostimulants and the continuing evolution of the drug landscape indicate a need for a rapid, multifaceted, and broad approach that includes more timely and comprehensive surveillance efforts to inform tailored and effective prevention and response strategies,” CDC researchers reported last week. “Because some stimulant deaths are also increasing without opioid co-involvement, prevention and response strategies need to evolve accordingly.”   

It is now common to hear about the “biopsychosocial” model for treating chronic pain – understanding the complex interaction between human biology, psychology and social factors. This same model has a lot to offer substance use and drug policy.

Substance use and addiction involve a complex interplay of genetic and epigenetic factors combined with social and cultural determinants. Treatment must be more than just saying no or interdicting suppliers. At present, medication-assisted therapy for opioid use disorder remains hard to access. And other forms of addiction have no known pharmacological treatment.

Addressing the drug overdose crisis will require not only more and better treatment but also increased efforts at harm reduction, decriminalization of drug use, improvements in healthcare, and better public health surveillance and epidemiological monitoring. Further, the underlying social and cultural factors that make American culture so vulnerable to addiction must be addressed.

None of this is going to be easy. Current efforts are misdirected, making America feel helpless and look hapless. Novel and possibly disruptive options may prove useful, from treating addiction with psychedelics to reducing risks of drug use through safe injection sites and clean needle exchanges.

We are long past the prescription opioid phase of the crisis, and are now in what is variously being called a “stimulant phase” and a “poly-drug phase.” Recognition of the shape of the drug overdose crisis is an essential first step toward changing its grim trajectory.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Study Finds 90% of Medicare Patients Have Little Risk of Opioid Overdose

By Pat Anson, PNN Editor

Current methods used to identify Medicare patients at high risk of overdosing on prescription opioids target many people who are not really at high risk, according to a team of researchers who found that over 90% of patients have little to no risk of overdosing.

"The ability to identify such risk groups has important implications for policymakers and insurers who currently target interventions based on less accurate measures,” said lead author Wei-Hsuan "Jenny" Lo-Ciganic, PhD, a professor of pharmaceutical outcomes and policy at the University of Florida, who reported her findings in JAMA Network Open.  

Lo-Ciganic and her colleagues at the University of Pittsburgh, Carnegie Mellon University and University of Utah studied health data on over half a million Medicare beneficiaries who filled one or more prescriptions for opioids between 2011 and 2015. The researchers identified which patients overdosed and then used machine-learning algorithms to analyzed their demographics and health records.

The computer models developed three risk groups that predict which patients are at risk of overdosing over a 12 month period.

  • Low risk patients (67.5%) have 0.006% risk of overdose

  • Medium risk patients (23.3%) have 0.05% risk of overdose

  • High risk patients (9.1%) have 1.77% risk of overdose  

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Put another way, out of 100,000 Medicare patients in the low risk group, six would have an overdose; while there would be 1,770 overdoses in a high risk group of the same size.

Not surprisingly, the computer models found that high doses of opioids and a prior history of substance abuse significantly raise the risk of an overdose. So does a person’s age, disability status and whether they are co-prescribed benzodiazepines. Patients who live in certain states (Florida, Kentucky or New Jersey) are also at higher risk.

Top 10 Predictors of Opioid Overdose

  1. Total MME (morphine milligram equivalent)

  2. History of substance or alcohol abuse

  3. Average daily MME

  4. Age

  5. Disability status

  6. Number of opioid refills

  7. Resident state

  8. Type of opioid

  9. Number of benzodiazepine refills

  10. Drug use disorders  

The study found that the machine-learning algorithms the researchers developed performed well in predicting overdose risk and in identifying patients with a low risk. Machine learning is an alternative analytic approach to handling complex interactions in large data.  It can discover hidden patterns and generate predictions in clinical settings. Based on their findings, the researchers concluded that their approach outperformed other methods for identifying risk used by the Centers for Medicare and Medicaid Services.

