I’ll be writing a series of little posts here about various articles in the media regarding the war on opioids, as I find that the news media often doesn’t tell the full story, and seems to be following (or promoting) a morality play or political narrative, rather than actually presenting the problem as it is.
This article from The Economist I found curious mainly because writers such as this almost always maintain — without any real attempt at argument– – that prescription opioids don’t “work” for chronic pain. As a someone who suffers from chronic pain, I can assure you that nothing could be further from the truth.
Prior to having spinal fusion in 2013, I was on a long-acting prescription opioid. Because I still had some pain, I thought the medicine wasn’t working, so I went off of it, only to become essentially nonfunctional for six weeks. I was in so much pain that I lost my wallet, my keys, my Kindle, my smart phone, and even my car all within a span of six weeks.
It was then that I discovered that my spine was essentially crumbling, that I had no disk left at L5, and that L4 wasn’t looking too much better. I needed major surgery on my lumbar (lower) spine.
If we restrict access to pain medications, the result will be more people in pain, more nonfunctional, and more on disability. Back pain is the most common cause of disability in the entire world. Restrict access to pain medications in the way that so many advocates demand, and we’ll essentially be denying needed relief to millions of people in serious pain. That relief allowed me to work. Was opioid use ideal in my case? No, it wasn’t, but it kept me working, and it’s hard to discount the importance of a paycheck.
It’s already challenging enough to get these medications, even with a prescription. In fact, I’d have to see my doctor monthly to get the relevant prescriptions in New York State, where I live. The fact that these visits are both costly and medically unnecessary seems irrelevant to politicians content to sacrifice people like me to their newfound compassion for addicts.
We can do little for addicts who refuse assistance. Some of them will die. But by indiscriminately trying to control the availability of these medications both to addicts and to those who genuinely need them, we would deprive millions of people access to the medications they need to avoid having to live a life completely in thrall to physical pain. In weighing the costs and benefits of any policy concerning pain medications, it might help to imagine what it’s like to live a lifetime in serious pain–with painkillers, and without.
Policy of Truth 
The Economist article certainly skirts around the issue, but I wonder whether the contention of Ohio’s law suit is entirely consistent with your point here. In the Economist’s words, the suit accuses drug companies of “exaggerating the effectiveness of opioid painkillers while downplaying the risk of addiction.” The article then suggests rather obliquely that opioids are less effective for chronic pain than for acute pain. I’m not sure exactly how we should cash out that distinction, but by at least one criterion your pain plainly counts as chronic, and opioids help you. I doubt, though, that anyone seriously supposes that opioids just don’t work for chronic pain, at least if working means relieving pain. We’re talking about some serious drugs here; it would be very surprising if they did little or nothing to relieve pain, and if the difference between chronic and acute pain is just that the former keeps coming back over a longer period of time, then aside from the possibility of building up tolerance to a given drug and so requiring more of it to relieve the pain, it’s not plausible that opioids don’t relieve chronic pain. What they won’t do is address the causes of chronic pain, and so to manage chronic pain simply by taking opioids seems like covering up a cut with a band-aid so that you won’t see it, but making sure that the wound gets re-opened every night while you sleep. The contention of the lawsuit, as I understand it, is that doctors too often simply rely on opioids as the main mode of treatment for chronic pain (and that drug companies are to blame for this, having influenced doctors and patients through shady advertising techniques); if that’s true, then the fact that you and many other people like you have needed opioids to manage chronic pain is a bit beside the point, since the objection isn’t to cases like yours, but to cases in which painkillers are treated as the treatment (as if nobody ever bothered to look at your back and say, ‘wow, you should have surgery; that’ll help’).
I don’t know whether it is true, though, and the Economist article doesn’t do much to avoid reducing the question to a simplistic one about whether opioids work for chronic pain. In part that’s because the article is really about the lawsuit and its focus on advertising, but it wouldn’t have taken much effort for the authors to add the qualifications necessary to avoid the problem.
As for regulatory proposals, I find myself responding with a sentiment that I hope is unjustified: what’s really needed here is for doctors to make more careful decisions about when to prescribe what to whom for how long, and while some regulations or other might seem like a promising way to promote better decisions, they’ll never be sufficient, and it’s possible that they’ll prevent doctors from making some good decisions, too. But I don’t expect doctors suddenly to become paragons of practical wisdom without any external prompting, either. I don’t like being so cynical, but so far I haven’t seen much reason not to be.
I know too little about this issue, though, so I hope you keep writing about it here.
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I found the Economist article tendentious and irresponsible. By stipulation, the focus of the article is this lawsuit in Ohio, but the writer clearly gives the impression that he regards the suit as having merit, by analogy with similar suits against tobacco companies. The “marketing effort” is reductively described as though it involved nothing but marketing, but we’re not told a word about what was said, or what merit there might have been in what was said.
