Shoving epidemic in Washington; quit it! say officials

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  1. Sign up for Morning Rounds
  2. The Addicts Next Door
  3. The Face of Heroin Addiction

They were basically saying that I'm a druggie when I have been fine for four years.

My first pill count ever, and they boot me. Without the OxyContin, Craig says, "every morning is a challenge to get out of bed. I can't expect to live a life like this. I'm not a junkie. I'm not a threat to society. I'm not a threat to myself. I simply want to live my life without pain. Like other patients across the country, Craig is a victim of the recent crackdown on prescription opioids, which is based on a narrative that mistakenly blames pain treatment for a plague of addiction and death.

Most Americans believe we are in the midst of an "opioid crisis" that began in the s with the introduction of OxyContin. According to the generally accepted account, deceptive marketing encouraged reckless prescribing, which led to widespread addiction among patients and record numbers of opioid-related fatalities—a situation President Donald Trump has declared a public health emergency.

Former New Jersey Gov. Chris Christie, who chaired the President's Commission on Combating Drug Addiction and the Opioid Crisis, invokes that narrative when he talks about "the injured student-athlete who becomes addicted after [his] first prescription" or remembers the law school classmate who died of an overdose after getting hooked on the oxycodone he was taking for back pain.

Such examples are misleading because they are rare, accounting for only a small percentage of opioid-related deaths. Contrary to the impression left by most press coverage of the issue, opioid-related deaths do not usually involve drug-naive patients who accidentally get hooked while being treated for pain. Instead, they usually involve people with histories of substance abuse and psychological problems who use multiple drugs, not just opioids. Conflating those two groups results in policies like the pill count that left Craig without the pain medication he needed to get out of bed in the morning, go to work, and lead a normal life.

The rationale is that cutting people like him off will stop them from ending up dead of an overdose in a Walmart parking lot next to a baggie of fentanyl-laced heroin. But the truth is that patients who take opioids for pain rarely become addicted. A study found that just 1 percent of people who took prescription pain medication following surgery showed signs of "opioid misuse," a broader category than addiction.

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Even when patients take opioids for chronic pain, only a small minority of them become addicted. The risk of fatal poisoning is even lower—on the order of two-hundredths of a percent annually, judging from a study. Despite such reassuring numbers, the government is responding to the "opioid epidemic" as if opioid addiction were a disease caused by exposure to opioids, a simplistic view that ignores the personal, social, and economic factors that make these drugs attractive to some people. Treating pain medication as a disease vector, the government has restricted access to it by monitoring prescriptions, investigating doctors, and imposing new limits on how much can be prescribed, for how long, and under what circumstances.

That approach hurts pain patients by depriving them of the analgesics they need to make their lives livable, and it hurts nonmedical users by driving them into a black market where the drugs are deadlier. A large majority of opioid-related deaths now involve illicitly produced substances, primarily heroin and fentanyl.

As usual, the government's efforts to get between people and the drugs they want have not prevented drug use, but they have made it more dangerous. The reason it's become an epidemic is because opioids have been overprescribed by my colleagues, who were led to believe that we didn't have to worry about addiction. Kolodny, who is also co-director of opioid policy research at Brandeis University's Heller School for Social Policy and Management, says the American Pain Society and the American Academy of Pain Medicine AAPM started to "advocate for opioids" in the late s, taking the position that "the risk of addiction has been overblown, even that the risk of overdose death has been overblown, and that we should be prescribing much more for people with chronic pain.

This gloss is superficially plausible. According to the U. Centers for Disease Control and Prevention CDC , the amount of opioids prescribed in the United States more than quadrupled between and , rising from to morphine milligram equivalents MME per capita. During the same period, according to CDC data , the annual number of deaths involving the kinds of opioids prescribed for pain also roughly quadrupled, from about 4, to about 18, The relationship is not quite as straightforward as it might seem. Opioid prescriptions, measured by MME per capita, fell by nearly a fifth from to , while deaths involving these drugs continued to rise.

The CDC's numbers also indicate that deaths involving opioid pharmaceuticals are not always more common in states with higher prescription rates. In , for instance, West Virginia's death rate was more than twice as high as Tennessee's, although it had fewer opioid prescriptions per capita. Rhode Island, New Mexico, and Utah had higher death rates than Oklahoma, where opioids were prescribed substantially more often.

