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The Opioid Crisis: Facts that news coverage is missing

Medicine Bottle with Hydrocodone Label and TabletsPop quiz:

In the last two weeks, what class of drugs was mentioned in the State of the Union address, was the subject of new guidelines proposed by the Centers for Disease Control and Prevention (CDC), was reported to kill more Americans than car accidents and whose users are 40 times more likely to abuse heroin? If you guessed opioids—these would be drugs like hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), hydromorphone (Dilaudid), codeine, and related drugs–you’re right.

It’s not clear whether this recent spate of news coverage is normal, but on the evening of January 22nd, while waiting on a delayed flight in an airport, I did a quick Google news search on the term “opioid,” not sure what to expect. I found that out of the top news postings appearing over the previous three days (Jan 19-22) there were 27 stories, from such diverse sources as the Huffington Post, WSKG news, a TV station serving the southern tier of New York and Northern Pennsylvania, the Sacramento Bee , the Central Penn Business Journal, the Boston Globe and NPR.

The key thing I gleaned from these stories was the overwhelming sense of an epidemic of such unmanageable and complicated proportions it’s hard to know where to start. According to the CDC it is estimated that in 2012 alone there were about “259 million prescriptions for opioids, [or] enough to give every U.S. adult a bottle of pills,” and the prescribing of these drugs has by some estimates quadrupled since 1999. The carnage, approaching 19,000 (2014 data) overdose deaths due to opioids, and the economic costs, pegged at more than $55 billion (in 2007 dollars), gives you some idea why these drugs continue to generate headlines.

What makes this so complex above the human stories of addiction, overdoses and deaths is the involvement of physicians genuinely interested in helping patients relieve their pain. As far as I can tell, there are three irrefutable facts about the opioid crisis:

Fact 1: There are real patients with real pain asking, sometimes begging their doctors to step up to the plate to prescribe them sufficiently strong drugs to do the job. One estimate from the Institute of Medicine says there are 100 million Americans suffering from chronic pain and somewhere between 5-8 million people who take opioids for that pain. Unfortunately opioids rarely “do the job”; even as they make people feel good in the short term, over time their effectiveness wanes and people become trapped by physical dependence on the drugs.

Fact 2: There is a very widespread problem of drug abuse, opioid-related overdoses and an increase in the use of heroin (for people who are so desperate when they can’t get their fix from the doctor). It doesn’t help that heroin is cheap and readily available.  The underlying gravitas to these stories is that most people are getting these drugs not from pill mills (ie: home-based manufacturing) but from a prescribing pad.

Fact 3: This is an American problem, but also Canada and Australia have high rates of opioid use. For some drugs, the US tops the charts.  For example, the per-capita ingestion of oxycodone in the US is the highest in the world, almost twice as high as the next country (Canada) and between five and ten times the rate of other developed countries (2013 data).

It’s hard to precisely apply the HealthNewsReview.org criteria to these stories as they are more like “social issue” stories than healthcare stories, yet a couple of notable points are worth mentioning.

In terms of evidence, opioids are mostly studied in short-term randomized controlled trials against placebo.  After all, few patients in chronic pain are going to enroll in longer-term clinical trials because, as Janet Woodcock, head of the FDA’s Center for Drug Evaluation and Research told TIME Magazine: “It’s not practical for us to require people to go for a year on a placebo.” [Note: I couldn’t access the original TIME story].

Having said that, there are a range of other drugs for pain such as non-steroidal anti-inflammatory drugs (known as NSAIDS). Very few of the stories give any sense of comparative effectiveness of these drugs, and there is scant mention that the benefits of opioids for longer term, chronic use is scant and inconclusive.

Very few of the stories discuss the cost of opioids (which clearly can grow into multiple times the pharmacy cost when they are sold on the street to addicted people). The huge costs of opioid abuse are not just related to the effects on the patient, but also the family. An oxycodone addict might not be able to work or function well in society, have difficulty looking after him or herself and may neglect other important aspects of their lives like caring for children and other loved ones.

While the most severe adverse effects are almost always mentioned, (addiction, overdose and death) the lesser effects of opioids such as constipation, which can sometimes be severe and occasionally fatal, are not.

Nor do the stories state specifically which kind of patient would benefit from an opioid and which might not. Stories on opioids need to be more explicit in saying how much is too much (in terms of developing dependence) and what signs a person might have when they are getting addicted. These facts should not be corollaries to a story, they are must-haves.