It’s true that opioids were originally reserved for cases of acute pain or end-of-life amelioration. It’s also true that there’s been an uptick in addiction-related deaths. But it is irresponsible to ignore the fact that 50 million people suffer from chronic pain, that there are no other more effective medications for all of those cases, that the cases of chronic pain that respond to opioids may outnumber the cases of premature mortality owing to opioid addiction, and that there are some cases of chronic pain for which there is no further remedy but the use of a painkiller.
You say:
But there are cases in which there is nothing to be done to “address the causes of chronic pain” except either to medicate it or to endure the pain sans medication. In other words, there is no further clinical intervention that will resolve the underlying problem. The patient simply has to accept the fact that the pain will be there forever, and live with it.
One of the biggest problems with this debate, as I see it, is the failure to distinguish between physical dependence from addiction. Physical dependence is a sheer physiological dependence on a substance such that withdrawal from the intake of the substance leads to a characteristic withdrawal syndrome. (That’s circular if intended as a definition, but clear enough otherwise.) An addiction (as I see it) is a physical dependence that is net harmful. But in cases where a person faces a lifetime of severe chronic pain, and there’s no remedy for the underlying condition, it’s not at all clear that physical dependence on a painkiller by itself entails addiction in the “net harm” sense I’ve described. All things considered, it may be better to be dependent on a painkiller and without pain than not dependent but in constant pain.
One of the strangest features of the contemporary debate is that when it comes to, say, anti-depressants, you won’t (typically) find people saying that life-long use is “addiction.” Psychiatrists typically say that life-long use is medically indicated. When it comes to opioids, by contrast, life-long use is regarded as “addiction” regardless of any other clinical consideration.
Since long-term use is prevalent, and it’s unfashionable to blame the addict, a scapegoat has to be found for widespread “addiction,” and the reflex is to “blame the corporations.” Well, maybe they are blameworthy, but to ignore all of the preceding complications and then declare that Big Pharma is “exaggerating” the efficacy of opioids (and thus deserves big ticket public interest lawsuits) is journalistic malpractice. It’s telling that the direct quotations in that article come from professors of law, not patients or physicians. (Imagine an article on abortion that took this form–right-wing anti-abortion law professors talking about sticking it to Planned Parenthood, full stop.) What do professors of law know about chronic pain or its amelioration? Nothing. It’s as though The Economist was unable to find a single pain-management physician, whether academic or in private practice, for a reality check–to say nothing of someone in chronic, otherwise untreatable pain. But this article is typical; the whole contemporary debate is like this. It’s as though all that matters is the sexy anti-corporate story. The clinical details are an afterthought, if they come up at all.
I’m curious to pull some of my physician friends and relatives into this conversation, to hear what they have to say. I’ve heard very different things about “overprescription of opioids” by physicians. I’ve heard some physicians say that overprescription has become routine, but I’ve heard others insist that opioids are already highly regulated and that claims about overprescription are much ado about not much. Considering the role of fake fentanyl in the addiction crisis, it’s not clear that doctors are responsible for as much addiction as is being claimed, and considering the non-opioid factors cited in the Case-Deaton research on “deaths of despair,” it’s not obvious that the disproportionate (or almost exclusive) emphasis on opioids is warranted.
Here is a summary of the Case-Deaton research:
The Case-Deaton research mentions “drugs” (not just opiates), alcohol, suicide (not just addiction-generated suicide), labor participation rates, and chronic pain. But somehow, the insistent journalistic focus is on: opiates. I think it’s worth asking how and why that’s happened.
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“But there are cases in which there is nothing to be done to “address the causes of chronic pain” except either to medicate it or to endure the pain sans medication. In other words, there is no further clinical intervention that will resolve the underlying problem. The patient simply has to accept the fact that the pain will be there forever, and live with it.”
I’d assumed that everyone of worth participating in the debate about opioid prescriptions was aware of such cases and that the debate wasn’t about them. If there is genuinely nothing to be done to address the causes of the pain and the pain is not manageable otherwise than by opioids, then barring physician-assisted suicide an opioid prescription would seem to be the only reasonable option. I haven’t paid close attention to the debates, though; are we really in a situation where the majority of cases are of the sort you describe, and yet people are complaining about opioid prescriptions?
If so, then it goes without saying that the debate is silly and the Economist article is not simply focusing its attention elsewhere, but irresponsibly ignoring a central point.
