Opioids

Misdiagnosing Causes and Casualties in the Opioid War [Corrected]

Do the pain relief benefits of prescription opioids outweigh their addiction risks?

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Rui G. Santos/Dreamtime

"The opioid crisis is an emergency," declared President Donald Trump in August. "And I am saying officially right now that it is an emergency, a national emergency. We are going to spend a lot of time, a lot of effort, and a lot of money on the opioid crisis."

As of this week, President Trump and his advisors have not yet completed the paperwork for an official national emergency declaration. So how much of a crisis is the "opioid epidemic"?

In 2015 some 33,000 Americans died from overdosing on various synthetic opioids. Some researchers forecast that as many as 500,000 Americans could die of opioid overdoses in the next decade. The drugs most associated with overdose deaths are prescription pain pills like oxycodone, along with black market heroin and fentanyl.

Lots of media reports have made pharmaceutical manufacturers, distributors, and "pill mill" physicians the chief villains in the rise of overdose deaths. "The Drug Industry's Triumph Over the DEA," published earlier this week by The Washington Post and CBS' 60 Minutes, is one such "exposé."

While it is true that some unscrupulous phyisicians and pharmacies have overprescribed opioid medications, Josh Bloom, director of Chemical and Pharmaceutical Sciences for the American Council of Science and Health provides a helpful guide to some of the deceptive claims being peddled by drug warriors. Specifically, Bloom decodes Andrew Kolodny's "The opioid epidemic in 6 charts," over at The Conversation.

Kolodny, executive director for Physicians for Responsible Opioid Prescribing, cites data from the National Institute on Drug Abuse showing that more 60,000 Americans died of drug overdoses in 2016. Bloom suggests that that assertion misleads readers into thinking that those deaths are mostly the result of taking prescription opioids.

The actual number of deaths associated with overdosing on prescription opioids was around 17,000 last year. And as Bloom points out, most of those overdose deaths occurred in conjunction with benzodiazepines (like Valium and Xanax) and black market heroin and fentanyl.

A recent Center for Disease Control Morbidity and Mortality Weekly Report focusing on drug overdose deaths in Ohio found that 90 percent of the decedents tested positive for fentanyl, 31 percent for cocaine, 27 percent for benzodiazepines, 23 percent for prescription opioids, and 6 percent for heroin. Once these are taken into account, Bloom estimates that "the number of deaths from opioid pills alone will be much lower, perhaps in the neighborhood of 5,000."

Bloom also objects to Kolodny's observation that the "effects of hydrocodone and oxycodone on the brain are indistinguishable from the effects produced by heroin." Both prescription opioids and heroin operate on the same receptors in the brain, but hydrocodone and oxycodone are four and two times less powerful, respectively, than heroin. And they are 200 and 100 times less powerful than fentanyl.

Long-term use of prescription "opioids are more likely to harm patients than help them because the risks of long-term use, such as addiction, outweigh potential benefit," Kolodny says. Bloom counters that the "absence of evidence is not evidence of absence." His main argument is that Kolodny cannot make his claim for the simple reason that no long term studies on the effects of opioids to manage chronic pain have been conducted.

In any case, Bloom cites 2010 research that the risk of addiction is below one percent for patients who use prescription opioids for short term pain control. A 2013 review similarly reports the risk of addiction is below one percent and concludes, "The available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence."

A 2015 review article in the Annals of Internal Medicine reported that "reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date." However, the Annals reviewers were less sanguine than Bloom about prescribing opioids to treat pain. "Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction." The Annals review also notes that various studies found the prevalence of prescription opioid addiction ranging from 2 to 14 percent.

Some pharmaceutical companies, Bloom acknowledges, helped fuel the opioid problem by falsely claiming their medicines were less addictive and less subject to abuse than other pain medications. For example, Purdue Pharma, the manufacturer of Oxycontin, admitted it had misled physicians and paid in a fine of $653 million in 2007.