"Machine-learning models that use administrative data appear to be a valuable and feasible tool for identifying more accurately and efficiently individuals at high risk of opioid overdose," says Walid Gellad, MD, a professor of medicine at the University of Pittsburgh and senior author on the study. "Although they are not perfect, these models allow interventions to be targeted to the small number of individuals who are at much greater risk."

Prescription Opioids Rarely Lead to Heroin Use

By Roger Chriss, Columnist

A recent Politico column by three anti-opioid activists asserts that “opioid use disorder is common in chronic pain patients”  and that the nation’s overdose crisis “stems largely from the overprescribing of opioids.”

Andrew Kolodny, MD, Jane Ballantyne, MD, and Gary Franklin, MD --  who are the founder, president, and vice-president, respectively, of Physicians for Responsible Opioid Prescribing (PROP) – also wrote that “many individuals become addicted to prescription opioids through medical or non-medical use, and then switch to heroin after becoming addicted."

This claim is an oversimplification of the tragedy that is heroin addiction. It both ignores the complex trajectory of drug use that culminates in heroin and omits the known risk factors of the people who suffer from heroin addiction. It also runs counter to the known data about various forms of opioid addiction, which clearly shows that most people on opioid therapy do not develop problems with misuse, abuse or addiction, and rarely move on to heroin.

The National Institute on Drug Abuse (NIDA) estimates that about 10 percent of patients prescribed opioids develop an opioid use disorder. And only about 5 percent of those who misuse their medication ever make the transition to heroin.

Further, the number of people addicted to prescription opioids -- about two million -- has been stable for over five years, while rates of heroin use have been rising, suggesting there is not a strong corelation between the two.

From 2002 to 2016, the number of Americans using heroin nearly tripled, from 214,000 to 626,000. Overdose deaths involving heroin also soared during that period.

The reasons behind this are complex and not fully understood. One theory is that heroin became more popular when prescription opioids became harder to obtain and abuse. According to a study by the RAND Corporation, the introduction of abuse-deterrent OxyContin in 2010 was a major driver in the shift to heroin.

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Heroin use is also strongly associated with mental illness and childhood trauma. Studies have found that 75 percent of people with heroin addiction have another mental illness, with about half showing signs of psychiatric problems or post-traumatic stress disorder (PTSD) before age 16. At least half were abused or neglected as children, with especially high rates of sexual abuse.

In addition, it is well established in psychiatry that certain mental health disorders – such as borderline personality and bipolar disorder -- have a significantly increased risk of substance use.

Thus, heroin use and addiction is far more complex than just a result of opioid misprespcribing. Most people placed on opioid therapy do not misuse their medication, and the few who do become addicted rarely transition to heroin. Recent studies also suggest that more people are starting on heroin without prior exposure to other opioids.

Heroin addiction is most often the tragic outcome of a shattered childhood or mental illness, and not simply a result of medication exposure. To claim that heroin addiction stems largely from pain management is a disservice to both addicts and pain patients, and will only further the suffering of both groups by diverting attention from the real issues.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

3 Reasons the Opioid Crisis is Getting Worse

By Roger Chriss, Columnist

The opioid crisis is now a public health emergency. The CDC reports increasing rates of fentanyl overdoses.  And The Economist warns the crisis is entering “a new and deadlier phase.”

The strategy to stop the overdose epidemic has largely focused on the supply side: limiting access to prescription opioids. History seems to support this idea. Two hundred years ago, a tincture of opium called laudanum was widely used to treat all kinds of ailments.  The “epidemic of laudanum” didn’t end until 1906, when the federal government got involved and started regulating opium-based medications.

So it seemed natural to curtail opioid prescribing. Washington State issued prescription opioid guidelines in 2010, Oregon in 2012, and the CDC in 2016. Other states followed with laws limiting the number of days opioids could be prescribed for short term, acute pain. Health insurers like Kaiser Permanente and Intermountain Healthcare have also reduced coverage of prescription opioids and drug store chains like CVS will be limiting prescription length and dose. 

In a narrow sense, this is working. Prescription opioid levels peaked in 2010, as a result of lower production quotas mandated by the DEA and reduced prescribing in a variety of clinical settings.