It is perhaps worth noting that at least the last time I paid attention a few years ago, the Economist had an official editorial position in favor of the decriminalization of all drugs. I suppose that position is consistent with grumbling about drug companies and doctors overprescribing a drug, but if you think government has no business prohibiting the sale of crack and meth, it seems odd to get worked up by doctors overprescribing painkillers (if that is in fact what they are doing, contra what I take to be your suggestion above). Perhaps it’s a gripe about the corruption of medicine; after all, one needn’t accept doctors acting like drug dealers just because one accepts drug dealers.
As for why people are talking only about opioids, I dunno. But as for why they’re talking about opioids, I think this is why:
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As far as that chart goes, again, if you do just a bit of research what you’ll find is that the recent increase in deaths has been the result of illegally manufactured opioids containing fentanyl. In the case of ANY illegal drug, if it is manufactured in a dangerous manner, many people will die. That doesn’t mean that doctors and big pharma are causing the problem, does it?
I have no problem with the media calling attention to the fact that there are dangerous drugs on the streets but what is happening here is that the media and politicians have implied that doctors and big pharma, not the criminalization of these drugs, are the culprits.
Another thing to consider is that it is possible that more people are using opioids because our population is aging, and with aging comes an increase in arthritic conditions and thus chronic pain. My guess is more people are also using anti-inflammatories and other drugs for pain as well. That’s a guess but I’ll bet if you research it, you’ll find it to be true. There’s most likely an increase in the use of ALL drugs that combat chronic pain.
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One MORE thing: just looked at one study regarding use of anti-inflammatories. Here are the results from the first study I found regarding changes in use: “regular NSAID use increased over time and varied by demographic features. Participants over 60 years of age, women, participants with high body mass index, increased waist circumference or heart disease were significantly more likely to be regular NSAID users. By contrast, non-Hispanic African American and Mexican American participants were significantly less likely to regularly use NSAIDs.”
Here’s another blurb from a different study: “Nonsteroidal anti-inflammatory drugs (NSAIDs) are the cornerstone of pain management in patients who have inflammatory, acute pain (eg, headache, postoperative pain, and orthopedic fractures), and chronic pain (eg, rheumatoid arthritis, osteoarthritis, and gout)…Approximately 70% of people 65 years or older use NSAIDs at least once per week, with half of them taking at least 7 doses per week…The use of NSAIDs is likely to increase even more as the US population continues to age and experience painful conditions that are more common among older adults.”
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If we’re to believe the chart, it is misleading at best to say that “the recent increase in deaths has been the result of illegally manufactured opioids containing fentanyl.” The number of deaths from overdose of commonly prescribed opioids begins to rise sharply in 2000, dips a bit around the beginning of the decade, but then rises a bit and holds fairly steady at a much higher rate than found at the beginning. It’s of course true, again assuming we believe the chart, that very recently deaths relating to fentanyl and related substances have risen very sharply. But if the chart is accurate, there’s no denying that overdoses from prescribed opioids have risen a good deal, and the strategy of blaming it all on illegally manufactured drug use is simply inconsistent with the data. So I don’t see any evidence here that what’s really going on is that the media is blaming illegal drugs on big pharma.
It would be interesting to see data on the relationship between opioid prescriptions (or use more generally) and overdoses. But the issue that has people worried is emphatically not that more people are using opioids; it is that more people are overdosing on them and dying. If the overdoses have in fact remained proportionate to the prescriptions, then perhaps we could conclude that this is really just the result of more people using opioids because the population is aging, or something along those lines. But if the overdose deaths have increased not only in total number, but in proportion to prescriptions, then that effort to explain the problem away won’t work either. I don’t have the data, but I doubt that it would show a steady proportion of overdose deaths to prescriptions.
I worry that you’re a little too eager to deny that there’s any kind of problem here at all, and not simply to point to oversimplifications in the way it is discussed in the media and in politicians’ rhetoric. It’s worth noting that HHS takes there to be an opioid epidemic in which prescription medicines play a considerable role (https://www.hhs.gov/opioids/about-the-epidemic/index.html); HHS is of course not infallible, but it is also not liable to the same kind of distortions and simplifications that politicians and journalists are, and it is not run by a bunch of people without relevant medical experience. Of course HHS is no authority on what the political response should be, but it is a tolerably qualified authority on whether there is a problem and whether it is really just a matter of illegal drugs, old people, and so on. Coincidentally, the HHS’s emphasis on abuse rather than addiction seems to me to go a good way toward meeting one of Irfan’s earlier complaints; I don’t see what the relevance of addiction to the discussion is, whether or not we follow Irfan in reserving the term for things that are harmful; as the HHS recognizes and as anybody with two seconds to reflect should also see, one does not need to be an addict in order to overdose and die. Insofar as Irfan’s complaint is about the discussion of the issue in media, though, what HHS has to say is irrelevant.
