Opioids

A New Study Finds No Relationship Between Opioid Prescriptions and Unintentional Injury Deaths

The data do not support the conventional wisdom that pain pill prescriptions are driving drug-related fatalities.

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It has long been clear that the conventional understanding of the "opioid crisis," which focuses on patients who inadvertently become addicted to pain medication, is highly misleading. A new study reinforces that point.

The study, reported in the journal Injury, looked at the relationship between pain pill prescriptions and fatal injuries, including unintentional deaths, suicides, and homicides, in all 50 states and the District of Columbia from 2006 through 2017.* It found that shipments of prescription opioids "did not show a consistent or statistically significant relationship with injury-related mortality, including with any subgroups of unintentional deaths, suicides, and homicides."

The authors say "this is the first study to combine national mortality and opioid data to investigate the relationship between legally obtained opioids and injury-related mortality." They hypothesized that "legally obtained prescription opioid consumption would be positively associated with injury-related deaths" in the United States. Yet "in every state examined, there was no consistent relationship between the amount of prescription opioids delivered and total injury-related mortality or any subgroups, suggesting that there is not a direct association between prescription opioids and injury-related mortality."

That is a pretty remarkable finding when juxtaposed with the common assumption that excessive prescribing is driving opioid-related deaths—in this case, deaths from traumatic injuries caused by hazards such as car crashes, falls, drowning, fires, machinery mishaps, and suffocation.* Nor does there seem to be a consistent relationship between opioid prescription rates and overdose deaths. Data from the Centers for Disease Control and Prevention show that states with high prescribing rates do not necessarily have high rates of fatal opioid overdoses, even when the analysis is limited to deaths involving pain pills.

The focus on pain pills has driven ham-handed efforts to reduce opioid prescriptions, including legal restrictions and official guidance that discourages medical use of these drugs. Those efforts have succeeded in driving down prescriptions but not in reversing the upward trend in opioid-related deaths, which has not only continued but accelerated. Meanwhile, bona fide pain patients have been deprived of the medication they need to control acute or chronic pain.

Phoenix surgeon Jeffrey A. Singer, a Cato Institute senior fellow (and a donor to Reason Foundation, which publishes Reason), hopes the Injury study will encourage physicians to reconsider indiscriminate reductions in the medical use of opioids. "Writing last month in General Surgery News, Josh Bloom and I criticized the recrudescent opiophobia sweeping the medical profession, fueled by the prevailing—and wrong—narrative," Singer writes. "Surgeons have been encouraged to use intravenous acetaminophen (Tylenol) to treat postoperative pain, rather than risk 'hooking' their patients on opioids. We cited research that shows intravenous acetaminophen is ineffective for controlling postoperative pain. This latest study will hopefully further convince surgeons to shake off their opiophobia."

The other perverse effect of the crackdown on pain pills is that it has driven nonmedical users toward black-market substitutes, which are far more dangerous because their potency is highly variable and unpredictable. A 2017 study reported in the journal Addictive Behaviors, for example, found that the share of people entering addiction treatment who said heroin was the first opioid they tried rose nearly fourfold between 2005 and 2015.

"Our data document that, as the most commonly prescribed opioids— hydrocodone and oxycodone—became less accessible due to supply-side interventions, the use of heroin as an initiating opioid has grown at an alarming rate," the researchers reported. "Given that opioid novices have limited tolerance to opioids, a slight imprecision in dosing inherent in heroin use is likely to be an important factor contributing to the growth in heroin-related overdose fatalities in recent years."

That problem has only been magnified in recent years as illegally produced fentanyl, which is much more potent than heroin, has become increasingly common as a heroin booster or substitute, which has increased the variation in the strength of black-market opioids. The category of opioids that includes fentanyl and its analogs accounted for 73 percent of opioid-related deaths in 2019, up from 14 percent in 2010. "Natural and semisynthetic opioids," which include commonly prescribed analgesics such as hydrocodone and oxycodone, were noted in connection with less than a quarter of opioid-related deaths, and many of those cases also involved heroin or fentanyl. The number of opioid-related deaths in 2019 was higher than ever before, and preliminary data suggest the record was broken once again in 2020.

*CORRECTION: This post originally reported that the fatal injuries examined by the study included overdose deaths, which is consistent with how the CDC defines "unintentional injury" (i.e., to include deaths from poisoning). The study was actually limited to "mortality after traumatic injury" caused by hazards such as car crashes, falls, drowning, fires, machinery mishaps, and suffocation. The post has been corrected accordingly.

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  1. See everyone? Big Pharma good. They would not harm millions of people for profits. They only have your best interests in mind.

    1. Try to go without pain medication after major surgery. I dare you.

      1. Actually you can go without them it depends on the person.

        1. I tried to once after a minor surgery. It went very badly.

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        2. No, it depends on the surgery.

          1. definitely. had major wisdom teeth surgery and a major wrist surgery. needed any and every pain pill i could get both times.

            also had a minor wrist surgery, didn’t need anything for that one (they still prescribed some though)

      2. I have a dozen surgeries under my belt, I fully understand recovery. However, in the 90s and 2000s, military personnel were being given massive amounts of opiates before and after surgery. Big Pharma had the military doctors believing that it was safe. We were given quart sized bottle of pain meds. They did not start to reign it in until people were OD’ing and killing themselves by mixing them with alcohol.

