Opioids

Opioid Commission Mistakenly Blames Pain Treatment for Drug Deaths

The panel wants to make prescription analgesics even harder to obtain.

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Governor's Office

In the report it published yesterday, the President's Commission on Combating Drug Addiction and the Opioid Crisis, chaired by New Jersey Gov. Chris Christie, endorses what has become the standard explanation for the rise in opioid-related deaths during the last decade and a half. "A widely held and supportable view is that the modern opioid crisis originated within the healthcare system," the report says. The problem began, it explains, with "a growing compulsion to detect and treat pain."

According to this narrative, doctors in the late 1990s began to underestimate the risk of addiction and overdose among patients prescribed narcotics for pain. Responding to ill-informed advocacy on behalf of pain patients and deceptive marketing by drug companies, they lost their entirely appropriate fear of opioids and began prescribing them left and right. The surge in prescriptions led to a surge in "iatrogenic addiction" (i.e., addiction caused by treatment) and overdose deaths. To correct that disastrous mistake, the Christie commission says, doctors need to worry less about the suffering caused by untreated pain and more about the dangers posed by painkillers.

That response is fundamentally misguided because the narrative endorsed by the commission is wrong in several crucial ways. Doctors did not mistakenly believe that the dangers posed by opioids had been greatly exaggerated. They correctly believed that the dangers posed by opioids had been greatly exaggerated, and they were right to think that excessive fear of opioids had led to inadequate pain treatment. Contrary to the impression left by a lot of the press coverage, opioid addiction and opioid-related deaths rarely involve drug-naive patients who accidentally get hooked while being treated for pain. They typically involve polydrug users with histories of substance abuse and psychological problems. Attempts to prevent overdoses by closing off access to legally produced narcotics make matters worse for both groups, depriving pain patients of the analgesics they need to make their lives livable while driving nonmedical users into a black market where the drugs are more variable and therefore more dangerous.

"The catalyst of the opioid crisis was a denial of [these drugs'] addictive potential," the Christie commission says. The report does not try to quantify that potential, but survey data and studies of patients help to put it into perspective.

According to the National Survey on Drug Use and Health (NSDUH), 98 million Americans used prescription analgesics in 2015, including both legal and illegal use. About 2 million of them qualified for a diagnosis of "substance use disorder" (SUD) at some point during the previous year. SUD is a catchall category that subsumes what used to be known as "substance abuse" and the more severe "substance dependence." The Substance Abuse and Mental Health Services Administration, which oversees the survey, does not report the breakdown between mild, moderate, and severe SUD. But based on this survey, it looks like somewhere between 1 and 2 percent of prescription opioid users experience addiction in a given year. By comparison, NSDUH data indicate that about 9 percent of past-year drinkers had an alcohol use disorder in 2015. That group was about evenly divided between "abuse" and "dependence."

The NSDUH numbers provide a one-year snapshot. Some studies of patients who take opioids for extended periods of time find higher addiction rates, but they are still generally modest. A 2010 review found that less than 1 percent of patients taking opioids for chronic pain experienced addiction. A 2012 review likewise concluded that "opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence." A 2015 review noted addiction rates in various studies ranging from 3 percent to 26 percent in primary care settings and from 2 percent to 14 percent in pain clinic settings.

The risk of fatal overdose among patients is very low. The CDC cites "a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain" who were followed for up to 13 years. The researchers found that "one in 550 patients died from opioid-related overdose," which is a risk of less than 0.2 percent. A 2015 study of opioid-related deaths in North Carolina found 478 fatalities among 2.2 million residents who were prescribed opioids in 2010. That's an annual rate of 0.022 percent.