I’m certainly with you both on wanting to see more nuanced and careful discussion than what we find in the Economist piece. But if you’re trying to maintain that there’s really no problem here, I’m unconvinced.
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A thought for DJR from a late-comer, if I may: there is a major difference between “drugs prescribed by a doctor for pain” and “prescription drugs”. But this distinction is regularly ignored in both CDC statistics and most of the public conversation on addiction. Liberal prescribing policy of the 1990s put a lot of opioids in medicine closets. And a lot of those opioids were diverted or stolen. But the notion that drugs prescribed to pain patients and managed by a doctor become a driver in widespread addiction simply isn’t supported in medical evidence.
Regards
Richard A “Red” Lawhern, Ph.D.
Patient Advocate
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My point exactly. Thank you for being a patient advocate. We need people like you. It would be a travesty to leave millions of patients to live in daily pain (which is exactly what is being proposed due to the misinformation out there).
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Yes, I think this point was raised earlier in the discussion, and unless I’m misunderstanding the documents I linked to in those posts (entirely possible, since I’m not anything close to an expert on this stuff), it’s not especially relevant to the studies that have led medical researchers to conclude that opioids are often overprescribed. One might, of course, think that even if a vast majority of overdose deaths are not linked to overprescription, their prevalence might constitute a reason to control prescriptions more tightly — not an argument that I’ve made, but one the possibility of which renders the relevance of the distinction you draw to the more general debate unclear. In any case, the conclusion you seem to draw in your final sentence seems severely undersupported by what precedes.
I’d be interested in credible studies that support your final sentence. Absent such studies, the limited evidence I’ve seen suggests to me that it is false.
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I would like to add that the qualifications are lacking in many coroners to determine what actually caused a death especially if polypharmacy and alcohol were involved, many are elected officials without the necessary forensic background, lack resources and required tools. In addition I will say insurance companies refusing to pay for the more expensive abuse deterent pain medications {after pharmaceutical companies went through the research and expense to formulate them} are partially responsible as well,Are they being sued?. However I don’t care about the Blame Game thats happening now because I can no longer access my pain meds that made my life tolerable {not pain free},for 9 years, yes I was given my street referral 4 months ago without warning, but I hav’nt nor do I plan on using that referral even though every day I lose more function physically,socially, financially,and spiritually and emotionally. I have to ask exactly what criteria the CDC was planning on using to evaluate the guidelines success or lack thereof. They did state Harm Reduction and reduced Overdoses/deaths did’nt they? Well How long is it going to take them to rewrite guidelines using credible, unbiased ,scientific guidelines in place of the ones which have increased Harm Immeasurably and caused deaths to skyrocket. We are not just numbers in their anylytics we are individual human beings who want to live our lives!
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I think to understand this issue it does help to be a patient and to actually have the experience of being treated for chronic pain because patients know what is standard; clearly these reporters do not. The fact is that pain management doctors never go to opioids as a first line of defense against chronic pain. That just isn’t the standard of care. The only doctors that start with opioids are bad doctors!
Treatment starts out conservatively, usually with anti-inflammatories, physical therapy, and/or muscle relaxants. If a trial of these interventions doesn’t work, epidural injections might be tried depending upon the condition. Occasionally, oral steroids are used, but if you want to experience mania followed by a serious depressive episode, take steroids! Steroids did prevent my nerve inflammation from causing a loss of bowel and bladder function so despite their negatives, I had to take them once. Surgery is also an option; in some cases, it’s merited and in other cases, it’s too risky.
This article — and many like it — blatantly misrepresents what goes on in doctors’ offices. There will always be bad doctors just as there are clearly bad reporters. Bad doctors are not the norm. This article would have you believe that pain management doctors automatically reach for opioids with a knee jerk reaction that is conditioned by big pharma, as if a good or even an average doctor has no mind of his or her own, and can’t possibly be expected to do anything other than make their patients into addicts. I don’t know for sure, but my guess is that most doctors’ critical thinking skills might be just a little bit better than this since it’s basically common sense.
As far as the issue of whether or not opioids work for pain, you would be surprised how many doctors and psychotherapists will assert that opioids don’t work for pain. What they base this on is a little something I call “myth.” Look for that proposition when you read about opioids and you’ll see it stated all the time. I certainly had enough doctors tell me this, and I went off of these medicines enough times to learn that they were wrong (and that also supports the notion that I wasn’t addicted because if I was, I wouldn’t have been able to come off of the medicines). Every time I stopped the medicines, I found they had been working much more effectively than I realized. They just didn’t eliminate ALL of the pain.
