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."