But given that most of the opioid deaths now result from consuming illicit drugs, Bloom argues Kolodny's effort to blame the problem on drug companies is now irrelevant.

Kolodny rejects the claim that the reformulation of prescription opioids after 2010 to make them more difficult to snort or inject pushed many users to black market heroin and even more dangerous substances in search of highs. Bloom points out that after 2010 the number of deaths attributed to prescription opioids flattened while those from heroin and fentanyl increased almost five-fold.

Bloom decries what he calls the "opioid pain refugee crisis," in which new federal rules restrict patient access to effective drugs to control severe pain. In 2012, the Institute of Medicine at the National Academy of Sciences issued a study, Relieving Pain in America, that reported: "Chronic pain affects about 100 million American adults—more than the total affected by heart disease, cancer, and diabetes combined. Pain also costs the nation up to $635 billion each year in medical treatment and lost productivity."

"We do not question that opioid misuse is a serious and growing public health problem," writes Arthur Lipman, editor of the Journal of Pain & Palliative Care Pharmacotherapy. "We do not, however, accept the simplistic solution of limiting opioid use that is advocated by many commentators as being rational. Although opioid overprescribing and access undoubtedly contribute to the problem, opioids are still seriously underprescribed for and unavailable to many legitimate patients with moderate to severe pain who need these medications to function adequately."

While Kolodny argues for substantially increasing restrictions on patient access to prescription opioids, he also urges federal and state governments to "ensure that millions of Americans now suffering from opioid addiction can access effective addiction treatment."

Instead of pursuing the failed Drug War policies of restriction and prohibition, one good way for President Trump to "spend a lot of money" to help those opioid users who do become addicted is to increase access to medication-assisted therapy programs as recently suggested by my Reason colleague Mike Riggs.

Disclosure: I have worked on a couple of projects for ACSH in the past, including my report, "Scrutinizing Industry-Funded Science: The Crusade Against Conflicts of Interest."

Correction:

Andrew Kolodny, executive director for Physicians for Responsible Opioid Prescribing, called to complain that my article was badly mistaken in some respects and had in others unfairly mischaracterized his views. He then led me through my article pointing to his specific concerns.

So from Kolodny's point of view, what did I get wrong? To the extent that the term drug warrior is associated with vigorous law enforcement of drug prohibition, I was clearly wrong to suggest that Kolodny is one. I also misconstrued Kolodny's claim that opioid users switched to heroin largely because it was "easier to obtain" as implying that he rejects the claim that oxycodone's reformulation in 2010 pushed opioid users toward black market heroin.

Below I provide more context and my responses to other objections raised by Kolodny.

Kolodny's first objection was to the way I summarized Josh Bloom's interpretation of Kolodny's opening statement: "Drug overdose deaths, once rare, are now the leading cause of accidental death in the U.S., surpassing peak annual deaths caused by motor vehicle accidents, guns and HIV infection." Bloom asserted that "most people will read what Kolodny wrote and arrive at the conclusion that 60,000 people were killed by prescription pain medications."

Is Bloom's interpretation unreasonable?

Kolodny follows up his opening claim by asserting: "The data show that the situation is dire and getting worse. Until opioids are prescribed more cautiously and until effective opioid addiction treatment becomes easier to access, overdose deaths will likely remain at record high levels."

In his next four paragraphs, Kolodny chiefly explains why he thinks that prescription opioids are responsible for engendering the opioid crisis and then observes: "Over the last two decades, as prescriptions for opioids began to soar, rates of addiction and overdose deaths increased in parallel."

His initial mention of heroin is to compare its effects with the prescription opioids hydrocodone and oxycodone. As evidence that Bloom's interpretation is wrong, Kolodny cited his observation: "Until 2011, most opioid overdose deaths involved prescription opioids. Then prescription opioid overdose deaths leveled off, while overdose deaths involving heroin began to soar."