And it is true that medicines are sometimes bandaids. They don’t cure and they don’t claim to. But would you not take insulin if you were diabetic because it’s a bandaid and you’d be reliant and dependent on it? Do you refuse cold medicine to manage your symptoms? What about anti-depressants or anti-psychotics or Lithium salts? Medications for gout? It would be great if all medicines were cures; the fact that one isn’t doesn’t argue against its use.
What the Economist does here — and many media outlets as well as politicians — is misrepresent what is commonly done and represent, without any evidence, that the outliers are the norm. That’s highly problematic when, as Irfan Khawaja has pointed out, over 50 million people suffer from chronic pain. Where is the focus on these people’s lives? Where is the focus on the disability and suffering of the chronic pain patient? It is true that not enough research has been done to eliminate chronic pain, but the fact is that opioids are only one form of treatment for pain and they are commonly used as a LAST resort, not the first-line of defense. It is patently untrue and an exaggeration that doctors reach for opioids first.
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I have plenty of anecdotal evidence that opioids work for chronic pain, having once lived with someone who suffered from fibromyalgia and found relief only through opioids. I’m surprised to hear that many doctors deny that they work, though I also know better than to suppose that my experience must hold true generally. But I don’t see how much of what you say here is really to the overall point.
I don’t think I or the Economist article suggested that doctors generally just prescribe opioids for chronic pain at a first go. What I understand the general worry to be is that doctors don’t work hard enough to find ways to treat the cause of the pain, and instead opt for one or another painkiller as the main treatment, with an increasing turn to opioids. There’s no denying that opioid prescriptions have risen a great deal in the last two decades. What isn’t clear from anything I’ve read is whether or not the bulk of those prescriptions have gone to people for whom there is no possibility of treating the cause of pain. You and Irfan are emphasizing cases like those, but it seems to be a widely shared view by critics that those cases cannot account for the increase in prescriptions. I don’t claim to side with them; I just don’t see that you or Irfan have shown that most opioid prescriptions are in fact necessary or that they are used to treat pain the causes of which cannot be addressed in other ways.
I may be misunderstanding exactly what you want to say, but so far I don’t see how much of what you say is inconsistent with the view that there is a serious problem with opioid abuse and that overprescription of opioids is a leading cause of it. Note again that I’m not asserting that view; I’m just not convinced that it’s wrong by what you and Irfan have said.
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Here’s what I find most puzzling: why exactly is it that the rise in overdoses and abuse more generally should be blamed on overprescription? Even supposing that the drugs are overprescribed — prescribed to people who do not really need them as opposed to some other, safer alternative — there is no necessary connection between not really needing to take the opioid and taking so much of it that it kills me, is there? I can abuse and overdose on a drug whether I need it or not. No doubt if people are getting prescriptions for purely recreational use that has nothing to do with chronic pain, then they’re more likely to overdose, and no doubt that if it is possible to kill yourself by taking too much of a drug (and it’s not hard to take too much), then we should want doctors to avoid prescribing that drug unless it’s necessary — still, is there something about opioids that makes it especially likely that users will abuse them in potentially fatal ways? I know they can be quite pleasant, but so can plenty of other things that kill us in excess. Irfan’s point about addiction is spot on insofar as it’s that dependence as such is not necessarily a bad thing, and dependence does not need to correlate strongly with overdose. So what is the connection between overprescription and overdose supposed to be, exactly?
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Chronic pain has a multitude of causes, some known, some unknown. The bulk of the time there is no cure for the “cause,” and pain has to be managed. That is what pain management is after all. It does not purport to cure. What evidence supports the allegation that doctors are not working hard enough to find the “cause” of chronic pain? That has never been my experience, as I’ve suffered a lifetime of chronic pain.
It is also in question where these pills are coming from, and I’m not seeing evidence that over-prescription is a leading cause of these opioid overdoses . That is being assumed in the face of fentanyl-laced pills coming into the U.S. from China, Canada, and Mexico from at least 2015 if not earlier. Really? Fentanyl is much stronger than what most doctors are prescribing for pain, and I would venture to guess that they are the likely culprits given that they are completely unregulated. Fentanyl pills labeled as Oxycodone were found in Prince’s home after his overdose.
Prescriptions for opioids are already highly regulated (as is acknowledged in the article).
Blaming doctors and big Pharma for the problems of addicts does have a chilling effect on the treatment of chronic pain, and makes obtaining these medications that much more difficult. Not easy when you can’t walk to traipse all over town because pharmacies will not confirm that they can or will fill a prescription over the phone.
I deeply resented government interference in my care, and the stress that it caused me when I often could not get medications due to regulations that were not designed for my benefit or to protect me, but to protect a small percentage of individuals who were not interested in such protection, and who often wreaked havoc in doctors offices. As I said earlier, addicts come out of the woodwork to invade clinics, emergency rooms, and doctors’ offices attempting to get their hands on any form of addictive medication. That cannot be blamed on anyone but the addict/drug dealers.