The risk of addiction and overdose is not random. A 2012 study of opioid-related fatalities in Utah found that 80 percent of the decedents had received prescriptions for analgesics in the previous year and 89 percent were reported to have suffered from pain. Those results may seem consistent with the story the Christie commission is telling about pain treatment leading to iatrogenic addiction and death. But when you look at the characteristics of the people whose deaths were attributed to prescription opioids, you see that 61 percent had used illegal drugs, 80 percent had been hospitalized for substance abuse (including abuse of alcohol and illegal drugs as well as prescription medications), 56 percent had a history of mental illness, and 45 percent had been hospitalized for psychiatric reasons other than substance abuse. Troubled people who find emotional relief in various drugs, including prescription opioids, are far more common than accidental addicts like the law school classmate frequently cited by Chris Christie, who died after washing down Percocet pills with a bottle of vodka.

So-called overdose deaths typically involve combinations of drugs. In the North Carolina study, for example, benzodiazepines were detected in 61 percent of the deaths attributed to prescription opioids. The numbers in New York City are similar, and that's just for one class of depressants. Over all, more than 90 percent of opioid-related deaths in New York involve drug mixtures. For the most part, people are not dying simply by taking too many pain pills. Even Christie's friend, whom he describes as getting hooked on oxycodone prescribed for back pain, mixed the pills with alcohol.

What's true of prescription opioids is also true of heroin: Most "overdoses" involve combinations. The danger is magnified by the unpredictable potency of black-market heroin, which in turn has been magnified by the recent proliferation of fentanyl as a heroin adulterant and substitute. The dramatic increase in heroin-related deaths since 2010 seems to be driven largely by the crackdown on prescription opioids (including the 2010 reformulation of OxyContin), which has pushed nonmedical users toward more hazardous substances.

The crackdown also has affected patients, leaving many without the medication they need to keep agony at bay and driving some to suicide. The prescription guidelines that the CDC issued last year, which encourage physicians to be stingy with opioids, already have had a noticeable impact on patients' ability to get adequate treatment for their pain. "There are many pain clinics flooded with patients who have been treated previously by their primary care physician," says Jianguo Cheng, president-elect of the American Academy of Pain Medicine. "They have a lot of patients trying to find a physician, and it has been a problem for many, many pain specialists." He says these refugees include patients who have responded well to opioids for years.

The Christie commission thinks there is nothing wrong with the CDC guidelines. In fact, the report recommends updating and extending them to pain specialists. It calls for "a national curriculum and standard of care for opioid prescribers," presumably aimed at reinstilling the good, old-fashioned fear that the commission credits with preventing abuse. The commission thinks patients should no longer be asked about the adequacy of pain treatment in surveys mandated by the Centers for Medicare & Medicaid Services, lest providers "use opioids inappropriately to raise their survey scores." The commission criticizes the campaign to treat pain as "the fifth vital sign," which it blames for encouraging excessive opioid use. It recommends closer and more comprehensive scrutiny of prescription practices.

If the aim is reducing deaths from drug poisoning, there is not much logic to making prescription analgesics even harder to obtain. According to a 2016 analysis of opioid-related deaths in Massachusetts, just 8 percent of the decedents "had an opioid prescription in the same months as their deaths." Prescription opioids were the deadliest drug in just 5 percent of the cases, while 85 percent involved heroin and/or fentanyl.

Today I heard from one of the pain patients I interviewed for an upcoming Reason feature story about recent trends in opioid use. He fits Cheng's description of patients who have functioned well on opioids for years but were arbitrarily cut off by providers in response to the CDC guidelines. This patient thinks the Christie commission is pushing the government further in the wrong direction. "If they go through with those recommendations," he wrote to me on Twitter, "I may as well drive my car off a cliff. This is horrible news. The CDC will threaten MDs, the DEA will step up their intimidation practices, and the few pain MDs that are left will fold. This is barbaric."

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  1. “a growing compulsion to detect and treat pain.”

    Holy shit.

    OK, guys, set a good example for us…hurt yourselves and then refuse pain treatment.

    1. An unbelievable sentence that was.

      There also seems to be a growing compulsion to treat cancer.

      There’s also a growing compulsion to insist on freedom of speech on campus.

      There’s a growing compulsion to protect the private communications of American citizens.

      There’s a growing compulsion to send kids to charter schools.