But in a broader sense, the focus on prescription opioid levels is failing. Opioid addiction and overdose rates continue to climb, despite the reduced availability of prescription opioids. There are three reasons for this.

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First, the main drivers in the crisis are now heroin and illicit fentanyl. Importantly, heroin is increasingly the first opioid of abuse.

“As the most commonly prescribed opioids - hydrocodone and oxycodone - became less accessible due to supply-side interventions, the use of heroin as an initiating opioid has grown at an alarming rate,” researchers recently reported in the journal of Addictive Behaviors.

Second, according to the National Survey on Drug Use and Health, approximately 75% of all opioid misuse starts with people taking medication that was not prescribed to them. These pills are sourced from friends, stolen from other people’s prescription bottles, or purchased online illegally.

Contrary to common belief, opioid therapy for chronic pain conditions rarely leads to misuse or addiction. Most addictive behaviors start during adolescence, usually with substances like alcohol or tobacco, long before anyone gets their hands on opioid medication.

Third, nearly 10% of drug overdoses are intentional.

"Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides,” wrote Dr. Maria Oquendo, President of the American Psychiatric Association, in a blog for the National Institute on Drug Abuse.

In other words, the crisis may have started with prescription opioids, but it has evolved. We are now facing a crisis driven primarily by heroin, illicit fentanyl, and other street drugs, as well as social and economic conditions that have led to an "epidemic of despair."

Therefore, the current intense focus on prescription opioids -- from the CDC’s Rx Awareness campaign to the recommendations of the President Trump’s opioid commission -- is woefully off target. Reducing access to prescription opioids has not decreased addiction and overdose rates, and may actually be making them worse.

Exactly what will be required to end the crisis is not clear. But an essential step is to understand the nature of the crisis as it stands today so as to end the opioid disconnect.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

A Pained Life: Too Many Pain Pills

By Carol Levy, Columnist

I have a confession to make. I watch a number of the court TV shows. Sometimes they can actually teach me something, sometimes they are laughable. Sometimes they are cringe worthy. Sometimes they are simply infuriating.

The judge on one show uses his program as a platform to vilify “pain pills.”

A plaintiff or defendant is invited to tell their story. More often than not, it is a hard luck story. Within a few minutes, many of them blame much of their life struggles on substance abuse problems. Sometimes it is a happier story. They have kicked their drug addiction.

Either way, the judge is curious. “How did you get started using these drugs?” he asks.

The most common answer is that they had a bad back, toothache, neck pain, etc.

“I started to take pain medication for it, and next thing I knew I was addicted and my life spiraled out of control,” they often say.

The judge nods sagaciously and pronounces his sentence on opioids: “Oh yes. It is easy to get addicted to them.”

Never mentioned, and I do understand the issue of time and editing, is the benefit of these medications for those in legitimate pain. Or that those with chronic pain rarely become addicted to them. Instead, the false narrative continues to stand: Pain pills are given for specious reasons and quickly lead to addiction.

Also omitted is the question: “Where do these pills come from?”

The Centers for Disease Control and Prevention states: “Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report.“

The CDC reported last week that 17,536 Americans died in 2015 from overdoses of prescription pain medication, a 4 percent increase from the year before.

Patients don't write these prescriptions, yet the CDC’s opioid guidelines and other government regulations seem intended to punish them. As a result, we need to go to the doctor more often. That means more money, more trips, and more waiting. As I write that, I can see folks without pain saying, “So what?”

The “what” is that having to make these extra trips usually translates into more pain, which may necessitate taking even more pain meds. The guidelines meant to “help” may actually increase the need for opioids.

But the CDC itself has let on where the problem lies.

It is not with the patient. It is with the doctors and prescribers who give out these prescriptions like candy. A dentist giving a 30-day supply for a tooth extraction, or a primary care doctor prescribing narcotics to a patient with lower back pain or other issues that could well respond to physical therapy, aspirin, and changing their behavior.  They are the culprits.

The source of the problem is clear. Too many prescriptions are being written by too many doctors.

The CDC guidelines let them off the hook. And puts the patient on it.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” 

Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.