These drugs are NOT easy to get like cigarettes were and are, and in my experience doctors were trying to limit the drugs being given to addicts who were demanding more and more of the medications and who were already coming to the clinics addicted. I doubt addiction usually starts in a pain management doctors office. I highly doubt that.
Sent from my iPhone
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Perhaps I misunderstand the relationship between fentanyl and prescribed opioids. You keep talking about fentanyl as if it were relevant to the question of whether there is a problem with people overdosing on prescription opioids, but the data I’ve cited clearly distinguish them and clearly show a marked increase in overdose deaths from prescription opioids since 2000. Are you disputing the data? Do people who get prescriptions for opioids end up with fentanyl instead? Is there really a connection here? It looks like a giant red herring to me.
I’ve expressed my own skepticism about whether overprescription is really to blame for the increase in overdose deaths; I’m not even sure exactly what the claim is supposed to be, let alone whether it’s true. But if the marked increase in overdose deaths is correlated with an increase in the number of prescriptions and the proportion of overdose deaths to prescriptions has also increased, that’s prima facie evidence of a causal connection between the increase in prescriptions and the overdoses. Obviously it’s not decisive evidence, but it is evidence. As I said, I’m not fully informed of the relevant data here, so I don’t know whether the relative frequency of overdose deaths has increased, but I’m assuming it has, since otherwise it’s hard to see why health professionals would be worked up by it, and many of them are worked up by it.
I’m still confused about exactly what you want to maintain here. It looks to me like you’re upset because poorly designed regulations caused problems for you, and that you’re taking your own experience to be representative. I’ve no doubt that your experience with chronic pain is common — though note that your own earlier description of it does not fit the pattern of chronic pain the cause of which was not at all treatable; you described it as an effect of spine problems that were treated via surgery, so that at least something could be done besides managing pain via medications — but in any case I don’t think cases like yours are supposed to be the main concern. What remains to be seen is that cases like yours are far and away the standard cases, and that cases in which opioids are prescribed when they don’t really need to be are marginal. I haven’t seen any reason to think this is true from what you’ve said. I don’t maintain otherwise, but as someone without a settled view on the matter, I’m not going to settle it in favor of your view just because you say that your case is representative of the vast majority.
But I’m really not sure I understand just what your view is. I think I’ve said all I can say without some further clarification of what, more precisely, you want to say about the supposed problem.
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To be honest, David, I’m a little confused as to what’s confusing here so I’ll try to just say as simply as possible what my beef with the Economist’s article is and leave it at that. My dispute with the article was that it does not address the very strong possibility that the opioids referred to in the article were NOT prescribed by doctors. And if the article were to have addressed that, then the focus on doctors and big Pharma as responsible parties falls flat on its face. Look at the title of the article itself, “How the Pain Pills Were Sold.” Don’t you think the reporter should have known, because it’s easy enough to find out, about the influx of illegally manufactured drugs in Ohio and that even officials in Ohio know that those deaths were not caused by opioids prescribed by doctors? It’s also possible that so-called “prescription” opioids were purchased illegally from Canadian sources as well as others. Something’s rotten in Denmark is all I’m sayin’!
It only takes a little bit of research to find this out. I suggest you check it out. I’m going to leave it at that because I’m also getting confused as to what we’re even talking about. I’ve shared what information and experience I have not only as a patient but as a clinician who worked with addicts for over four years. I am skeptical when addicts are treated as victims who have absolutely no agency, and whose deaths are blamed on anybody but themselves. I’m not judging the addict; I liked working with addicts. I’m sympathetic to addiction. I can completely understand reaching for a substance that takes away both emotional and physical pain. Life is hard. It’s shitty at times, and most of the addicts I worked with were highly traumatized individuals (but they were often some of the most interesting people I’d ever met).
It comes down to a couple of very simple truths: addicts will take anything to get high and often engage in high risk behavior. These are the people who often wind up dead. To blame that on doctors who are treating patients for chronic pain is highly suspect. I have to question the purpose of what appears to be, on its face, outright deception. That deception affects the lives of innocent parties (specifically innocent parties like myself). I have had a stake in this and I take it personally. I’m also concerned for the millions of people who need these medicines, and the complete lack of empathy for the chronic pain sufferer.
As Irfan mentioned to me, the focus on opioids in the media appears to be a focus on the “drug du jour.” It’s fashionable right now for politicians to use professed concern over opioid deaths to present themselves in a compassionate manner. But if they really cared about people’s lives, they’d be focusing on ALL drugs and the question is why they’re not (my guess is they don’t want their alcohol and tranquilizers taken away). I know I sound very cynical but that’s because I am.