        1. BS. Any self-abuse is on the patient. Stop looking for being a ‘victim’. Employ self-control. Understand that when the meds are not needed the MEDS ARE NOT NEEDED. You go on after they are NOT NEEDED and its then ON YOU.

        2. Why were patients ODing? Why were they mixing them alcohol? Didn’t the medications come with warnings against those things? Not sure how you can blame “Big Pharma” when the patients were directly defying the directions for safe use.

          1. On the prescription it states the use of alcohol will intensify the effects. I thought that meant drinking a few beers with it would make it work better.

            1. That’s why most die, combination with alcohol. That has been the recipe for many decades. What is amazing is ALL incurable severe pain patients have been cut of. Ten-Million of us…
              True addiction is very rare and is dicovered to be genetic.
              See everything at Youtube by Dr. Thomas Kline…

          2. These are ILLICIT users. Legitimate severe pain patients used their medicine to stay alive…
            Now Ten-Million of us are cut-off. And we are getting nowhere with out Reps. 20 a day suicide. We have used the medicines for decades without increasing dosages or overdosing. Ten-Million. 1/36th of the population.

      3. I got Percocet or oxy after all of my L&Ds alongside ibuprofen. The most I ever needed was the ibuprofen. And barely that.

        But I get occasional back pain if I fail to stretch out after a long day on my feet. So a Percocet helps me stretch it out.

        I think there are Willy nilly Scripts written and I think poor pain management on the individuals’ part on top of easy accessibility would play a role in abuse.

        But how would a study of prescription drug use tell us anything about illicit drug use?

        1. It doesn’t but the narrative is that people are ODing on prescription meds and it’s the fault of over prescription.

          1. I thought the narrative was that people were getting addicted to their prescriptions, which leads to illicit drugs when they can no longer get their prescription refilled because the “opioid epidemic” has made doctors less likely to prescribe or refill.

          2. Wrong. Street, multi-drug and alcohol are where the ODs come from…
            These are ILLICIT users. Legitimate severe pain patients used their medicine to stay alive…
            Now Ten-Million of us are cut-off. And we are getting nowhere with out Reps. 20 a day suicide. We have used the medicines for decades without increasing dosages or overdosing. Ten-Million. 1/36th of the population.

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    4. These are ILLICIT users. Legitimate severe pain patients used their medicine to stay alive…
      Now Ten-Million of us are cut-off. And we are getting nowhere with out Reps. 20 a day suicide. We have used the medicines for decades without increasing dosages or overdosing. …Ten-Million. 1/36th of the population.

  2. It’s clear though that drugs are easy to get and easy to get hooked and OD. It would be better to have legal dispensarys rather than the Chinese crap people are now taking. And it’s clear who benefits from the current arrangement (cops, courts, feds, and of course the assholes overseas who want us drug addled and useless)

  3. The data do not support the conventional wisdom that pain pill prescriptions are driving drug-related fatalities.

    “Everything you know is wrong!”

    1. Exactly…

    2. Doesn’t matter – CHOICE is the underlying massive factor.
      Take responsibility for your own life instead of everyone else’s.

      1. What?! And just LET people choose?

      2. That freedom to do good has been taken away. The misery is indesribable. Many legitimate severe pain sufferers suffer far more than I and I am half dead. Cut off since 2017 for full spine canal and foraminal stenosis.

  4. recrudescent opiophobia

    I’d like to offer my most enthusiastic contrafibularities on this article.

    1. That was a crapulescent indignifibrilulation! You take that back!

  5. But what about the nobility of suffering?

    1. There is no “nobility” in needless suffering.

  6. Legalize it!

    1. Ending Drug War – seems counter-intuitive but actually a legal safe supply will greatly reduce illicit street fentanyl deaths from overdose.

  7. This is such a misleading load of crap. The intro of the study even states there are 130 opioid related deaths per day. This study takes some narrowly defined cause of death called “injury related death” and “surprisingly” find no link between the two. It would be like being surprised that opioid use didn’t increase the rate of deaths by hiccups. The comments by the surgeon are also garbage.

    In my practice, I have many patients addicted to opioids because they had post operative pain. Instead of managing the pain themselves, the surgeons kick them to the curb and say “follow up with your pcp for more opioids.” Thanks a million for that. One of my patients recently almost died because a surgeon have her a bunch of dilaudid on top of what I was taking already (and what I was trying to taper). So by the criteria of this study, that patient wouldn’t have counted as an injury related death.

    When it comes to prescription opioids, the practices during the epidemic were about as close as we got to legal opioids and it costs hundreds of thousands their lives. I’m all for legalization of drugs that don’t kill, but this one does.

