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.