Still, the expansion of the legal market for opioids obviously had something to do with the increase in illegal use of these drugs. Many of the pills were diverted to nonmedical users, either after they were prescribed or through theft from points higher in the distribution chain. But greater availability of prescription opioids cannot by itself explain the rise in addiction and drug-related deaths. Part of the answer, he thinks, can be found in the same factors that helped elect Donald Trump. When Kolodny says "we got our patients addicted," he discounts the way unhappy circumstances, such as unemployment and dim economic prospects, make drug use more appealing.

He also implies that pain treatment has been the main route to opioid addiction during the last two decades. But that is not what the evidence indicates. Another 16 percent bought or stole pills from friends or relatives, while 4 percent bought them from strangers. About 6 percent mentioned other sources, including online purchases, forged prescriptions, and theft from doctors' offices or pharmacies.


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Just 20 percent of nonmedical users said they obtained opioids through prescriptions written for them. Although some people who now obtain opioids indirectly may have had prescriptions at some point, these results undercut the notion that nonmedical users typically start as bona fide patients.

Even among the heaviest users, just 27 percent had prescriptions at the time of the survey, and it is not clear how many of those were legitimate at the outset. In most cases, says Sidney Schnoll, a physician specializing in addiction and pain treatment who works for the consulting firm Pinney Associates, "These are people who were drug-seeking.

They are not people who went to a physician, got a prescription, and suddenly became addicted to the drug. Stefan Kertesz, a University of Alabama at Birmingham internist who, like Schnoll, specializes in pain and addiction, agrees that the prevalence of iatrogenic opioid addiction that is, addiction resulting from medical treatment has been exaggerated. The NSDUH data reinforce the impression that doctors frequently prescribe more pain pills than their patients end up needing.

People who take opioids after an injury or surgery might receive enough pills for two weeks but use only half of them. It seems likely that diverted opioids more often come from such short-term prescriptions than from medication prescribed for people suffering from severe chronic pain, who probably are not keen to share or sell the drugs that keep their agony at bay. The fact that people frequently have leftover opioids that they give away, sell, or leave in their medicine cabinets to be swiped suggests these drugs are not quite as irresistible as they are reputed to be.

Judging from their responses to survey questions, about 2 million of them—slightly more than 2 percent—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.

But based on this survey, it looks like somewhere between 1 percent and 2 percent of prescription opioid users experience addiction in a given year. By comparison, NSDUH data indicate that 9 percent of past-year drinkers had an alcohol use disorder in That group was about evenly divided between "abuse" and "dependence. Stanton Peele, a psychologist and addiction expert, observes that, contrary to conventional wisdom, "narcotics are not that appealing" to most people. In addition to the NSDUH data, he cites research finding that hospital patients who are allowed to self-administer pain medication tend to take less than those who get it on a fixed schedule.

The notion that opioid addiction is "an equal-opportunity destroyer," as politicians and drug treatment boosters like to say—or that "everyone is at risk and every family prey to loss," as Mitchell Rosenthal, founder of the Phoenix House treatment centers, told the Christie commission—is "absolutely false," Peele says. To the contrary, opioid addiction is strongly associated with unemployment, poverty, family dysfunction, and pre-existing psychological issues.

Well-adjusted people with supportive families, strong social ties, and good economic prospects are much less likely to seek refuge in opioids than people who lack those advantages. To put it another way, mere exposure to opioids does not produce addiction. A drug will become the focus of a tenacious habit only if it serves an important function in the user's life. I'd had a lot of trauma that I wasn't dealing with, and everything was piling up. The appeal of heroin was it turned everything off. It was like a vacation. Kolodny concedes that most people who use opioids do not develop an addiction.

It's repeated use that puts people at very high risk of becoming addicted.


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  4. But even in studies of patients who take pain medication repeatedly and regularly, sometimes for months or years, the addiction rates are generally modest. Thomas McLellan, a former deputy director of the Office of National Drug Control Policy, noted in a New England Journal of Medicine article, "Addiction occurs in only a small percentage of persons who are exposed to opioids—even among those with preexisting vulnerabilities.

