Opioids

The Washington Post 's Simplistic Assumption That More Opioid Prescriptions Mean More Drug Overdoses Is Demonstrably Wrong

The causes of opioid-related deaths are more complicated than "too many pain pills."

|

"America's largest drug companies saturated the country with 76 billion oxycodone and hydrocodone pain pills from 2006 through 2012 as the nation's deadliest drug epidemic spun out of control," The Washington Post reports, citing newly released data from the Drug Enforcement Administration (DEA). That lead and the headline above the article ("76 Billion Opioid Pills: Newly Released Federal Data Unmasks the Epidemic") tell a simple and familiar story: Because doctors prescribed too many pain pills, people died—"nearly 100,000″ from 2006 through 2012, according to the Post, although data from the U.S. Centers for Disease Control and Prevention (CDC) indicate that the actual number for the drugs the Post is talking about was more like 68,000.

The reality is more complicated than the story told by the Post. It is clear that doctors, in many cases, did prescribe more pills than their patients ended up needing, since a lot of those pills were diverted to nonmedical use. But by counting all 76 billion as self-evidently problematic, the Post ignores the benefits of opioids for the millions of Americans who actually need them for pain relief—patients who are now suffering because of the crackdown encouraged by indignant and simplistic press coverage like this.

What is the right number of pills? The Post does not know, and neither does the DEA. But since misuse of prescription analgesics co-exists with undertreatment of pain, indiscriminate reductions in the total supply have predictably bad consequences for patients. That ham-handed approach also has driven nonmedical users toward black-market substitutes that are much more dangerous because their potency is inconsistent and unpredictable, which helps explain why the increase in opioid-related deaths accelerated in recent years even as the government succeeded in driving down opioid prescriptions.

It is also important to recognize that the "epidemic" described by the Post is not an increase in nonmedical use of opioids or even in "pain reliever use disorder." According to data from the National Survey on Drug Use and Health, the incidence of both has been essentially flat since 2002, including the period on which the Post focuses. But the number of fatalities involving prescription analgesics has increased dramatically since 2002, part of a long-term upward trend in drug-related deaths that began in 1979—17 years before the introduction of OxyContin, which the Post fingers as the main pharmacological culprit (although it also notes that OxyContin accounts for just 3 percent of the legal opioid market).

These deaths typically do not involve legitimate pain patients who accidentally got hooked on medication their doctors prescribed for them. They generally involve people with long histories of substance abuse and psychological problems who use diverted pain medication along with other drugs. CDC data indicate that at least 68 percent of deaths involving prescription analgesics also involve other drugs, most commonly heroin and illicit fentanyl. Judging from New York City data, the actual percentage may be as high as 97 percent.

The increase in deaths seems to be caused not by a general increase in the rate of misuse but by an increase in reckless consumption, including injection, higher doses, and drug mixtures. That behavior can be understood only in the context of personal, social, and economic circumstances, including whatever factors have been driving up drug-related deaths since the late 1970s.

The Post implies that there is a straightforward relationship between opioid prescription rates and opioid-related deaths. That is not true even if you focus on deaths involving pain pills. Between 2006 and 2012, the Post says, West Virginia received the most pills per capita, and "West Virginia also had the highest opioid death rate during this period," which was still true as of 2017, according to the CDC.

But what about the other states that rank high in pills per capita? Of the top 10 states listed by the Post, the CDC has data on deaths involving prescription analgesics for seven. In addition to West Virginia, they are Kentucky, South Carolina, Tennessee, Nevada, Oklahoma, and Oregon, and those are not the states with the highest death rates. Within this group, Kentucky had the highest death rate in 2017 (10.2 per 100,000), but it was still lower than the rates in Maryland (11.5) and Utah (10.8), both of which had substantially lower prescription rates.

South Carolina's death rate (7.1 per 100,000) was lower than the death rates not only in Maryland and Utah but also in Connecticut (7.7), the District of Columbia (8.4), Maine (7.6), New Mexico (8.5), Ohio (8.4), and Rhode Island (8.8). Again, all those states had lower opioid prescription rates, in some cases much lower. The same pattern holds true for Tennessee, Nevada, Oklahoma, and Oregon, all of which had lower death rates than states where fewer opioids were prescribed. The disparity is especially striking for Oregon, where the rate of deaths involving pain pills was just 3.5 per 100,000, lower than the rates in most states, even though Oregonians received more opioid prescriptions per capita than 29 states and D.C.

The point is not that pain pill prescriptions have nothing to do with deaths involving pain pills. But other factors are clearly at work. How does Oregon manage to have such a low death rate even though it has a relatively high prescription rate? Why do Utah and Maryland, both of which have lower prescription rates, have death rates much higher than Oregon's? The answers to such questions could point the way to policies more nuanced and effective than the blanket demand that doctors stop prescribing so many pain pills.