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  2. …chaired by New Jersey Gov. Chris Christie…

    Ugh.

    1. Christie would freak out from withdrawal if his lunchtime Double Whopper was 5 minutes late.

    2. Have no doubt that Chris Christie can stand severe and chronic pain,
      as long as its someone else’s pain.

  3. I appreciate the alt-text telling me that was Chris Christie, I didn’t recognize him with the Bond villain hair.

  4. Saddest debate I had with my prog friends in recent memory was their full acceptance of:

    1) opioids are bad
    2) autonomy is dangerous
    3) government needs to save us from us
    4) and lastly, I am a dick for trying so hard to challenge 1-3.

    1. Well, it seems obvious that point 2 and 3 are mutually exclusive but you’d probably have to spend a few minutes explaining why since a Progressive can only be either evil or stupid; but not both.

      1. Nah they’re not mutually exclusive. I’ll show you how with prog logic

        Autonomy is dangerous because people are prone to making emotional and irrational decisions (according to my definition of what is rational for them of course) or lack all of the necessary information to consistently make the rational decision

        When people become government employees, they transcend humanity and are no longer subject to these issues

    2. When I bring up a counter point to Progressives, they call it “fake news”. They are a religion that believes in self-sacrifice to their rulers. You can’t talk to Progressives. You have to tell them off.

    3. Vox is the biggest media-outlet cheerleader for the War on Narcotic Analgesics. Progs invented the War on Drugs.

      1. man you guys are a broken record. Doesnt matter what the issue is, its always “the progs” isnt it? The war on drugs has been going on for a century. I admit that Pelosi looks like a Walking Dead extra, but shes not *that* old. Srsly, narcotics interdiction is & always has been a very much a bipartisan effort. Nixon & Reagan were the two presidents who arguably bear the most responsibility for the modern drug war. Reagan in particular made two things happen that have proved disastrous for liberty: 1. requiring urine testing for gov contractors normalized the sick practice of seizing bodily fluids as a requirement for employment. 2. invented the practice of tying LEO funds from the fedgov to local police drug arrests. Nixon explicitly says on the whitehouse tapes that he wants to use the drug war to break up the black & youth dem vote. None of this is to say that dems like Clinton (in particular) were not essential to the slowmotion genocide that the drug war has become. The truth is that members of both parties at every level of US govt have lied, cajoled, stolen & abused their powers to ensure that generations of Americans will spend their lives in a cage for the crime of experiencing subjective reality differently for a few hours.

  5. National Overview on Drug Use and Health? Nah… National Survey on Drug Use and Health? Yeah, that’s it! Perfect!

  6. “Attempts to prevent overdoses by closing off access to legally produced narcotics make matters worse for both groups, depriving pain patients of the analgesics they need to make their lives livable while driving nonmedical users into a black market where the drugs are more variable and therefore more dangerous.”

    It will drive medical users into the black market as well. All of the behaviors attributed to pain killer addiction (going to multiple doctors, resorting to lies or even theft to get more) are adequately explained by under treated chronic pain. I’ve had some very painful experiences, fortunately none of them lasted more than a couple of weeks, but I can well imagine how desperate for relief someone facing a life time of severe chronic pain could get.

    1. Just look at the group getting hit hardest by the heroin epidemic. It isn’t adolescents or young adults engaged in youthful experimentation. It is people approaching middle age or beyond. Many of these people do have some painful condition that the medical establishment has stop treating due to political pressure. So they resort to street drugs.

      1. Or suicide like mentioned in the article. Of course for a true believer like christie its better for a chronic pain patient to off herself and die “without sin” then overdose. This new phase of the drug war is quite likely the most depraved its ever been. I never thought that they would claim this publicly that patients are all junkie pieces of garbage, but thats what i get for assuming some sort of basic human decency from a law enforcement professional.

        1. This new phase of the drug war is quite likely the most depraved its ever been

          It’s been awfully bad for so long it’s hard to say for sure, at least as far as America goes. The Philippines on the other hand, there’s some really depraved shit.

