Orthopedists Due Major Blame for Opioid Crisis? – PART I

Is this rational? Mostly, no.

It’s not that no one migrates from legitimate prescription to opioid use disorder (OUD) at all.

However, judging from news stories, the far greater part of the opioid crisis until 2013 arose from prescription pills diverted in large quantities to the drug-dealing black market. Since then, heroin, and lately, illicit fentanyl, have been the worst of the problem, while the diverted-pill problem continues to grow slightly.

The number of fatal overdoses of fentanyl and other synthetic opiates (not including methadone) soared from 3,105 in 2013 to 19,413 in 2016, a sixfold increase in just three years, according to the CDC. Heroin deaths rose from 2,399 in 2007 to 8,257 in 2013 and 15,469 in 2016, a more than six-fold increase in a decade. Deaths from opioids of the types prescribed by physicians (excluding methadone): 8,158 in 2007, 11,346 in 2013, and 14,487 in 2016, a smaller but still troubling 77% increase in a decade.

Dig past the headlines and it’s difficult, if not impossible, to establish a direct correlation between legitimate short-term opioid prescriptions for acute or post-operative pain and OUD.

Legitimate long-term prescriptions for chronic pain are a different story—but even the addictions arising from long-term prescriptions seem to be far too few to blame for the bulk of the opioid epidemic. A much more likely source: mass diversions of pills with no legitimate prescription involved. See below.

(Legitimate,” as used here, means prescriptions other than those written by the relatively few physicians who run so-called “pill mills.”)

Why Blame the Doc?

Then, why are physicians being blamed? To a large degree, it’s the politics of today, in which deep, complex facts matter less in the political world that winning a clickable headline by doing something, anything—or giving the appearance of doing something.

Also, the drug companies have been better at peddling influence in Washington than physician organizations have; pills are their bread and butter.

Both political parties are playing this clickbait game. To an extent, so are scientists. For this article, we ran across studies which lumped legitimate prescriptions with diverted pills as if they were the same phenomenon.

Statistics show that physicians are taking the opioid crisis seriously—perhaps even overreacting.

However, there are indications in the political wind that the heat on doctors (especially orthopedists and dentists, the leading prescribers for acute pain) will probably flare hotter when the 2017 opioid mortality statistics come out later this year. (CDC released the 2016 annual figures four days before Christmas in December 2017, so it’ll probably be a few months before the 2017 statistical shock wave hits.)

So, here’s what’s coming from your government with regards to opioid prescription rules and policies:

Eight Critical Trends in Opioid Prescribing to Watch

1. Raw numbers of opioid prescriptions are declining significantly.

From 2012 to 2017, opioid prescriptions declined 22%, says an April 2018 report from the IQVIA Institute for Human Data Science. The report says Prescription Drug Monitoring Programs (PDMPs) are a notably important factor (among many) in this decline. Federal and state authorities and medical academics are pressuring MDs not to write opioid prescriptions for chronic pain.

This is both good and bad news. The bad is that physicians may be unreasonably scared to write needed opioid prescriptions.

What should physicians do? There are alternatives, but they may not be covered by insurance. Some patients, especially those in chronic pain (other than cancer patients, who get a “bye” in this national debate), seem to have little alternative but to turn to the black market for pain relief.

2. Scary headlines will continue to trump scientific facts, to the detriment of patients in pain, and to the peril of prescribers.

A major example: The CDC published a study on March 17, 2017 saying that 2.6% of patients who were initially prescribed opioids were still on opioid prescriptions after a year.

Here were the headlines on this study found on Google:

“Opioid Painkiller Addiction Can Start Within Just a Few Days” – CBS News

“CDC Study Finds Opioid Dependency Begins Within a Few Days of Initial Use” – Highly respected science writer Jessica Wapner wrote in Newsweek.

Wapner also wrote, “As with any epidemic, understanding the epidemiology of drug addiction is crucial to ending it. That means knowing who is at risk, how it ‘spreads’ and the characteristics of the people who become addicted.”

Addiction starts in a few days on pain prescriptions? Is that really what the CDC study said?