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So as far as I can tell you are just rejecting the empirical data from the graph I posted above and maintaining that in fact, no, there has not been a significant increase in deaths from overdose on prescription medications. If we accept that data, then the Economist article’s focus on deaths from overdose on prescription medications makes sense given that the lawsuit the article is about obviously does not apply to overdose deaths on illegal drugs. So too, while there are grounds for skepticism about the role of pharmaceutical marketing and individual physicians’ prescriptions, the data prima facie suggests a connection between increases in prescription and increases in overdose deaths, which justifies some suspicion that the drugs are being overprescribed. You’re hedging on it, but you seem to want to say that the data is just false and that overdose deaths mostly come from illegal drugs (or that maybe they could, as though mere possibility enjoyed some kind of presumption of actuality). You say it’s “easy to find out,” but I’m not taking your word for it, particularly not against HHS and the CDC, according to whom half of all deaths from opioid overdose involve a prescription opioid (https://www.cdc.gov/drugoverdose/media/index.html).
I agree with you and Irfan that the media discussion is oversimplified, but I’m not convinced that your alternative is any less oversimplified, and insofar as you are rejecting empirical evidence solely on the strength of your own personal experience and intuition, it seems more problematic than the Guardian’s selective attention. I’m not out to defend the narratives that attribute the problem to corporate evil or identify a simple solution in government regulations, I’m just not going to reject apparently good empirical evidence on the basis of your anecdotes and unsupported assertions.
Your remarks about addiction and agency strike me as relevant to my confusion about what the alleged connection between overprescription and overdose deaths is supposed to be; overdoses are usually a result of poor decisions on the part of users, and while doctors might be indirectly responsible insofar as they fail to give patients adequate information or what not, it’s not clear just what role the critics think the prescriptions are playing here, or whether the thinking is as simple as “give people enough to overdose with, and they will; so don’t get them enough to overdose with.” But I guess you’re not too interested in this particular question, since you deny that prescription opioid overdoses are a significant problem.
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For what it’s worth, this is an interesting source of well researched information: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Note that according to research done in 2013, many physicians are themselves concerned about overprescription of opioids. Note too that, according to the CDC document, “Most guidelines [for physicians in prescribing opioids], especially those that are not based on evidence from scientific studies published in 2010 or later, also do not reflect the most recent scientific evidence about risks related to opioid dosage.” The document also takes the short-term effectiveness of opioids to be firmly established, but notes that no adequate studies of long-term effectiveness have been conducted. This might account for some of the disagreement about effectiveness among doctors. The document reports that the specialists most confident in the efficacy of opioids are pain management specialists, though.
In any case, the document as a whole strongly suggests that prescription practices can make a great deal of difference, have probably been far from optimal, and that at least some of the problem can be addressed by different prescription practices. Of course, approaching it via federal legislation might seem like using a sledgehammer to do some weaving. But perhaps better prescription guidelines can be developed and doctors can help to reduce the frequency of abuse and overdose without the imposition of further artificial legal constraints.
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Good points all. It’s quite possible that the regulations are enforced differently state to state as well so that while I can argue that in New York State it’s quite difficult for normal chronic pain sufferers to obtain their medications, that might be different elsewhere. I can tell you that I’ve come across many doctors who are not that knowledgeable not only regarding opioids and their effectiveness, but they’re also terribly ignorant when it comes to spine conditions. I had more than one doctor behave as if the pain caused by the four herniations I had in my lower spine was a figment of my imagination. I had other doctors not treat me with respect because they assumed I was drug-seeking. There’s a hell of a lot of ignorance amongst doctors in regards to both these topics in my experience. But I had to pay a very high price for the sociopathic behavior of addicts who go to doctor’s offices and threaten and cajole office staff to get the drugs; I paid the price for that behavior, the addicts and the dealers did not in my opinion.
I would not state that these are safe drugs at all. They are highly dangerous, and patients ought to be educated as to their potential lethality. What I do question is the extent to which doctors are being held responsible for overdose deaths given that these drugs can come from a variety of sources. And then there’s the age-old so what part of me that says okay, go ahead, clamp down on prescription medications, make things worse for chronic pain patients, and addicts will stick get SOMETHING if not prescription opioids and they will still die. Chronic pain patients will be the ones left to suffer because few are actually concerned about the lives of sufferers of chronic pain; I can tell you I feared permanent disability for years, there were times I thought I really would not be able to work anymore and those medicines kept me working. I’ll be totally honest with you when I say I have as much if not more concern for chronic pain sufferers than I do for recalcitrant addicts who refuse treatment. Not to say I don’t care, but I know the limitations of trying to treat these people.