  7. It’s nice to know that whoever won the 2016 presidential election, a callous, empty-headed demogogue was always going to unthinkingly appoint a corrupt, arrogant, lying cunt to promulgate moral panic about an inanimate object amongst those who do not own or know anything about it yet have been given the power to control the media narrative and legal exchange and ownership of it.

  8. Seriously, the one good thing about this is the fact that Christie is the one whose fat, smirking, severed-pig-head of a face is going to be plastered all over this outrage in the history books. You could not ask for a more blatantly, inarguably, pathetically evil bully to act as the symbol of everything that is blatantly, inarguably, pathetically evil about drug control.

  9. When patients who have used pain meds 5 & 10 years without problem are suddenly cut off,
    about 5% is going to have real problems that they didn’t have before.

    Some people simply can’t stand being in constant pain. They buy pills, but can’t afford it, so they turn to something cheaper and stronger.

    1. Oh id say that 100% of patients who are cut off of a long term opiod prescription will have a new problem in the form of withdrawal. But hey, if we can “stop just one overdose” & all we need to do is force a few hundred thouaand cancer, aids, etc victims to suffer in agony, who cares right? Only junkies take anything ither than tylenol anyway. Most of those “tumors” are just a scam so that pill pushing croakers can get rich quick turning our innocent children into street walking junkies.

      1. You are misinformed, Jay. I spent 30 years as an RN, half of that as an APRN in hospice. My specialty was pain and symptom management.

        I worked with a lot of people taking seriously high doses of morphine and other narcotic analgesia. Even those who took them for years did not exhibit any signs of “addiction.” Most would have been delighted to get rid of it all if their pain had gone away. The side effects from long term opioid use are terrible all by themselves.

        There are a number of good alternatives, but most are either not available to most folks, or they are themselves “illegal.” I have chronic pain myself due to serious back injury long ago, but have not seen a doctor for ten years. The last one I saw told me I didn’t “need” any medication at all, and that I should go swimming instead. Fat headed idiot… he was already on board with this nonsense.

        No government can save people from themselves, but can most certainly drive them to ever more desperate measures.

        1. Mamaliberty, I do believe Jay was being sarcastic.

  10. I’d feel a lot better if there was someway that chronic pain sufferers could “share” their pain with Chris, like in “Dune”.
    I think things would improve very quickly if people could feel the pain they cause.

  11. I was on prescription pain meds for about 6 months. Yes, they are addicting. But I would gladly go through a week or two of withdrawal than deal with 6 months of debilitating pain. And no commission (or physician) should be making that decision for me. I didn’t mix alcohol or illicit drugs and I’m fine now. I don’t have any desire to go back on pain meds but I won’t hesitate to do it again if necessary. People who haven’t had a major injury can’t even fathom what the suffering is like.

    1. +1 well said. Many americans have to work during their recovery also – something that isnt possible without some form of pain management esp for americans who have to work on their feet

  12. When this is all over, rich patients will be able to afford to see a doctor and get 5 pain pills at a time… Any more than that, us peons can NOT be trusted with!

    Poor patients will be stuck with cheap-shit booze for a painkiller, or….l Suicide as painkiller!

  13. The problem began, it explains, with “a growing compulsion to detect and treat pain.”

    “Can you detect any pain? How about NOW?!”

  14. The virtue signalling on Twitter over Joe Rickets shutting down DNAinfo and Gothamist is DEEEEEEEEE-LISH!!!!

  15. The goal is to classify use of opiates over 3 days as ‘addiction’ and any prescriptions after that as ‘treatment’. There will of course be a nationwide registry for the new addicts.

  16. Excellent article, Jake. This is the kind of quality stuff I used to expect out of Reason.

    Mike Riggs’ “reportage” on this beat is fucking awful.