[This post has been revised to correct the percentage of deaths involving pain pills that also involve other drugs, as indicated by CDC data.]

NEXT: Berkeley, California Will 'Degenderize' Its Municipal Code, Getting Rid of Words Like 'Manhole' and 'Ombudsman'

Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of Reason.com or Reason Foundation. We reserve the right to delete any comment for any reason at any time. Report abuses.

  1. When did it become virtuous for the left to go after drugs? Or is it actually the pharmaceutical companies that they are after?

    1. The left has always gone after drugs. Sometimes with an exception for cannabis. I’ve never heard any principled stand against prohibition generally from the mainstream left.
      The fact that there are evil corporations to go after probably helps get them motivated, though.

      1. But only the modern left and not the historical liberal left. Of course in that sense the left has shifted on pretty much every issue. Just virtue signaling with no principle or responsibility.

    2. The “corporate greed” thing is definitely a factor, but remember that both the general concept of prohibition and this specific War on Drugs have enjoyed broad bipartisan support for decades. People like Joe Biden and Bill Clinton are on the hook for it the same way Reagan and Bush are.

  2. When I was prescribed opioid painkillers for a recent surgery, I didn’t use all of them but that isn’t because the doctor “overprescribed” them. It was just difficult to predict exactly what my medication needs were going to be.

    As it happened, my recovery went better than expected. But I don’t imagine that scenario would appear in a simplistic view of the data.

    1. I had two surgeries in 2 years on both arms. The first one, I used all the painkillers given me, and went for the refill before I figured out I was lethargic, couldn’t poop, and shouldn’t drive. I just wanted to sleep thru my recovery.

      The next one I was off them by Day 3. The extra pills do come in handy every six months when I get a severe migraine

      1. Lucky you.

        The last time I went in for surgery they undermedicated me and I spent the first night writhing in pain. The anesthesiologist explained that he normally would have put me on a morphine drip, but because of the crackdown on pain medications and “pill mills”, he had to change his prescription habits or risk losing his license and being prosecuted by the feds.

        My son was told that they don’t prescribe opiates for a broken arm any more, and sent home to take ibuprofen and acetaminophen. They said he’d have to tough it out for about 3 or 4 days, and then the pain would be manageable. Yeah, they literally said that to an 11 year old boy.

        We’ve lost our minds on this one.

  3. OK,

    Now do the one about the simplistic assumptions that tariffs are always bad.
    Even when employed against a Marxist kleptostate that uses our notion of “free trade” against us to steal all IP, and has spent 30 years mounting an all out espionage effort by co-opting hundreds of thousands of ethnic Han with family back home into stealing any and all industrial, technological, and military research using forcible extortion, and is openly threatening both our tech infrastrucure and us and our allies in the Pacific militarily.

    1. Let China impose all the tariffs it wants. Instead of retaliating, encourage investment to become independent of China. As it is, the United States practices many of the tyrannical policies you describe. Also, tariffs always cause inefficiency and there is lots of evidence to suggest that they do not achieve their supposed purpose of pressuring foreign governments.

      1. No, the US uses none of the tyrannical policies I described. Neither does just about anyone else, for that matter.

        Cite?

        1. Corruption? Deep state/MIC? Foreign intervention? Strong-arm market intervention? Not to mention that they steal the most wealth from their citizens in the history of the state. So who is good and who is bad?

          1. Your word salad had nothing to do with my post. As I suspected

            1. And your moral nationalism is going to erode our freedom

    2. None of that has anything to do with this topic.

  4. I have never known an addict to be particularly picky about what they took. Opiates, cocaine, vicodin, pot, alcohol, whatever is around. They might have preferences, but needs must.
    Those I have known well were in a death spiral. They started taking drugs either from a sense of personal inadequacy or from a lack of ability to overcome boredom. Whatever the reason, drugs made the problem worse, so more drugs allowed them to ignore the mess they created for themselves. Few were interested in looking closely enough at themselves to even consider quitting – so it is a form of slow suicide.

  5. The causes of opioid-related deaths may be more complicated than “too many pain pills”, but you want to keep it simple for the jury when they’re determining the size of the damages.

    1. Yeah, this may have begun as a crusade to help prevent addicts or even to punish doctors who were enabling them – but it has unquestionably become a cash grab in this latest iteration. The states want a Tobacco style settlement regime and they haven’t been shy about saying so.

  6. As true of most Sullum articles, thi one is misleading to the point of being garbage.

    The point is Not that people are overdosing on the prescription drugs, it is that they are overdosing on street drugs once the prescriptions run out or become too expensive.