No. Nothing of the sort. In fact, the study’s authors acknowledged that they didn’t even ask that 2.6% whether they still had pain without their prescriptions. What it did say was that even when the initial prescription is as short as five days, some patients were still on opioid prescriptions a year later. It said nothing correlating initial prescriptions with addiction.

We asked the news media offices at the Centers for Disease Control (CDC), the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) about the news coverage of that study, and whether they could cite studies on causal links between legitimate prescriptions and OUD.

The CDC said it would get back to us but didn’t respond in time for this article.

A SAMHSA spokesman said that a search turned up nothing relevant to the question, but he found a 2013 study which concluded that non-medical use (that is, misuse) of prescription opioid pills leads to heroin use. That study also said that the reformulation of OxyContin in 2010 to reduce its misuse potential lowered the street price of OxyContin and “may have led potential abusers of OxyContin to switch to heroin.”

An NIH [National Institutes of Health] media relations staffer wrote back, “[Y]ou are correct that the news media interpretation that 5 days of opioid treatment leads to addiction is an inaccurate interpretation of that paper.”

She also attached a statistically dense 2015 study* from the International Association for the Study of Pain, which sought to cut through the fog of causation using advanced statistical methods. It concluded:

1. Most studies don’t distinguish carefully enough among misuse, abuse, addiction, aberrant use, dependence, non-medical or non-therapeutic use, physical dependence, and psychological dependence. As a result, the prevalence of problematic opioid use in the studied studies ranged from 0 to 50%.
2. In order to tell whether a patient is addicted, you have to ask about the patient’s pain, which the CDC study above didn’t do.

However, Opioids for Chronic Pain May Be a Significant Problem

3. This 2015 study* concluded that addiction rates among non-cancer patients taking long-term oral opioid prescriptions for chronic pain ranged from about 8% to about 12%. Those percentages, if true, are significant. They imply that using opioids for chronic pain is a measurable contributor to addiction rates.

* ”Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis,” by Kevin E. Vowlesa, Mindy L. McEnteea, Peter Siyahhan Julnesa, Tessa Frohea, John P. Neyb, and David N. van der Goesc.

None of the three agency spokespersons was able to find a study which established a causal link between short-term prescriptions for acute or post-operative pain and OUD.

3. The headlines are driving states to pile on with their own opioid legislation.

In 2017, New Jersey passed a law forbidding physicians from prescribing opioids for a period longer than five days. Only one legislator voted against it. Why five days? Apparently, the logic was that it let Gov. Chris Christie say he had the “toughest” opioid legislation in the nation; New York and Maine had already passed seven-day limits.

“Although Gov. Christie said, ‘we are taking action to save lives,’ his administration gave little proof of the efficacy of the law while patient groups decried the potentially dangerous approach. New Jersey physicians opposed the law’s ‘one size fits all’ approach and declared it ‘cruel” to patients.’ – “Addressing the Opioid Epidemic”—an article written for American Academy of Orthopaedic Surgeons (AAOS) by Manthan Bhatt.

Citizen comments about the new law under the NJ.com news story about it were nearly 100% negative.

“In some state legislatures, there is the perception that heroin and other opioid addiction began by a physician ‘over-prescribing’ opioid analgesics to their patients. The science is much more complicated than that, but it’s a political reality that the AMA [American Medical Association] works to counter on a regular basis.” – AMA President Andrew W. Gurman, M.D., a Pennsylvania orthopedist, in an interview with the AAOS.

Gurman said the AMA tracked 600 pieces of state opioid-related legislation in 2015. “For 2016, state legislators were even more active,” he said. “In 2017, the AMA expects more than 1,000 individual pieces of opioid-related legislation.” (“The Opioid Epidemic and Orthopaedics: Where Do We Stand?” – article by Terry Stanton on the AAOS website.

What’s your state doing in 2018? There’s too much to report here, but a good place to check is the website of the American Academy of Pain Medicine.

End of Part I: Next Week, Was DEA Complicit in the Illicit Opioid Pill Trade?