Given Kolodny's frequent initial mentions and resolute focus on prescription opioids as being the chief cause of the opioid crisis, it seems likely that casual readers might well draw the inference that most overdose deaths are caused by them.

Next Kolodny objected to the way I summarized Bloom's response to Kolodny's claim that the "effects of hydrocodone and oxycodone on the brain are indistinguishable from the effects produced by heroin." Bloom actually writes, "Yes, they are." But Bloom then argues that simply noting the pharmacokinetic similarity between opioids is not enough. Bloom counters that "heroin packs a much more powerful punch than hydrocodone, especially at doses that are used by addicts." In an effort to clarify Bloom's point, I linked to some data comparing the relative strengths of various opioids.

In our phone conversation Kolodny properly countered that addicts can adjust the dosages of whatever opioids to which they have access to match the effects of any other opioid they have been using. I think he makes a good point and I regret any confusion that my interpretation may have caused readers.

We had a brief discussion about the research on the rates of addiction among users of prescribed opioids, and he noted that I had linked to research suggesting higher rates than those cited by Bloom. Kolodny made it clear that he thought the studies finding higher rates of addiction to prescription opioids more credible. We moved on.

Kolodny most vehemently objected to my assertion: "Kolodny rejects the claim that the reformulation of prescription opioids after 2010 to make them more difficult to snort or inject pushed many users to black market heroin and even more dangerous substances in search of highs." This was my attempt to summarize and interpret his claim: "A common misconception is that so-called "drug abusers" suddenly switched from prescription opioids to heroin due to a federal government "crackdown" on painkillers. There is a kernel of truth in this narrative. It's true that the vast majority of people who started using heroin after 1995 switched from prescription opioids because heroin was easier to obtain."

Kolodny also strongly insisted that there has been no "crackdown" on prescription opioids. Curiously, it is fairly easy to find several articles and sources that do report over many years that there has been a "crackdown." These range from USA Today (2013), PBS NewsHour (2015), The Daily Beast (2016), The Hill (2016), Alcoholism & Drug Abuse Weekly (2016), to The Chicago Tribune (2017).

Aspects of the "crackdown" described in these and other sources include the CDC's tightening opioid prescription guidelines (a move applauded by Kolodny), increasing DEA enforcement efforts against prescribing physicians, switching hydrocodone from the less regulated Schedule III to Schedule II, and reformulating oxycodone to make it harder to snort or inject.

As noted above, it is clear to me now that I misconstrued Kolodny's claim that opioid users switched to heroin largely because it was "easier to obtain" as implying that he rejects the claim that oxycodone's reformulation in 2010 pushed opioid users toward black market heroin. Nevertheless, the question is not solely about whether heroin was just easier to obtain, but easier to obtain compared to what? Specifically, lots of oxycodone users switched to heroin because they could no longer access forms of the prescription opioid they could easily snort or inject.

Lots of research, including a 2012 study to which I link in my article, finds that it was reformulation, not just the availability of cheaper heroin as suggested by Kolodny that was the primary reason that many painkiller addicts switched to heroin. "The most unexpected, and probably detrimental, effect of the abuse-deterrent formulation was that it contributed to a huge surge in the use of heroin, which is like OxyContin in that it also is inhaled or injected," explained the principal investigator of that study.

Another fascinating new (2017) National Bureau of Economic Research study, "How the Reformulation of OxyContin Ignited the Heroin Epidemic," reports: "Between 1999 and 2009, opioid death rates were rising rapidly but heroin death rates were much lower and increasing slowly. In 2010, this changed; over the next four years, heroin death rates increased by a factor of four while opioid death rates remained fairly flat." In fact, the researchers "date the changes precisely to the month following the reformulation of OxyContin."