    1. What about Michael Rotch? Do you like him?

  17. OT:
    TV news has pants-shitting, hand-wringing and forelock-tugging over the proposed GOP tax scheme, with real estate sales folk encouraging people to contact the GOP legislators.
    Well, CA became a one-party state years ago; why should the GOP give two hoots about CA voters?
    Every time someone suggests I contact my reps, I laugh and laugh! Pelosi and Feinstein care about the desires of L voters exactly as much as the GOP cares about CA.
    Sew/reap, CA Ds. Threaten to vote D next time! Ha and ha.

  18. So you know who is responsible for drug deaths? The government, that’s who.

    1. Not sure what your point is. You want nosy-ass old lady neighbors reporting ppl to the police because they “never see” you going to work? Thats what the world needs right now? More dogs & kids kidding shot by cops doing a “safety check” because Granny Alzheimer forgot that people work night shifts?

  19. OT: In a tweeted statement, [Twitter] said Trump’s account was “inadvertently deactivated due to human error” by one of its employees.

    “Definitely not done on purpose by one of our Trump-hating employees. No, that’s just Rooskie-talk.”

    1. “Definitely not done on purpose by one of our Trump-hating employees. No, that’s just Rooskie-talk.”

      Tony and turd approve this message.

  20. Gives a whole new meaning to, “No pain; no gain.”

  21. So…people in intense physical pain are supposed to put up with it and have the self-discipline not to use pain relieving drugs…but people whose problem is that they are strongly tempted to abuse drugs aren’t expected to have the self-discipline to avoid the temptation?

    1. “When we finished, he shook our hands and said, “Endeavor to persevere.”

      1. S-
        Of course, the next step is to declare war on the Union.

  22. So is this commission chairmanship a reward for Christie’s timely political support of Trump? Christie gets his fat mug in the news a lot, but Trump gets to decide for himself what recommendations to follow if any.

    It would make sense that Christie is so lame that he has to settle for commission chairmanship instead of a cabinet post.

    I was trying to find a way to work the phrase “throw his weight” around into a sentence.

  23. If legislators and CDC officials had to deal with the same fucking pain that people that need opioids feel, opioids would be available over the counter tomorrow. In fact, if a genie came out of a lamp and offered me three wishes, that might not be my first, but it would be one of the three.

    1. Try to squeeze in anger control into one of your three wishes. TIA

  24. I hope his ED refuses him morphine during his inevitable STEMI. Wouldn’t want to get addicted.

  25. Per Licit and Illicit Drugs, opioid overdose deaths were practically unheard of when legal and unregulated, so why the change? Not to mention overdose isn’t terribly difficult to treat (supposing the response is timely), so it seems to me there is more to this than merely doctors over-prescribing.

    Also:

    frequently cited by Chris Christie, who died after washing down Percocet pills with a bottle of vodka

    Acetaminophen and alcohol are toxic together. I’d be really interested in the toxicology report. And someone who at least knew this is a deadly combination to head any presidential commission.

    1. Acetaminophen poisoning results in hundreds of thousands of hospitalizations each year. But better to burn a whole in your liver & kidneys than get “high” amirite?

      1. This is an excellent example of the screwed up statistics that are being used against pain patients. Dying of an overdose while taking opiates is counted whether the drug that killed was an opiate or the Tylenol that was packaged with it.

  26. “If the aim is to reduce deaths from drug poisoning . . .” Well, it should be pretty clear by now that reducing deaths, or reducing harm in general, isn’t and never was the “aim” of the drug war.

  27. Look, i get it. Reason has become more contrarian than libertarian. But there are far too many opiod pills on the streets and in the hands of dealers. Same with benzos. While these patients may not be the problem individually, a lot of their doctors are. Especially at “pain clinics”, several of which have been shut down near me in Pittsburgh for writing improper scrips for “patients” and dealers. One will even be tried under our states new law that allows dealers/doctors to be charged with manslaughter if a person od’s from opioids that can be traced to them.

    And how many of these “patients” aren’t addicted and don’t use their full scrip so they give them to friends for recreational use or resale?

