How Drug Reformers Have Failed the Opioid Crisis
The opioid crisis, the worst drug epidemic in US history, has taken a long time to register its weight in the national conversation, mainly because media outlets anchored on the coasts did not spend much time or many resources on the places worst affected by it.
All that changed when drug overdoses, driven by both legal and illegal opioids, became the country’s leading cause of accidental death. Suddenly Sam Quinones’ groundbreaking book Dreamland, which traced the fatal convergence between government approval of Purdue Pharma’s painkiller Oxycontin for a new market — chronic pain treatment — and the proliferation of potent Mexican black tar heroin, had devastating reach. In the course of the past year, his work has been supplemented by news reports, like the one from Charleston Gazette-Mail last December, that revealed drug manufacturers shipped over 9 million opioid painkillers to just one pharmacy in rural Mingo County, West Virginia. Mingo now has the fourth highest prescription opioid death rate in the United States.
Especially in areas ravaged by overdoses, medical professionals and public health officials cope with harsh realities — among them, that legal opioid painkillers have been overprescribed. To date, the Center for Disease Control (CDC) has made the strongest move to cut back opioid overuse by issuing voluntary guidelines for prescribing them. To curtail “doctor shopping,” eighteen states either require or encourage doctors to check a database that tracks opioid prescriptions by patient. Massachusetts, New York, Connecticut, Maine, and Rhode Island limit first-time opioid prescriptions as a matter of law, a move that upsets medical professionals dedicated to preserving physician autonomy.
Opioid pain relievers are a big business: the 2015 National Survey on Drug Use and Health reported that 97.5 million people (36.4 percent of all Americans over the age of 12) used a narcotic painkiller over the course of the previous year. Not surprisingly, from 2006 to 2015, Pharma spent $880 million to fight legislation designed to curb their use. Neither Purdue nor its competitors have jettisoned their commitment to promote opioids as an appropriate treatment for long-term chronic pain, in spite of the fact that Quinones and reporters at the LA Times revealed that the government’s approval to extend opioid use to that group was based on faulty data.
And Pharma has had plenty of help in resisting tighter regulation. A number of non-profit groups dedicated to “pain treatment” present an ostensibly independent source of opposition to regulations, but, as a recent article in JAMA Internal Medicine demonstrated, most organizations that oppose more stringent prescribing have financial ties to Pharma (and usually fail to disclose them).
While distressing, this is hardly surprising. We expect all this and worse from a business sector that continues to expose Americans to grievous harm for the sake of its own profits.
Recently, however, the effort to pushback against restricted prescribing has acquired a new and striking dimension: prominent members of the drug war reform community. Authors known for their work in this area have published op-eds that criticize restrictions on the supply of opioids for first-time users, and bureaucratic thresholds that must be met in order to prescribe for chronic pain.
I don’t know what motivates these particular interventions. What I do know is that they are hampered by the same kind of data selectivity and misrepresentations typical of other defenders of Big Pharma.
Johann Hari’s recent op-ed in the LA Times is a good example. After characterizing the well-documented coincidence of opioid prescribing for chronic pain and overdoses as too “coherent” a story, Hari ventures to provide a more complex one, claiming several key facts don’t fit this simple narrative. In his initial version of the piece, Hari pointed to a 2006 Canadian meta-analysis that he claimed found very low rates of addiction among those who used opioids to treat pain. My friend Michael Yost, an economics Ph.D. candidate, searched the internet for this surprising contribution to literature, but found only Hari’s book, Chasing the Scream, quoting a patently false summary of a 2006 Canadian meta-analyses that reached a very different conclusion. “Addiction or opioid abuse in patients with chronic pain cannot be assumed not to exist (despite popular statements),” the authors found, “because the existing randomized trials are not designed to evaluate it; the duration of the trials was too short to allow for the development or detection of aberrant drug use, even if appropriate screening tools for addiction had been used. An adequate measure of ‘diagnosis of addiction’ is also lacking in every study.” This meta-analyses also revealed that “90% [of the studies reviewed] were either funded by or had one or more coauthors affiliated with the pharmaceuticals industry.”
That’s a lot of coherence.
The LA Times compelled retraction from Hari on the Canadian review, but his remaining “facts” are not much better. He cites the 2012 National Survey of Drug Use and Health (NSDUH) to declare “only 1 in 130 prescriptions for an opiate such as Oxycontin or Percocet in the United States results in addiction,” but the link he offers goes to a recent piece in Reason magazine, which supplies that particular (NSDUH) statistic for “dependence or abuse,” not addiction.
When an older statistic is named, even though newer ones are available, skepticism is warranted, and in this case, justified. The government agency that runs NSDUH was so unsatisfied with how it measured misuse of prescription drugs that in 2015, they redesigned the entire component. In its revamped form, the 2015 survey found that 12.8% of opioid users “misused” the drug in some fashion over the course of the year, and an additional two million (1%) qualified as having a pain reliever use disorder — a specific diagnosis drawn from DSM V.