One of the main unreported aspects of the opioid crisis is the involvement of the drug companies in this mess. There is pretty clear evidence opioid manufacturers have played a substantial hand in ramping up opioid prescribing in the world by buying patient groups, infiltrating physician education, and encouraging doctors to be more bold in prescribing these drugs to patients who are in pain, while downplaying the dangers of doing so. There was a US Senate Finance Committee investigation several years ago that looked into the links between the manufacturers of pain medications and the patient and professional groups working in pain. The conclusions, dear reader, are not pretty.

There was some good reporting in the stories I found but also some naiveté. For example the Sacramento Bee rightly noted that the conversation has changed “from one of punishment to treatment” where opioid use has become viewed more of a public health problem than a criminal problem. It quoted a study from the Annals of Internal Medicine which found that people who overdosed on opioids “still have an easy time getting prescriptions from the same doctors.” It noted, somewhat puzzlingly, that “the researchers didn’t know why doctors kept prescribing opioids to at-risk patients. We don’t either.”  Hmm. Seemed like a missed opportunity to me. Couldn’t they maybe hazard a guess?

For some perspective I sent an email to Dr. David Juurlink, a Canadian expert on opioid research. He’s a physician at Sunnybrook Health Sciences Centre in Toronto and I asked him if he could map out the major issues about journalistic coverage of opioids and what is being missed. His response (which I condensed) formed a neat list:

  1. Virtually all patients who take opioids regularly for chronic pain are physically dependent (but not necessarily addicted) on them, and if they stop or reduce their dose, they’ll develop early symptoms of opioid withdrawal. This is the huge elephant in the room. Patients may not recognize withdrawal as such, but they quickly realize that their symptoms are alleviated by resumption of the drug. Consequently they come to believe they “need” ongoing opioids to function. This is a huge issue, because it causes dangerous and minimally effective drugs to become self-perpetuating chronic therapies. For many patients with chronic pain, these drugs don’t relieve pain well at all, but they are good at treating opioid withdrawal.
  2. Large numbers of patients are on high-dose opioids, which represent a major risk for death. No study has ever shown this to be a good thing. In fact, we recently showed that 3.8% of men and 2.2% of women on high dose opioids (defined as >200 mg of morphine or equivalent per day) went on to die of opioid-related causes.  This is simply staggering.
  3. Pharma is opposing moves to make opioid prescribing more rational. He referred me to what he called one of his ‘twitter rants.” He also pointed me in the direction of the Senate Finance Committee investigation mentioned above.

For some original research on the reporting of opioids I found the work of Dr. Emma McGinty who examined opioid reporting up to 2012. Over a 15 year period (1998 to 2012) her team found that more than 75% of the news stories mentioned a cause of the crisis, most commonly illicit drug dealing by physicians, patients, and others (57%), followed by physician-related causes (47%), patient-related causes (32%), and pharmacy-related causes (34%). She noted that most of the news stories depicted individual abusers of opioids (2/3 of whom were involved in criminal activity).

While Dr. McGinty’s work may have suggested that “the national dialogue around opioid analgesic abuse still frames this issue predominantly as a criminal justice issue rather than as a public health problem or treatable health condition,” my assessment of my Google news search in January 2016 would show that we’ve moved past that.

I can’t conclude much else after my mini-survey of opioids in the news except to say the reporting of opioid issues continues unabated, and that much of the coverage skimps on key issues including the costs and harms of these drugs and the role of pharmaceutical companies in perpetuating this crisis. The issue is highly complex and explosive and the solutions seem as elusive as ever.


Alan Cassels is a drug policy researcher in Victoria, British Columbia and a reviewer with HealthNewsReview.org. The opinions he expresses are his own. Follow his writings on twitter @akecassels.

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Comments (10)

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Ian Mitchell

January 27, 2016 at 11:20 am

A few other thoughts:

1. Race: There is a large racial component to this epidemic. First, the media exposure has been much larger than most drug epidemics. This is likely because the people affected are more likely to be young, white and suburban. Media is usually less interested in bad things that happen to poor, black people. Secondly, the reason that blacks have been spared is interesting; traditionally both white and black physicians have been less likely to prescribe opiates to non-whites. This appears to be the reason that blacks in the US have been less affected by this epidemic. .

2. The epidemic has been made worse by the appearance of fentanyl. This changes the dynamic from a bulk agricultural product smuggled with much danger from exotic places to a pure, cheaper product shipped from a factory in China, that is then added in unpredictable amounts to the heroin supply. There may be worse things to come, with the BCCDC reporting the street appearance of W-18, a synthetic opiate that is 100 X as strong as fentanyl.

