Prescriptions are not to blame for today’s opioid crisis

We need to understand more precisely who is at risk for abusing these drugs and how they get access to them. (iStock/Mitchell Wessels)We need to understand more precisely who is at risk for abusing these drugs and how they get access to them. (iStock/Mitchell Wessels)

In April, the Centers for Disease Control and Prevention announced that prescriptions for opioid pain relievers, like Percocet, Vicodin and OxyContin, declined by 10 percent last year alone, part of a downward trend that has been happening since 2011. This good news, however, does not necessarily indicate an end to the years-long increase in opioid-related deaths.

How to explain the paradox? Isn’t overprescribing behind the opioid epidemic?

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Not today. In the late 1990s and into the 2000s, prescription opioids were indeed the main cause of overdose deaths (at least when those pills were combined with alcohol and Valium-type drugs), but today the drivers are heroin and, even more, fentanyl, a synthetic opioid that is 50 times as potent as heroin. Fentanyl or heroin (which itself is usually tainted to some extent with fentanyl) was present in more than two-thirds of the roughly 42,000 opioid-related deaths in 2016.

Today the drivers of the opioid epidemic are heroin and fentanyl, a synthetic opioid that is 50 times as potent as heroin.

Pain relievers remain widely abused, and doctors and dentists need to prescribe them carefully. But caution will be effective only if we understand more precisely who is at risk for abusing these drugs and how they get access to them.

First, it is important to address the matter of addiction. Contrary to common belief, prescription opioids do not pose a significant risk of addiction to the average person who has had a tooth extraction or a surgical procedure.

According to a 2016 national survey conducted by the Substance Abuse and Mental Health Services Administration, 87.1 million U.S. adults had used a prescription opioid—whether prescribed directly by a physician or obtained illegally—sometime during the previous year. Only 1.6 million of them, or about 2 percent, developed a “pain reliever use disorder,” which includes behaviors ranging from overuse to overt addiction.

People who are given a few days’ worth of an opioid pain reliever like Percocet or Vicodin rarely develop an addiction. Yes, a subset is at risk; it includes people with histories of addiction and those struggling with psychiatric conditions, and caution is particularly important with young adults. It is wise to discuss if opioids are really needed (as they often are not), to prescribe as few pills as possible and to enlist a family member to manage them for a young adult.

People who are given a few days’ worth of an opioid pain reliever like Percocet or Vicodin rarely develop an addiction.

Addiction in chronic pain patients is a somewhat different story. Estimates for new addictions resulting from opioids prescribed to manage chronic pain cover a wide range, but the C.D.C. guideline on prescribing opioids cites a range of 0.7 percent at a low dose to 6.1 percent at higher doses from one study, though lower and higher estimates can be found.

Still, just because opioids do not produce high rates of addiction in patients does not mean doctors are not overprescribing. Few patients need (or use) more than a week of pain relievers for a temporary problem. The problem is that excess pills remain in medicine chests around the country and fall into the wrong hands. According to the Substance Abuse and Mental Health Services Administration, among people who misused prescription pain relievers in 2013 and 2014, about half said that they obtained them from a friend or relative, while only 22 percent said they received the drugs from their doctor.

While physicians must be cautious about prescribing, they must also be sensitive to the needs of patients with long-term and intense pain. Take the case of Anne Fuqua, a 37-year-old nurse from Birmingham, Ala. Previously, Ms. Fuqua worked in hospice care, but she has not been able to take care of patients for the past 14 years. In her late teens, she was diagnosed with primary generalized dystonia, a neurological disorder marked by involuntary movements and painful muscle spasms. She was unable to tolerate the usual medications prescribed for dystonia, but Ms. Fuqua and her doctor found that opioids dramatically reduced the rigidity.

Ms. Fuqua is among millions suffering from afflictions like rheumatoid arthritis, neurological illness and inflammatory conditions who receive opioids, sometimes at high doses. Without these drugs, many of them cannot get out of bed or hold a job.

While a strong case can be made for carefully reducing doses in patients with their consent, no data support nonconsensual or forcible dose reductions or curtailment in otherwise stable patients. There is also anecdotal evidence of harm (emotional trauma, medical or psychiatric deterioration and even suicide) from forced reductions or outright cessation of painkillers.

A compassionate approach to the many casualties of the opioid crisis is possible. Doctors need to be careful prescribers, and health systems and payers need to make more treatment available for those struggling with addiction. At the same time, we need to allow people crippled by pain to retain access to the medicine that enables them to live as full a life as possible.

rose-ellen caminer
1 week 2 days ago

Thanks for this article. Though I am in no physical pain and do not know anyone who is, I've been skeptical all along about this whole anti prescription drug propaganda. It does not make sense to me that people who are in physical pain and get needed relief from pain killers, will inevitably and in great numbers, become addicted after they heal and are no longer in need of pain killers. People with chronic pain conditions should be allowed to take pain killers routinely rather then to live in excruciating pain.It is reactionary to revert to the mindset of decades ago when the prime concern of doctors regarding dispensing drugs to people in pain, was that a person may get addicted by the pain relieving drugs. We finally progressed to recognizing how inhumane and stupid this policy was. It's inhumane to tell people in pain that they can think their way out of it, or use some other strategy that does not work when one is experiencing real pain. As anyone who has ever had a toothache. a severe earache, or severe sore throat or gone through child birth knows. Even non severe pain when chronic is a real suffering. It is stupid and callous to think that because some people are addicted to drugs, people in pain should, in addition to their pain, now have have to worry that there will not be any relief after an expired duration.