    It is equally ridiculous to take a look at the numbers and say “prescription opioids are not a problem” as it is to crack down on doctors treating patients with real chronic pain after debilitating accidents.

    As with a lot of things, ideology seems to be blindly forcing people into one of 2 unreasonable camps – drugs bad, or drugs not a problem.

    The reality is opioids were most certainly overprescribed, both by pill mill doctors in small town KY/WV/OH, and by the US Government’s own VA who didn’t want to properly treat veterans. That doesn’t mean that people with terrible back injuries shouldn’t get them and stay on them.

    1. Did you read it at all? He said pretty much everything you are accusing him of leaving out. And I don’t see him claiming that drugs aren’t a problem. Just that people are misidentifying the actual problem and blaming it all on prescription stuff.
      Here:

      That ham-handed approach also has driven nonmedical users toward black-market substitutes that are much more dangerous because their potency is inconsistent and unpredictable, which helps explain why the increase in opioid-related deaths accelerated in recent years even as the government succeeded in driving down opioid prescriptions.

      The point is not that pain pill prescriptions have nothing to do with deaths involving pain pills. But other factors are clearly at work.

      1. “The Washington Post ‘s Simplistic Assumption That More Opioid Prescriptions Mean More Drug Overdoses Is Demonstrably Wrong”

        That is FALSE. Of those overdosing on street drugs, many became addicts when first prescribed pain pills unnecessarily, or given too many refills, or they bought someone else’s unused prescription pills. And then the Rx ran out or became too expensive, and they switched to street drugs.

        So, overprescribing DOES lead to more overdoses. Demonstrably true. That does not mean there aren’t plenty of legitimate pain patients who need a steady supply or prescription pills.

        This isn’t hard to understand. The headline was a lie. This is more complicated than “drugs OK / drugs bad”

  7. “The reality is opioids were most certainly overprescribed…by the US Government’s own VA who didn’t want to properly treat veterans.”

    Really? The VA won’t even give me muscle relaxants because they say they’re addictive. I guess I”m just a victim of the anti-drug hysteria. Thank you Washington Post for saving me from pain relief.

  8. WaPo doesnt’ get it.
    Legalize all drugs, including opiates, and let the person taking this shit if they want to get off of it.
    Wouldn’t it be great if the ruling elitist turds in government would treat us like adults instead of a bunch of three year olds for a change?

    1. This is the problem with doctrinaire anarchoLibertarianism. An Ideology too often completely divorced from real world consequences.

      You don’t, and cant, just get off opiates “if you want to”. They are physically addicting. It is a grueling process to get unhooked, and often results in death upon relapse, as tolerance has relowered. Opiates should not be available for recreational use, like marijuana.

      There has to be a line drawn somewhere, if not at or around opiates, then certainly this side of methamphetamine, which permanently alters brain chemistry. These drugs actually do negatively impact more than the user, there are social costs.

      Cocaine, ecstasy, pot legalization is not the same as heroin, fentanyl, meth. Even staunch Libertarians recognize this, they all advocate for pot legalization, but curiously not many are caught singing the praises of meth in public.

      1. You don’t, and cant, just get off opiates “if you want to”. They are physically addicting. It is a grueling process to get unhooked, and often results in death upon relapse, as tolerance has relowered. Opiates should not be available for recreational use, like marijuana.

        What’s your feeling about alcohol? Alcohol is physically addicting, and is no easier to kick than opiates. It’s far more physically damaging than opiates, and has absolutely no medical application. It’s demonstrably way more socially destructive than opiates, or literally anything else, for that matter.

        Shouldn’t alcohol be outlawed immediately by your logic?

        curiously not many are caught singing the praises of meth in public

        Not singing the praises of something =/= thinking it should be illegal. I don’t have a single good thing to say about meth. I’ve known many who have gone through their phases with it, and it has always struck me as uniformly terrible and without merit. I still think people should be free to do it, because outlawing people’s favorite highs just drives them to worse highs.

      2. You don’t need to sing the praises for any drug to realize that drug prohibition is both pathetically ineffective at addressing the stated problem, and an unethical intrusion by the state into personal decisions among consenting adults.

    2. Better yet – remove the prohibition on “getting high” as a legal benefit of taking substances.

      Pharmaceutical companies have put a lot of work into figuring out how to create pain killers that do not come with “euphoric” side effects. So they probably have a few ideas about how to get the euphoric effects without other side effects.

      If you could sell coca tea for a cocaine pick-me-up in the morning (like they do in south america) and some short-acting intoxicant that doesn’t result in dependence (like opiods do), you’d have a nice little business. And we’d have a safer environment where maybe people don’t decide to use heroin or fentanyl from the black market because they can get a decent form of recreational drug from Walgreens.