    -angry internist that’s sick of opioid addicted people screaming at him

    1. You’re a PCP who still prescribes opiates?! Wow. Many states and hospital systems in those states decided that the CDC’s chronic pain guideline FOR PCPs meant that only pain management doctors and surgeons could prescribe opiates…never mind that PCPs tend to know their patients better. The overprescribing ended in most places by 2010…. Regardless the rise in illicit drug use since the crackdown on prescription pain killers has only created more deaths …it was safer for addicts before the crackdown. Pain patients have just given up. We don’t yell or scream at our doctors. We accept what we are given and spend more time in bed or on the couch. But yes the current system is so much better.

    2. Is it not a problem that patients are now denied effective opioid prescriptions and instead made to rely on ineffective medications like Tylenol? What is your solution?

    3. The reason opiates are cartelized is precisely the duress of addiction making addicts insensitive to price hikes. Americans participated in doping China and three wars resulted. TR and Taft’s efforts at opium reduction were the primary cause of WWI. That war delayed the price fixing and market sharing until the Treaty of Versailles was fastened to German ankles. Big Pharma evidently backed National Socialism, so the pattern of widespread addiction funding venal States looks more like causality with every iteration. Decriminalizing all non-opiates and returning the competition and alternatives that existed before the violence of law became panacea could hardly be worse than war after war.

  8. Most overdoses are intentional suicide attempts, and are a combination of drugs – everything they have in the house including alcohol. And they are often the result of the threat by the doctor to taper them. Thus, relaxing opiate prescribing will save lives. It’s actually pretty hard to overdose on opiates alone (fentanyl being an exception). And opiate pills are far less damaging to health compared to legal drugs like alcohol and smoking, even in the long term.

    Most addicts start by borrowing/stealing drugs (not from their own legitimate doctor’s prescription). In other words, they steal drugs that causes a ‘disease’ that makes them steal drugs. Hmmm.

    Don’t believe me? Go to your local AA/NA meeting and hear for yourself.

  9. But of course; Even if there isn’t a crisis politicians will INVENT one.
    Perhaps not a serious issue at the community level but Federal Nazism (def; National Socialism) is no excuse for INVENTED crisis.

    With the historical stain of humanity with Nazism; there really isn’t any excuse AT-ALL!

  10. There are people with chronic conditions who benefit from opioid pain medication. The perverse incentives of poverty mean that sometimes one of those people chooses to have only one pill a day instead of three, and in a given month they sell the rest to their dealer buddy, who then distributes them. Trade off between cash and pain and many people are somewhat used to that.
    Not sure how many people OD on their own prescriptions. “Overprescribing” could include the patient above, who was getting say 90 a month of something where they could get by on 30 or 45.

  11. Good article Sullum.

  12. Good reporting, but the people who drew up Herbert Hoover’s 1931 drug limitation convention all agreed with the German delegation that codeine and dionine are “not themselves habit-forming.” Yet all declared cocaine “capable of producing addiction.” Both statements of settled science are lies. The British delegates to several of these conferences blandly asserted that opium was not addictive if eaten–only if smoked. These are only 3 of thousands of lies and errors that lead folks to doubt Big Pharma and its bought expert witnesses.

  13. Millions of Americans living with debilitating painful chronic conditions, MANY of whom have lost treatment because of opioidphobia, already knew this. My wife had hEDS and had some modicum of quality of life while on prescription pain meds. Then her doctor, more scared for his own medical license than the well being of his patient, cut her off without warning, yelled at her, and left her to fend for herself. It was 2 years before we could find another doctor who was willing to treat her and prescribe her medication. But in that 2 years that she went without meds and was in too much pain to get out of bed, her body atrophied horribly and she is a miserable husk. Thankfully with treatment again, she no longer wants to die, but with the damage done, it will take years to recover any quality of life she used to have.
    And this is the kind of thing you will read dozens of stories about every day on pain patient forums. Literally millions of Americans being discriminated against due to the crime of having a disease that causes unending pain. Even with there being effective medication to treat many of those conditions, they’re still denied by so many doctors. It’s a tragedy that should never have happened.

  14. I honestly have to wonder why the puff piece protecting the Sach family….does old JS have some financial interest? Relatives, friends, classmates from Harvard? Neighbors from NYC? Sorry but you just have to ask…this is a bit of a weird subject given all the other attacks on our liberty Biden and the wokes are doing…why Jake..why?

  15. May I draw your attention to the holocaust imposed on our fellow citizens and America’s greatest medical tragedy; The ten-million incurable severe pain sufferers abandoned for “opioid crisis” which is entirely the ‘street’, illicit use, multi-drug overdose issue.
    True addiction is very rare and is GENETIC. 996 0f 1000 will NEVER ADDICT.
    America’s sickest folks simply can not be the unintended consequences of the response to a completely separate issue of smuggled, illicit, dose inconstant fentanyl and its analogs such as carfentanyl, the horse tranquilizer.
    We know legitimate, incurable severe pain sufferers on a medical doctor’s regiment including opiates encounter OUD or overdose at %0.6 (zero point six).
    Some of the best information available in support of our message is found at Youtube under Dr. Thomas Kline MD PhD.
    Best Regards,

  16. That freedom to do good has been taken away. The misery is indescribable. Many legitimate severe pain sufferers suffer far more than I and I am half dead. Cut off since 2017 for full spine canal and foraminal stenosis.

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