3. It is clear that chronic pain is poorly treated with opiates. One remedy is medical cannabis. Studies have shown that opiate deaths drop by 25% in areas where medical cannabis is available. A recent article from Vancouver physicians (Kerr, Montaner) emphasized that physicians have been too reluctant to prescribe cannabis in favor of opiates.

J Babin

January 27, 2016 at 6:13 pm

As the NIH recommended in 2014, there needs to be more research. To counter the problem of long-term placebo controlled studies, and subjective estimates of pain, there should be more studies using functional brain imaging. I think we are on the brink of being able to distinguish not just “this is your brain” and “this is your brain on drugs” with an egg/fried egg visual metaphor, but actual hard science showing actual differences between “this is your brain in pain”, “this is your brain on drugs that relieve your pain — or not” and “this is your brain addicted to drugs for non-medical reasons”. The Martinos Center for Biomedical Imaging at MGH and others are doing amazing work with function MRI and PET scanning technologies. This type of patient-centric monitoring, where the test can be an actual benefit the patient, should become the gold standard for efficacy instead of humiliating drug screens and pill counts, which truthfully, violate the 4th and/or 5th Amendment rights of patients and don’t say anything about the patient’s condition or treatment except that the vast majority of chronic pain patients are not criminals.

Another piece missing from the media coverage and the government discussion is the comparative risks of alternatives. The CDC is reporting 16,000 deaths per year due to misuse and abuse of opioids, but one study found that as many as 16,500 patients legally using NSAIDs die each year from the gastrointestinal side effects of NSAIDs alone. (Singh et al, J Rheumatol 1999;26:18-24). So if we switch all chronic pain patients to non-opioid therapy would there really be any net lives saved? Isn’t it just a value judgment that it is more important to save addicts from themselves save than pain patients?

Another problem with focusing on the supply side due to diversion of legally obtained medication is that it doesn’t work. Addicts will find another supply of opioids for non-medical use. This has proven to be the case with meth, where restrictions on pseudoephedrine-containing products now require behind the counter purchase of limited quantities because they can be diverted for use as precursors for cooking meth. Since the restrictions went into effect, sales of cough and cold medicines containing pseudoephedrine have plummeted, but the use and availability of meth is greater than ever! The supply of meth has just shifted from local, home cooks, to meth synthesized in Mexico and illegally imported by the drug cartels. Notably, the Mexican meth is much purer, more potent and more dangerous than home cooked meth. (Balko “As it turns out, meth laws have unintended consequences” Wash. Post October 14, 2014) This is what will happen and IS happening with opioids. If addicts can’t get diverted prescription opioids, a supplier will step in to fill the void, for example, with fentanyl that is currently being synthesized in Mexican drug labs. This is already happening — the lethal “Hollywood” heroin was spiked with fentanyl making it much more potent and lethal than ordinary street heroin. (http://www.masslive.com/news/index.ssf/2016/01/vermont_state_police_hollywood.html).

This whole witch hunt, in my opinion, is due to over-zealous law enforcement who get the knickers in a twist when they can’t prosecute physicians for prescribing opioids, and physicians fearful of law-enforcement. That’s not to say that physicians who run pill-mills shouldn’t be prosecuted. Everything should be on the table. But my value judgment weighs in favor of pain patients and there should be standards that protects valid medical use of opioids and the physicians who prescribe them in any “Guidelines” on opioid prescribing. California has such protections, at least against Medical Board disciplinary actions. Can you imagine what would happen if individual law enforcement agents refused to carry guns or pursue fleeing criminals out of fear they might be prosecuted for excessive use of force?

    Stephen Cox, MD

    February 1, 2016 at 8:58 am

    Ian Mitchel states above “It is clear that chronic pain is poorly treated with opiates.” This is not always true. I have seen cancer and arthritis patients able to function with their pain because of opiates, at low doses and without escalation over time. They need close monitoring but should not be denied some relief when nothing else helps or is safe.

      richard saltus

      February 1, 2016 at 1:23 pm

      Dr. Stephen Cox is quite correct. Blanket statements that opiates have no place in treating chronic pain are not helpful. I have undergone every option for treating arthritic, disc-related back pain except surgery (which I’m not a candidate for) and all have either failed or been effective for a time but no longer work for me, at age 70. Only Vicodin, taken as needed, calms the pain and muscle spasms so that I can walk and stand and do yoga, keeping me active. I am very fortunate not to have become tolerant to the meds – at least not so far — and I don’t feel any withdrawal symptoms when I stop for awhile. It’s not a panacea at all, but it’s made a big difference in enabling me to stay more mobile than I otherwise would. I have an “opioid contract” with my doctor that spells out the conditions under which he will keep prescribing them for me. In no way do I minimize the terrible problems opioids are causing and clearly we need much better pain medications. But it is hugely important that people who can benefit from opioids under closely watched circumstances continue to have access — and without being stigmatized.