Still, my summary suggestion that Kolodny rejects reformulation as a major factor in the rise of heroin overdose deaths is at least misleading; he doesn't discuss that possibility and instead focuses on comparative cheapness of the heroin alternative to prescribed opioid drugs. I think Bloom has the stronger argument when he notes, "Reasons for opioid abuse are multifactorial, but there is no question that epidemic began to escalate in 2010, not from any crackdown, but from an improvement in the formulation of abuse-resistant OxyContin and the unintended consequences that followed."

Kolodny further claimed that I had mischaracterized his views when I stated that he favors "substantially increasing restrictions on patient access to prescription opioids." He was concerned that readers would interpret that as suggesting that he favored more punitive DEA action against addicts. Given the fraught nature of the failed Drug War, it is entirely understandable that Kolodny is anxious that his views not be mistaken or misrepresented.

Still, as noted earlier, Kolodny does support the CDC's new more restrictive opioid prescribing guidelines. In addition, he favored moving hydrocodone from the DEA's Schedule III to Schedule II. He has also said that the DEA's recent deep cuts in the aggregate production quotas of prescription opioids are "too little, too late." And he praised the CVS pharmacy chain for announcing that it will limit most opioid prescriptions to seven days. I do agree that I should not have used the term "drug warrior" when characterizing Kolodny's policy endeavors. Nevertheless, it does not seem unreasonable to describe Kolodny as being in favor of "substantially increasing restrictions on patient access to prescription opioids."

I do try to get things right, but I occasionally do make mistakes. I do really appreciate Kolodny contacting me to let me know his concerns. I hope that this correction has made the discussion around the problems and policies associated with opioids, both licit and illicit, a bit clearer to readers.

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29 responses to “Misdiagnosing Causes and Casualties in the Opioid War [Corrected]

  1. Anything short of complete legalization is not a solution that will “solve” anything. But what we’ll get instead is just enough money thrown at the situation to take it off the front pages for awhile. Then everyone will pat each other on the back and pivot to the next manufactured “crisis”.

    1. R: I largely agree with you, but pursuing harm reduction strategies in the meantime is probably the best we can hope for politically for now.

      1. Yeah, Realpolitik. I am usually right on board but this issue is particularly infuriating.

  2. While it is true that some unscrupulous phyisicians and pharmacies have overprescribed opioid medications…

    Unbearable pain is in the eye of the beholder.

    1. You must have rolled a 20.

  3. hydrocodone and oxycodone are four and two-times less powerful, respectively, than heroin.

    What does “four times less powerful” even mean? Is negative power a measurable thing that heroin has, which when multiplied by four, yields the amount of power that hydrocodone has? Or does “X times less powerful” simply mean “25% as powerful”? In which case, why not just say that and avoid confusion?

    1. S: Comparisons are made by calculating morphine milligram equivalents (MMEs). As they say: Dose conversions are estimated and cannot account for all individual differences in genetics and pharmacokinetics.

  4. Opioids are cheap. Hospitals simply won’t pay for alternative analgesics that are still under patent.

  5. Long-term use of prescription “opioids are more likely to harm patients than help them because the risks of long-term use, such as addiction, outweigh potential benefit,” Kolodny says.

    The risks of long-term use include a weakening of your moral fiber and a sapping of your precious bodily fluids. Pain is God’s way of telling you you’re a sinful creature and deserve punishment for your ungodly heathenish ways and assuaging the pain rather than correcting your sinful behavior just compounds the sin. Instead of taking a pill you need to take a knee and pray to Our Lord and Savior Jesus Christ to strengthen your faith and turn you to the straight and narrow. Besides, taking pills for pain is the pussy way out. Be a man and walk it off, you pussy. And stop looking at porn on your computer, that’s probably why God gave you the degenerative nerve damage in the first place, you pervert.

    1. J: Similar argument was made in the 1800s against using anesthesia to ease the pain of child birth. “When the anesthetic effects of ether and chloroform were discovered in the mid 1800’s, many members of the British clergy argued that this human intervention in the miracle of birth was sin against the will of God. If God had wished labor to be painless, he would have created it so.”