Most important, no version of the National Survey, either before 2015 or since, endeavors to measure whether opioid use as directed by a medical professional can lead to dependence or a level of opioid use disorder that falls short of the most serious kind. These more subtle gradations that develop while following medical instructions are what people in the field call “iatrogenic addiction.” Hari is citing an impressively small rate of addiction from a survey that, by design, precludes examination of one of its major components.
Other studies do look at iatrogenic addiction, like the Washington Post/Kaiser Family Foundation survey released in 2016, which found one third of chronic pain opioid-users reported either addiction or dependence — although when the question was put to people living with these respondents, more than half said they “suspected addiction.” Another study conducted of 705 chronic pain patients using opioid pain relievers found 28% had mild symptoms of an opioid-use disorder, 9.7% moderate, and 3.5% severe.
At this point, these results should be regarded as provisional. All of them suffer by comparison because of discrepancies in how to define addiction and dependence, or how to weight self-reporting versus independent diagnosis. Experts have yet to supply a robust range for iatrogenic addiction.
But one should at least look to data that tries to measure it. The dangers inherent in iatrogenic addiction, or broad exposure to opioid medication generally, could not be more real. One paper published in the American Journal of Emergency Medicine matched prescription painkiller overdoses from San Diego country to California drug monitoring data and found that 73% had an entry — a legally filled prescription — within the past year. Other similar studies have found even higher percentages.
Rather than confront these coherent but unsettling facts, well-known authors like Maia Szalavitz draw unsound conclusions from cherry-picked data. In her “Myths about Heroin” piece for the Washington Post, Szalavitz uses the NSDUH survey from 2014 to declare that the majority of prescription drug misusers (75%) were not pain patients, since they reported obtaining their drugs from “friends and family.” (Nothing in the survey rules out these users having a prescription of their own.) After the survey was recalibrated in 2015, the ratio of “misused” painkillers obtained from friends and family fell to 53.7 percent.
Yet even this reduced percentage is far too high: no pain patient should have opioids to spare. The statistics Szalavitz and Hari rely upon are themselves indicative of overprescribing, and the scenario that explains most of these exchanges — extra pain pills on hand from a thirty-day supply for recovery from a surgical procedure — is most effectively dealt with by passing the very state laws they oppose, which carve out exceptions for chronic pain prescribing as well as for opioid maintenance and therapy.
The Real Story in the Data
Opioid pain relievers have not just been overused, their effectiveness has been underwhelming. Hari and Szalavitz point to the many opioid users who report neither addiction nor dependence, as though this were, by itself, vindication of these drugs. In fact, the Post/Kaiser Foundation poll found that two-thirds of opioid users said prescription painkillers made their pain tolerable. Opioids work for a majority, Hari and Szalavitz conclude, even if they may be disastrously bad for some (in their telling) exceedingly small number of patients.
Not only is this a cavalier notion of risk management for public health, it is also, in itself, a misrepresentation of data. The only thing that remains totally unproven in the literature is the effectiveness of opioids in managing long-term chronic pain. Where Hari and Szalavitz see success, there is only absence of evidence.
A 2015 literature review conducted for a workshop of the National Institutes of Health designed to evaluate both the harm and the effectiveness of long-term opioid use for chronic pain found: “No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction.” The authors concluded that the “evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function,” but, as for harm, the “evidence supports a dose-dependent risk for serious harms.”
What Post/Kaiser Foundation respondents declared “tolerable,” more and more medical professionals are coming to view as poor pain management, or, to use the words of one paper, a “pharmaceuticalization” of pain treatment that rewards the preference of insurance companies for cookie-cutter drug reimbursements over the kind of multi-disciplinary and customized care many physicians recommend. The National Institutes of Health workshop reported evidence that “40% to 70% of persons with chronic pain do not receive proper medical treatment, with concerns for both overtreatment and under-treatment.” Right now, in the field of chronic pain, there is chronic medical failure.
In this way, dispensing opioids indiscriminately abets the worst tendencies in American medicine. For this reason alone, but especially in light of opioids’ risks, it is bizarre to suggest, as Johann Hari does, that “blunt restriction of prescription drugs will actually increase deaths, just as the war on illegal drugs has.” This bravado assertion has no obvious bearing on laws designed to restrict acute care (usually recovery from surgery) opioid use from thirty days to seven.
Instead, there is ample room to crusade against the war on drugs without jeopardizing opioid crisis primary prevention (minimizing new cases of addiction or dependence, including via mandatory prescribing limits); secondary prevention (screening for addiction and dependence); and tertiary prevention (including tapering and maintenance, and harm reduction like safe injection sites). I am a drug reformer, and I regard all three as necessary and interdependent.
Without question, there is much more to this drug crisis, including its current escalation, driven by illicitly produced synthetics from China. As outgoing CDC director Dr. Thomas Frieden recently said, “it’s not all doctors’ fault.” Nevertheless, he stood by the CDC’s guidelines, and told his interviewer that, “for chronic pain, other modalities of treatment are much safer and can be at least as effective, and may even be more effective.”
There is no false allure to Frieden’s coherence; just a good faith reading of the available evidence.