The lowest common denominator of some people becoming addicts, should not determine opioid prescription drug policy. Some people become addicts and they need treatment and empathy. But to deprive people in pain from relief because some people, no longer in pain, become addicted to opioids, is to dismiss people who are suffering and in need of relief.

If you take an opioid when you are healed of what caused the pain, initially, I don't believe it is the drug you took while in pain that is pushing you .It's merely a strong desire,[such a person has an innate susceptibility to becoming an addict] at that initial first take, after the pain is gone. Most people don't feel any need to take the drug when the pain is gone. Most people are not susceptible to being addicted. That the whole medical establishment is jumping on this anti opioid for pain relief, bandwagon is stupid and callous and immoral. The role of medicine is to alleviate suffering and to cure, if possible. That we now have drugs that can stop people's pain but now doctors are reluctant to use them because some people become addicts, undermines the whole ethos of civilization; the physician is for the patient; his/hers every one; to heal or to alleviate their suffering and that means if nothing else to stop the pain!

Anne Fuqua
1 week 2 days ago

Thank you for understanding this and being willing to take the time to express your opinion. Greatly appreciated!

Anne Fuqua
1 week 2 days ago

I’m the patient Dr. Satel mentions in this article. I’m really glad to see this in a publication that will reach Catholics in the pro-life community. I feel this is an unrecognized issue for the pro-life movement. I have lost more friends to suicide because they no longer had any quality of life than I can stand to think about and am aware of many more who I didn’t know personally while they were alive. There are patients who are actually pursuing death with dignity options where it available in the US and Canada or traveling to Europe. Some of the older ones with Parkinson's, ALS, and MS would likely be approved as their health has rapidly declined due to pain. Most patients who commit suicide do so through more conventional means. Many are never recognized as they chose to make it appear an accident.

Christians of all denominations have been reluctant to support patients with chronic pain who are losing access to opioid medications. Their voice is one that’s sorely needed. If you support life begins at conception, use the fetal pain argument to support the fight against abortion, lobby against the death penalty, and protest euthanasia, you should support measures that promote quality of life for patients with chronic/intractable pain as well. Life without quality isn’t REALLY LIVING at all. It's existing; it’s watching time pass you by and missing out on your dreams.

Opioids ARE NOT helpful to all patients with chronic pain and staying on a lower dose IS better for MOST patients, but not all. Some people have metabolic disorders, intestinal malabsorption, and others we may never fully understand the etiology behind their need for a higher dose. The human body is complex and we are genetically diverse as a species.

Jesus Christ taught us to love one another and do for the least among us. This developed into a wonderful tradition of the Church founding hospitals and providing care for the aged, infirm, and disabled. Relieving pain is part of this. God provided a means for his children to do this when he created the poppy plant - this is what morphine and codeine are still made from. Thousands of years later, technology evolved and scientists have developed semi-synthetic and synthetic opioids that include common drugs like hydrocodone, oxycodone, oxymorphone, and yes, fentanyl. The fentanyl you hear about causing tragic overdoses on your local news is not what pain patients take though. Illicit fentanyl and illicit fentanyl analogues like carfentanil are manufactured in non-standardized conditions in countries like China with uncertain potency and possible contaminants. Fentanyl is not commonly used for chronic pain but transdermal fentanyl patches can be extremely helpful for patients who have conditions that cause malabsorption, nausea, dysphagia, or require a very steady level of medication.

What can YOU DO?
Write your senators and representatives. Let them know you believe pro-life means promoting quality of life for people who are living with pain in addition to the traditional pro-life efforts like abortion, the death penalty, and euthanasia. There's a critical bill being introduced to preserve nonstandard pain care for patients like me. This is a project of Families for Intractable Pain Relief.
http://familiesforiprelief.com/.
They need to know they have constituents who care about this. All the information you need for this is right here:
https://drive.google.com/open?id=1-9Q1hd-6X4_0cmmGCodvy0eB8ONH1NpF

Talk about this issue in your parish and your community. Educate yourself and others. This is the biggest weapon against stigma. Encourage others to write as well.

Reach out to members of your parish and community with chronic/intractable pain who are facing involuntary dose reductions, having their medication discontinued entirely, or are already coping with this and struggling with their normal activities. Offer to pick groceries, do errands, and just let them know you care. You probably aren’t aware of how many people are going through this. That lady with the cane who sits in the pew behind you normally but hasn’t been to mass recently might be in this situation. If you’re talking about this, it will make patients dealing with this more likely speak up. Stigma surrounding pain medication leads to shame and secrecy that further isolates patients who are already likely to be alone much of the time anyway.