Karen Koss

February 1, 2016 at 5:38 am

The US federal government’s tying patient satisfaction to hospital reimbursement is a hidden contributor to this issue. One set of questions focuses on how well the patient perceives their pain was controlled. Pain management is a laudable goal. It is also complex. Tying pain ‘control’ to reimbursement has to be examined.

Martne van Eijk

February 2, 2016 at 12:28 pm

I’ve been in this field of research (drug policy in the widest sense) for over 20 yrs. I have learned that when something that is an obvious problem for over a decade already, suddenly hits the news, there is a powerful party who likes this. The disadvantages of these painkillers are not new. Perhaps I got too suspsicious and you should erase this comment. I think something new (less addictive, with a new patent) is coming to the market soon. This is not a new tune in our field.

Sherrie Harris

February 2, 2016 at 8:03 pm

I am a chronic pain patient. I have five things that causes chronic 24/7 pain I know my body is dependent on the medicine but mentally I am not wish I had my life before all this happened to me. If it wasn’t for opioids I would be in bed 24/7 there are no natural medication for me in this state what should I do? ?

Charles Mauldin

February 3, 2016 at 6:55 pm

I’ve seen this coming for a long time, starting emergency medicine practice in 1975 and changing to rehab medicine with a heavy chronic pain emphasis in 1989. Pain as the 5th vital sign and doctors willing to take the 1-10/10 number at face value made it too easy for people who like opiates to get all they want to take or to sell. Declining reimbursement and patients’ health plans changing physician panels have lead to less meaningful contact with patients. Most of patients I see coming from primary care physicians wouldn’t trip my trigger to prescribe opiates.

Un-PC, I would suggest legalization of everything, just about, with taxing and with standardized dosing. Not many people want to OD because they want to do their drug tomorrow. And give the 1.1 billion Obama proposes to throw at the problem to physicians, at least those who see medicaid.

Kevin Lomangino

February 4, 2016 at 1:29 pm

Occasional HealthNewsReview.org contributor Mark Schoene, editor of the Back Letter, wrote to us with some comments about this post that I’m including below:

I think there are some inaccuracies in the otherwise intriguing HealthNewsReview.org essay on the opioid overtreatment and addiction crisis.

100 Million US adults with chronic pain?
The Institute of Medicine report Relieving Pain in America did assert that 100 million Americans suffer from chronic pain—and implied it was serious chronic pain in need of treatment. That figure has been thoroughly debunked by journalist John Fauber and numerous researchers. A more accurate estimate is that some 10-25 million American adults experience severe, activity-limiting chronic pain. (See BackLetter, November 2014).

Does Chronic Pain Require Drug Treatment?
It is not clear to what extent even severe chronic pain demands drug treatment. This is a key issue, as the IOM report, and most media stories, assume that chronic pain has to be treated for people to have healthy, productive lives. The most recent population-based epidemiologic study on pain in the US from NIH concluded that about 50% of respondents with severe pain reported their health to be good or excellent. (See Nahin, J of Pain, 2015). It is not clear that US MDs are focusing on the right aspects of chronic pain in their treatment decisions. (See BackLetter, 2016). Pain scores are deceptive. Analgesics are often not the best answer for pain. There are any number of ways of coping with chronic pain.

“Nor do the stories state specifically which kind of patient would benefit from an opioid and which might not. Stories on opioids need to be more explicit in saying how much is too much (in terms of developing dependence) and what signs a person might have when they are getting addicted. These facts should not be corollaries to a story, they are must-haves.”
There is no compelling scientific evidence, nor medical consensus, on these points, as the recent NIH workshop on chronic pain concluded. Higher dosage and longer duration will increase habituation and addiction potential. But there does not appear to be any proven “safe” opioid threshold in terms of prognosis for extended use. And addictive behaviors are hard to distinguish in medical settings where patients have easy access to opioids. (https://prevention.nih.gov/docs/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf)

Dee Green

February 6, 2016 at 10:13 am

Sorry to comment but you turned to Jurick for opinion-he belongs to PROP, a highly controversial Antiopioid group in the US and he frequently rails on Twitter in opposition to opioids for any long term treatment for pain. Leads for your story would be better if you sought out actually chronic pain patients #PatentsNotAddicts who are being ignored in the conversation by all entities ????