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    A analysis in the Cochrane Database of Systematic Reviews found that less than 1 percent of patients taking opioids for chronic pain experienced addiction. A review in the journal Addiction likewise concluded that "opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence. A study reported in The BMJ this year tracked , opioid-naive patients who took prescription pain medication following surgery and found that 5,, or 1 percent, showed signs of "opioid misuse" during the course of the study, which included data from through Although some studies have described "rates of misuse, abuse, and addiction-related aberrant behaviors" as high as 26 percent among chronic pain patients, Volkow and McLellan reported, "rates of carefully diagnosed addiction" average less than 8 percent.

    Fatal overdoses among patients are even rarer. A study reported in the journal PLOS One followed chronic pain patients treated with narcotics for up to 13 years and found that one in died from an opioid-related overdose, which is a risk of less than 0. A study of opioid-related deaths in North Carolina, reported in Pain Medicine , found fatalities among 2. Kolodny cites a study of deaths involving prescription opioids in Utah, reported in the Journal of General Internal Medicine , to support his contention that iatrogenic addiction accounts for "the bulk of the overdose deaths.

    Other studies, however, indicate that prescribed drugs play a smaller role in opioid-related fatalities than that number suggests. In the North Carolina study, only half of the decedents had active prescriptions for opioids when they died.

    The Addicts Next Door

    A study of West Virginia deaths involving opioid analgesics, reported in the American Medical Association journal JAMA , found that most of the decedents had never been prescribed opioids. A study of opioid users in Maine, reported in Addictive Behaviors , found that two-fifths reported chronic pain, but more than three-quarters of those subjects said their opioid use preceded their symptoms.

    A study of people who were treated in emergency rooms for overdoses involving prescription opioids, reported in JAMA Internal Medicine , found that just 13 percent had a chronic pain diagnosis. Even when someone who dies from drug poisoning has an opioid prescription, it does not necessarily mean he was a bona fide patient. Patients can fool doctors, and some doctors are eager to be fooled. Such examples do not tell us much, if anything, about legitimate patients who become addicted while being treated for pain.

    Whatever share of people who die from drug poisoning began using opioids as legitimate patients, the share of patients taking opioids who die from drug poisoning is tiny—and the risk is not random. In the Utah study cited by Kolodny, 61 percent of the decedents 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. NSDUH data indicate that most nonmedical users of prescription opioids use other drugs as well, a fact that is reflected in mortality data.

    In the West Virginia study, 79 percent of the deaths involved combinations of drugs. In North Carolina, benzodiazepines such as Valium and Xanax were detected in 61 percent of the people whose deaths were attributed to prescription opioids, and that's just one class of depressants. In New York City, which has one of the country's most thorough systems for recording causes of death, 97 percent of drug-related deaths involve more than one substance. Sure, let's have Christy Huff informing doctors. Informing doctors? If this all sounds vaguely familiar it is no accident.

    Not so well, really. Far more people are dying than in , and this is no coincidence. Photo credits: Clarion Ledger.

    The Face of Heroin Addiction

    Haven't these meddlers done enough damage? Apparently not, since they now want to put their collective feet down on another class of drugs - one which is very much safer - despite the fact that they screwed up royally the first time around. Or maybe we could leave physicians alone and let the good ones - the vast majority of them - do their jobs without incompetents and tyrants breathing down their necks. The Agency acknowledges that the available data demonstrate an association-though not necessarily a causal relationship-between opioid dose and certain serious risks of opioid use.

    However, FDA also agrees that more data are needed regarding the relationship between opioid dose and adverse effects, and the relationship between opioid duration of use and adverse effects, before the Agency can determine whether additional action needs to be taken. More data are also needed on the point at which the risks of opioid use at escalating doses and longer durations of treatment may outweigh the benefits of opioid analgesic therapy. View the discussion thread. Since that time he has published more than 20 op-eds in regional and national newspapers on different aspects of the crisis.

    At that time almost no one had heard of the drug. He was also the first writer to study, dissect and ultimately debunk the manipulated statistics used by the CDC to justify its recommendations for opioid prescribing, which have resulted in Draconian requirements for prescribing pain medications as well as government-mandated, involuntary tapering of patients receiving opioid treatment, both of which have caused great harm and needless suffering to chronic pain patients.

    Those without employer-based insurance were priced out of the market because of pre-existing condition exclusions. Prior to Medicaid expansion under ACA, a person had to be both very low income and disabled to be eligible for Medicaid. Log In Membership Newsletters Obituaries.

    By Amy B. Wang The Washington Post. More in Trump Administration.