    Maybe these “patients” and reason are misdirecting their scorn at the government instead of the shady docs pushing these things out to the streets that brought on this whole fiasco in the first place. As my cousin who recently od’d and withdrew from benzos told me, it’s a lot easier for him to get any kind of pill than it is booze or weed in high school. That’s on doctors n whoever is prescribing these things, plain and simple.

    1. If you don’t like those “shady doctors”, just wait ’til you meet the Taliban and Chinese fentanyl pushers.

      Oh, wait, you don’t have to!

    2. The point of the article isn’t scorn at the government. It’s to show 1) that it isn’t actually a “fiasco”, media sensationalism aside. And 2) that prescribing, and over-prescribing (which is of course a relative term), isn’t the culprit anyway.

      I’m sorry to hear about your cousin, but to blame doctors for his plight is the perfect example of redirecting personal responsibility. And at the risk of being insensitive here, the question that must be asked is: your cousin was apparently unable to handle taking these medications, but how come there are literally millions of people who are? That’s not a rhetorical question by the way. It’s a question that scientists are actively investigating. If we can do a better job of identifying people who may be at risk, doctors can make more informed treatment recommendations.

      1. Oh id say it is absolutely that fiasco, and the benzos are part of it and must be included.

        Regarding my cousin, his use was all recreational. As i stated, he and his friends got into them cuz they f you up and were so easy to get. Many of his friends/schoolmates simply got fake scrips for xanax by lieing to the doc and resold them.

        Back to the opioids though, it isn’t over prescribing. It’s prescribing to people who dont/no longer need them in the first place. Look at the Utah stats, 87% of opioid deaths had a scrip in last year, but 80% were also hospitalized in that year, 60% had illegal drug issues, 50% mental health issues etc. If we knew about those 80% being hospitalized, 60% with drug issues, 50% with mental issues, then why were they all given opiate scrips? What doctor knows those things and still writes these people a prescription?

        1. The doctor that knows that there’s a heroin dealer pushing fent just down the way?

  28. Also, we need to include benzos in this convo. As the article mentions they’re regularly found in the systems of opioid overdoses, and id assume the same for amphetamines. Benzos are used to amplify the effects of opiates and as a way to calm down/come down from amphetamines and cocaine. They act on the same receptors as alcohol, impair you far greater, have “date rape” drug like affects on memory, and withdraw can be fatal, unlike opioids. They’re the common undercurrent to all our current addiction and prescription abuse problems

    1. Benzos are certainly not benign, but their utility is FAR more extensive than how you present it. They are extremely effective at treating a shit ton of disorders that affect a massive proportion of the population — including severe depression, anxiety, and conditions like migraine. And they often do so far more effectively than alternative therapies.

      The bottom line is that abuse is a factor that should be considered for all kinds of drugs. That doesn’t mean you just rip those drugs away from people and let them suffer. I know you’re not directly suggesting that, but adding red tape invariably ends up making that happen.

      1. Benzos are by far the most currently abused prescription pill. And as this study states, they’re showing up in high percentages of o.d. Opiate Deaths. I’d be willing to bet its the same for o.d.s on other drugs because i know they’re now being used by amphetamine users to come down, as well as dui’s. Benzos are fine until any alcohol or heavy stimulant is mixed, but that’s literally why people take them recreationally, to get more f’d up n not get sick. Like being mentally drunk but not in your stomach. And their toxicity is low so you can’t od on them alone.

        And while i agree they may help with those conditions, it’s far to easy for a kid to tell his doctor he’s anxious in school or nervous around people and get a xanax scrip. Personally i think mental medicine has run amok and is over diagnosed/prescribed anyway because i know how easy it was (and still is) for people to get Adderall scrips when i was in college to sell, and its the same with benzos now.

        1. What in hell makes my pain, and what I need to control it… any of your damned business? Or that of anyone else, let alone the non-voluntary government?

          That’s the problem in a nutshell.

          The root of all evil is the desire, compulsion, glee in controlling other people… regardless of virtue signaling or supposed motives.

          MYOB, and I’ll be happy to mind mine.

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