  9. The implication is that there’s a less ham-handed approach possible that would both diminish improper and increase proper use of the drugs in question. If so, what is it?

    I’m mostly asking that question vainly, but I’d also like to ask it seriously in case somebody has ideas. It’s clear that in the foreseeable future, no country is going to adopt a laissez-faire approach to narcotics, so barring a technologic fix (strong analgesics that far fewer people would be interested in using non-medically), what can be done policy-wise that won’t either increase misuse or decrease proper use, while at least either diminishing misuse or increasing proper use? Are there good incentives that could be brought into play? Better criteria for distinguishing needs?

    1. Safe injection sites and over-the-counter sales of overdose reversal drugs would be good ways to reduce harm without restricting legitimate use at all.

    2. Every prescribing doctor needs an RN to educate patients about weaning off prescriptions. Like the nurses who teach how to inject insulin. Those with severe chronic pain can be managed by teaching about maintenance doses. The father of US surgery, Dr William Halsted, was a morphine and cocaine addict. He was a rare functional addict who was the first to teach surgeons the necessity of washing hands between patients. He also invented the clamps that tie off blood vessels during surgery.

  10. A more correct headline would be:
    ‘The Washington Post is simplistic and misleading’

  11. Haven’t ODs been increasing since they started to crack down on prescriptions? Or is that just what the news wants me to think?

    1. No, OD’s were up and cracking down on prescriptions was the response. It probably made the problem worse though by pushing people into fentanyl, but I don’t believe there’s a 1:1 correlation with that.

      1. Check out the first graph here: https://www.drugabuse.gov/opioid-summaries-by-state/new-hampshire-opioid-summary
        That’s for NH, because that’s what I hear most about (and it’s supposedly worse here than many places). There was a big uptick around 2014, which I believe is when they really started cracking down on prescriptions in NH. The death rates from prescription opioids actually go down while there is a big spike in synthetic opioids (e.g. fentanyl). That suggests to me that, at least in NH, the crackdown on pills made being a junky a lot more dangerous, but no less common.

  12. The Washington Post isn’t a person. It didn’t make an assumption about opioid prescriptions. /hit & run pedant

  13. When opium and poppy products were legal, the US was a leader in the Industrial Revolution. Did drug wars and stronger concentrates lead to daily death and addiction levels of the past few years? Did ignorance about weaning off prescription narcotics or maintaining minimal functional levels add to misery?

  14. While in general I agree with your analysis and comments, the fact is that the overall predicament is captured in one word: overtreatment. Getting past the political dynamic playing out with opioids, the market drive of the manufacturers, distributors, pharmacies and physicians is to prescribe a pill: and the more pills the better. This kind of overtreatment occurs in many other therapeutic areas. Examples? Antibiotics are now becoming progressively useless owing to explosive use. Resistance is widespread. A hospital acquired infection can in many instances be a death sentence.
    The dynamic for prescribing comes from guidelines that are developed by physician organizations in conjunction with pharma companies. A useful example of how the guidelines work is the upgraded definition of hypertension. Previously that definition was set as a systolic pressure of greater than 140 and a diastolic pressure of greater than 90. The new definition is 130 and 80 respectively. An article in Medscape indicated that over half of all of the people in the world are now officially hypertensive with the new standard. Guess what. With that blood pressure no one would even notice and the risk of a near term medical event is clost to zero. But the perceived future risk is measurable and so mitigating that risk drives treatment, trips to the doc and pharmacy etc. And does anyone wonder why medical spending is out of control?
    Now certainly, any individual patient in consultation with their physician can decline treatment. But how many will? From the medical marketing viewpoint the answer is that they could care less about any individual, they just need enough of a patient population in aggregate to drive sales. And they will get that since if taking a pill makes them feel they are mitigating some perceived future risk, most people will. And the profits roll in.
    No one will write newspaper articles about the malign actors in the medical marketing complex since few will overtly die from taking blood pressure medication. No one will lobby to reduce the supply of blood pressure medications in the system. But the process and outcome is exactly the same: market driven overtreatment. And we all end up paying.

  15. Opioids are a problem because it it’s the Deplorables in flyover states who use them, and they’re the ones who should be punished. Pot and coke (except for the crack that blacks use) are drugs of the Progressives, and so should be legalized.

  16. […] to the conventional narrative of the “opioid crisis,” it is clear from U.S. data that there is no straightforward relationship between narcotic analgesic prescription rates and […]

  17. […] to the conventional narrative of the “opioid crisis,” it is clear from U.S. data that there is no straightforward relationship between narcotic analgesic prescription rates and […]

Please to post comments

Comments are closed.