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David, the data doesn’t say where the “prescription” opioid drugs came from. Those drugs could have been prescribed by a doctor or not so I’m not rejecting the data, I’m interpreting as it is — and that data is only calling the drugs prescription opioids (I understand this can be confusing but when the term “prescription opioids” is used, it doesn’t mean that the medications were obtained via prescriptions). I don’t think you’re actually reading what I’m writing here and I think you’re missing some major points. When they use the term prescription opioids, this does not mean that a doctor prescribed them. Such drugs can be obtained through online pharmacies without a prescription.You are misinterpreting the data.
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I didn’t claim or assume that a prescription medication can only be obtained with a prescription. For this fact to do the work you want it to do — to undermine concern that prescription practices have a role to play in the increased number of overdose deaths — it would have to be the case that the vast majority of opioid overdoses from prescription medications were from medications that were not prescribed to the person who overdosed, but purchased illegally, acquired from someone with a prescription, etc. Given the correlation between the rise in prescriptions and overdose deaths, that seems extremely unlikely. In any case, you’ve given no reason to think it’s true. I’m not misinterpreting the data. If you’re not denying it, you certainly seem to be trying hard to come as close as possible.
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In any case, here is the CDC with evidence that overdose deaths are not mainly linked to users who lack a prescription: “For example, a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose (25).”
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1 in 550 = .18%
1 in 32 = 3.13% (and that’s of the percentage that get >200 morphine milligram equivalents per day, such a high dose that it’s likely an extremely low percentage of chronic pain patients overall)
These numbers demonstrate my point. See the doctor’s comment (above I believe).
The first figure means that 99.82% of those who received opioids for noncancer pain DIDN’T overdose. My point has never been that it’s impossible for those with prescriptions to overdose; my point was that it’s unlikely due to the controls already in place via the DEA as well as other reasons I’ve already gone into.
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I don’t recall suggesting that your point was that it was impossible for people with prescriptions to overdose. If we set aside the kind of rhetorical tactics that I don’t even tolerate from my 15 year olds in class and get serious, then the issue is this: is the number statistically insignificant or not? You haven’t given anything that even pretends to be a reason to think so, unless “3.13%” is supposed to do that work by insinuation (“oh, that’s a small number, I bet it’s insignificant!” Well, humans share 98.8% of DNA with chimpanzees; that’s a big number, so I should conclude that humans aren’t significantly different from chimps?). I’m perfectly open to the conclusion that it is, but if you want me to accept that conclusion you’ll have to give me reasons for it and not try to spook me with numbers. A very large number of people with far greater claims to expertise than you disagree with you, so if you want those of us who don’t claim to have any special insight into the issue to disagree with them and agree with you, you’ve got an argumentative burden to bear, and I can’t see that you’ve even begun to do so.
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I haven’t had a chance to work through all of the comments on this thread, and I’m sure I do at my peril, but I thought this was relevant and worth reading:
http://www.nj.com/opinion/index.ssf/2017/07/im_a_responsible_opioids_patient_dont_take_my_drug.html#incart_river_index
Another link, if that one doesn’t work. From The Star-Ledger (Newark, New Jersey). It discusses the CDC data.
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Also worth reading is the comment thread on one the articles linked in the Star Ledger piece (in the link below). This is a nice exception to the supposed rule that articles are worth reading but comment threads are not; in fact, the reverse is the case here. Some of the comments are more worth reading than the article they’re commenting on.
https://www.painnewsnetwork.org/stories/2016/1/23/cdc-over-counted-opioid-overdose-deaths
There are a couple of good comments there, but the one by Richard Lawhern is a nice example of what I think of as “populist blogging” in the best sense. Whether he ultimately ends up being right or wrong, he intelligently raises issues that are at odds with what is taken to be the expert consensus, and that would have to be answered by experts if we’re to give them the credence they demand.
I don’t know the literature on opioids, but I’ve read a bit on sedative-hypnotics, and the phenomenon Lawhern is describing is one I’ve encountered there: anti-drug partisans conducting studies on drug overdoses are often extremely imprecise (and misleading) about how they describe the etiology of “deaths due to drug overdose,” but are very adamant that the mortality rate “due to” the drug is spectacularly high.
I was alluding to that problem in this post a few months back (about sedative-hypnotics, not opioids):
https://irfankhawajaphilosopher.com/2017/02/22/d-f-kripke-on-the-use-of-sedative-hypnotics-a-query/comment-page-1/
Kripke’s research gives the outward appearance of being very precise, and marshals all kinds of impressive-looking statistics. It also happens to be published in a peer reviewed journal. But methodologically speaking, it’s garbage. If the opioid literature has the same problems (I’m agnostic there), I’d give it the same characterization.
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