      1. Well, since we are born without knowledge of Jesus, I guess God also wanted us not to practice religion.

        1. I am hoping the first comment was sarcasm! Opiods, actually, have less damage associated with them, when compared to the kidney damage and bleeding from NSAIDS, or the liver toxicity of Acetaminophen. There are retrospective studies that show a .008% (8/100,000) risk of addiction in chronic pain patients, that have been published, too. The claim that anyone who takes opiods habitually for chronic pain relief leaves a lot of people for the “drug treatment programs” to rake in a lot of dough. Unscrupulous doctors also seem to be “addictionologists” who would tell us that 60%, of the country’s population, are addicted to something! They would tend to benefit immensely, with the increased income, from treating patients with expensive substitutes, like Suboxone! People who use opiods, as prescribed, may have withdrawal if they stop. But, if they have a good reason not to stop, say pain that restricts their ability to work, then the result is completely opposite of addiction. Addiction is a psycho-social dysfunction that continues, in spite of harm to the patient. Sadly, as a chronic pain patient, I have little sympathy for people who claim they were addicted by one prescription from a doctor.

          1. Those people tend to be the type that claim they did not know the drugs were addictive. WHAT CENTURY HAVE THEY BEEN LIVING IN?! I have known about heroin addiction since I was ten years old, or about fifty-five years. And, if a country boy from central Illinois knows about it, why would the “more sophisticated” people, from the big cities, not have any understanding about it! It is complete BS. The opiod epidemic is due, mainly, to clandestinely manufactured Fentanyl. Those who would abuse that have some real mental problems. And, if it were investigated properly, it would be found that most addicts have some form of mental illness, often from a history of abuse, when younger. The treatment of mental illness would go a long way into fixing the problem, more than inflicting pain, that could be treated, upon people, who have no control over their pain. Just like so many problems that our government tries to fix, they are only making things worse! And, people like Kolodny are just looking at the dollar signs! $$$$!! That is their only “concern” with chronic pain! My faith is in a loving God that has given us the brains to be able treat the pain that allows people to function with pain that would, otherwise, be disabling! And, to those who have not experienced intractable pain, there are worse things than dying!

  6. I’m not seeing the phrase ‘accidental deaths’ in any of this reporting. Until you eliminate suicides from the total, the entire argument is specious.

    Suicide by opioid seems like a reasonably pleasant way to go. Certainly better than a gun or jumping off something and ruining other people’s lives.

    1. I’d like to die in my sleep, like my grandfather did, not yelling and screaming like the passengers on the bus he was driving.

      1. At least it was a short bus, so the yelling and screaming wasn’t even about the impending crash, but about the apple rolling down aisle.

  7. There are plenty of studies and surveys that indicate that the connection between prescription opioids and deaths by overdose is more tenuous than a cursory review of the subject would indicate. There seems to be a number of factors that have driven the “Opioid Epidemic”, which is an imprecise term for a broader set of problems:

    1) A small percentage of people who take prescription opioids will become addicted, however this a small part of the problem.

    2) Increased use of prescription opioids across the population due to the economic downturn in 2008 (more people receiving disability benefits) and the Medicaid expansion. If X% of people will overdose on painkillers and more people are taking painkillers, there will be a corresponding increase in the real number of overdoses even though X remains constant. Additionally, some percentage of unused pills will enter the illegal market, which explains why most people who overdose on prescription opioids were never prescribed the medications.

    1. 3) The sudden supply of cheaper heroin (see the Xalisco Boys), which prompted many people who were previously abusing methamphetamines and other drugs to switch to opioids, despite the increased danger. The variations in potency between batches of heroin lead to increased risk of overdose, since users don’t know for sure how much of the drug they are taking. Additionally, other criminal groups attempt to mimic the success of the Xalisco Boys and introduce lower quality heroin, which is often cut with dangerous chemicals.

      4) The introduction of illegally-manufactured fentanyl and other powerful synthetic opioids. These drugs have been added to heroin and reprocessed prescription opioids to increase the potency. Poor manufacturing of these drugs can lead to dangerous chemical by-products being introduced into the heroin supply, plus the increased potency is not consistent.

      1. 5) Increased awareness of the opioid problem leads to more autopsies identifying opioids as a contributing factor to the death. Since a large percentage of the population is taking prescription opioids, the chance that an individual will test positive for opioids at death is significant. Determining whether or not the opioids were a causal factor in the death is very difficult. It is likely that a significant percentage of deaths where opioids are ruled to be a factor are not actually directly caused by opioid use.

        6) The DEA crackdown on prescribers and changes in various state laws led to fewer numbers of prescription opioids. This led to a corresponding decrease in the availability of prescription opioids on the illegal market. Recreational users of prescription opioids now turned to heroin and other drugs, which led to increased overdoses.

        1. The conflation of these various issues into one large “epidemic” makes it difficult to find solutions to these problems. Many of these factors occurred independently of each other and attempts to fix the problem (such as the DEA crackdown) have almost certainly increased the number of deaths. However, I have no faith in the ability of the general public or lawmakers to take a nuanced and informed view of these issues. The narrative has already been identified and there is a villain (the drug companies) and a hero (the DEA) that people can understand and point to.

          1. Well said!

            Thank you,
            Michael G Langley, MD

  8. Misdiagnosing?

    I was in the ER last week. I had to repeatedly fend off offers for pain-medication – at least 8 times. My pain wasn’t that great, more than managable, so I kept refusing. I was even offered pain medication after i told them I drove myself to the hospital, which even though they assured precluded me from recieving pain meds, were offered anyways.

    There was even a sign posted in my assigned ER cubicle that read, “Pain Managment is Our Top Priority”, for fuck’s sakes.

    My point is, I’m not sure this is a diagnosis issue as much as a policy issue.

    1. That’s because you’re not a chronic pain patient and you were probably offered some form of an NSAID… it’s next to impossible to get Opiates in the ER if you take them regulary. They know exactly how much you’ve been prescribed and which doctors…HIPPA be damned. And Koldony is an addiction specialist who wants to get people to go to his rehab clinics, addiction and pain wise… He was part of the secret cabal that created the CDC bullshit guidelines. Every year since 2003 it’s gotten harder and harder to get proper pain relief from chronic pain. THAT’s the real epidemic. Frankly, the DEA and the CDC and people like Koldony are responsible for killing all the drug addicts who had to switch from the safe supply of prescription oxy to the black market unreliable heroin/fentanyl. And the legalization of marijuana is making them fear for their jobs so they’re making up this epidemic and it’s the people in pain who are suffering.

      I’ve been on the same dose of Oxcycodone and Valium for 10 years. Have apparently not stopped breathing yet. Because i take them for chronic pain and do not abuse them. More people die of alcohol abuse than anything else.

  9. “In any case, Bloom cites 2010 research that the risk of addiction is below one percent for patients who use prescription opioids for short term pain control”

    So, when used as directed there is a fractional problem. When abused there is a big problem. Punishing the responsible for the actions of the irresponsible, in this or anything else, is not the answer.

  10. Do the benefits outweigh the risks? I would suggest that the answer to that question should be left up to the individual who actually runs the risk, not up to politicians. Any drug, any medical procedure, carries risks, be they mild (as in cannabis) or potentially deadly (as in chemotherapy). We don’t allow politicians to deny chemo to cancer patients on the grounds that the treatment may turn as deadly as the disease. We don’t allow them to deny people suffering from depression, or anxiety, or diabetes, or heart disease, access to life-giving medications, because the drugs themselves can cause harm. What we do is require ongoing studies about the possible dangers and/or efficacy of the drugs, allow free dissemination of that information, regulate their production for quality and purity, and provide patients who use the drugs safe, nonjudgmental access to medical care. And we require people dispensing that care to be educated and licensed. Why should adults seeking relief from pain be treated any differently?

  11. Kolodny appears to have a penchant for citing/relying-upon older 2015 information (apparently in hopes of bolstering his published prohibitionist polemics). While searching through old information, perhaps he missed this 2017 RAND report (“Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioid”; Wharton, Powell, Pacula): “We find that the OxyContin reformulation significantly reduced OxyContin misuse, but also led to a large increase in heroin deaths. Specifically, states with the highest initial rates of OxyContin misuse experienced the largest increases in heroin deaths. Event study results show that this differential increase in heroin deaths began precisely in the year following reformulation.”. “This study quantifies the high degree of substitutability between heroin and medically-intended opiates in response to a large supply reduction in abusable OxyContin. While opioid policies have generally focused on disrupting the supply of opioids for nonmedical use, our findings demonstrate how the availability of unregulated substitute drugs can severely undermine the effectiveness of such policies.”. Only when morals/ethics matter.

  12. Regarding moral/ethical negligence of waging a deadly War on People who use Drugs, the Heller School at Kolodny’s own Brandeis University PDMP-TTAC program (via IDJP web-site) references, “Today’s fentanyl crisis: Prohibition’s Iron Law, revisited”; Beletsky and Davis, 2017 stating: “These increases in harm were as predictable as they are disastrous. Simply removing access to OAs without replacing this therapy with other pain management modalities and delivering evidence-based opiate substitution treatment could lead only to only two outcomes: increases in untreated pain, unmanaged withdrawal or substitution with other, likely more potent, opioids.”. “As this crisis has evolved, the iatrogenic risk to the health of people who use drugs was not just foreseeable, but in some cases directly foreseen by policymakers. One of the most shocking articulations of this came from Pennsylvania’s former Physician General, who recently remarked, “We knew that [drug user transition to the black market] was going to be an issue, that we were going to push addicts in a direction that was going to be more deadly. But … you have to start somewhere”. This statement is emblematic of the belief that decisive action is more important than reducing overall societal harm. While seemingly widespread, this sentiment is inimical to both public health scientific and ethical norms.”. Such blatant and craven disregard for human life should rightly be anathema to medicine and to public policy.

  13. The idea that Kolodny in any of his published statements has given anything but short-shrift to the reality that, “oxycodone’s reformulation in 2010 pushed opioid users toward black market heroin” is laughable. Good journalistic work in causing him to concede that fact ! A 2013 SAMHSA published report [entitled, “Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States”; Muhuri, Gfroerer, Davies; based upon a 9-year NSDUH study (2002-2011; n=609,000; ages 12-49)] found that only a mere 3.6% of recreational prescription opioid users willingly transitioned from recreational prescription opioid use to Heroin in a 5-year time period following initiation of recreational prescription opioid use – notably during a time period when pharmaceutical opioids (i.e., Oxycontin OC formulation) were much more freely available to such recreational users. Respondents almost universally preferred the safety of pharmaceutical opioids as compared to the dangers of street Heroin – even when the presence of Fentanyl(s) was a rarity. I get the impression that “little elves” may (possibly) be busily at work seeking to “burn the books” ? While an HTML version of the report can still presently be found on the SAMHSA web-site, the PDF version has (within just the last few days time) been removed completely (leaving many reference links defunct) – although it has (thankfully) been archived by the “Wayback Machine”.

  14. “Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.” ? “The biologist’s or physician’s claim that he represents disinterested abstract values – such as mankind, health, treatment – should be disallowed; and his efforts to balance, and his claim to represent, multiple conflicting interests” ? “should be exposed for what they conceal, perhaps his secret loyalty to one of the conflicting parties or his cynical rejection of the interests of both parties in favor of his own self-aggrandizement.”
    – Thomas Szasz, “The Theology of Medicine: The Political-Philosophical Foundations of Medical Ethics”

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