Last and most importantly, pray. Only God can fix this. Pray for the patients whose lives are affected. Pray for the doctors, nurse practitioners, and physician assistants caring for these patients. They face enormous stress, fearing investigation by their licensing board and the DEA that could wipeout the career they worked so hard for and interfere with their ability to provide for their family. They can even face criminal charges and incarceration. Pray they have the courage to stand up for their patients and don’t allow fear and stress to take away their compassion and empathy for their patients. Pray for our leaders and government officials. Pray they come to understand the harm being done and have the courage to rectify the wrongs.
My own doctor faced investigation by the DEA. I know firsthand that none of the allegations were true. They refused to close the case, even when the allegations couldn't be proven, promising to continue their work unless he chose to cease prescribing above 90 MME - despite the fact his patients were doing well with no history of overdose in his nearly 40 years of practice. Medical decisions like this aren't supposed to be their jurisdiction anyway. This finally led to his retirement. My chance of finding a new prescriber is slim.

MORE ABOUT ME

This was the original article Dr. Satel wrote with Dr. Stefan Kertesz about me:
https://slate.com/technology/2018/03/pill-limits-are-not-a-smart-way-to…

This is an Op Ed I wrote for The Washington Post:
https://www.washingtonpost.com/outlook/the-other-opioid-crisis-pain-pat…

Maia Szalavitz wrote these. The second one talks primarily about the DEA’s investigation of my doctor, Forest Tennant.
https://www.vice.com/en_us/article/8qb4dg/the-feds-are-about-to-stick-i…
https://tonic.vice.com/en_us/article/a3jd94/dea-raided-chronic-pain-doc…

I wrote “Relieving Pain Should Be a Pro-life Issue” back in January of 2017 in reaction to Felice Freyer’s BOSTON GLOBE article “Doctors Are Cutting Opioids Even if it Harms Patients”.
https://www.painnewsnetwork.org/stories/2017/1/4/relieving-pain-should-…

Here’s some other articles that provide background on this story. Email me at fuquaanne@gmail.com and can supply more.

News story from May 2018 about Tiara Pacheco, a 27 year-old with muscular dystrophy who is on a ventilator, in severe pain, but has been told the risk of addiction is too high to prescribe an opioid.
http://amp.thedenverchannel.com/2587213473/coloradans-with-chronic-pain…

PEER-REVIEWED SCHOLARLY ARTICLES

Turning the Tide or Rip Tide? The Changing Opioid Epidemic
Stefan Kertesz, MD.
https://www.tandfonline.com/doi/abs/10.1080/08897077.2016.1261070

Pain Management, Prescription Opioid Mortality, and the CDC: is the Devil in the Data?
Michael Schatman, PhD and Steven Ziegler, PhD, JD
https://www.dovepress.com/pain-management-prescription-opioid-mortality…

Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain.
Martin Cheadle, PhD, Rolland Gallagher, PhD, and Charles P. O’Brien, MD, PhD
https://www.ncbi.nlm.nih.gov/pubmed/28379504

MAINSTREAM MEDIA AND POPULAR ONLINE PUBLICATIONS

Strict Limits on Opioid Prescribing Risk the ‘Inhumane Treatment’ of Pain Patients
Stefan Kertesz, MD and Adam Gordon MD
This is the most commented article in the history of StatNews (project of Huffington Post), published February 24, 2017, patients still post comments on a near-daily basis. Please read through as many you can. Suicides of patients are mentioned and at least patient, Patricia, a friend of mine, posted a heart-wrenching comment prior to taking her life. At that point she’d been so demoralized that she used “Painful Pat” as her name in her post.
https://www.statnews.com/2017/02/24/opioids-prescribing-limits-pain-pat…

A ‘Civil War’ Over Painkillers Rips Apart the Medical Community — and Leaves Patients in Fear
Bob Tedeschi, interview with Sean Mackey, MD from Stanford University Pain Management, also has many comments from patients
https://www.statnews.com/2017/01/17/chronic-pain-management-opioids/

Cutting Down on Opioids Has Made Life Miserable for Chronic Pain Patients
Stefan Kertesz, MD and Sally Satel, MD
http://www.slate.com/articles/health_and_science/medical_examiner/2017/…

The Orphaned Patient: Treating Chronic Pain with Opioids
Peter Grinspoon, MD
https://leanforward.hms.harvard.edu/2018/02/01/the-orphaned-patient-tre…

Medicare Is Cracking Down on Opioids. Doctors Fear Pain Patients Will Suffer
Jan Hoffman
https://www.nytimes.com/2018/03/27/health/opioids-medicare-limits.html#…

Patients in Pain, and a Doctor Who Must Limit Drugs
Jan Hoffman
https://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addicti…

Patients With Chronic Pain Are Collateral Damage in Opioid Epidemic
Daphne Bramham
This profiles a friend with spina bifida. Since this was published, he had a heart attack at only 42 years-old as a result tapering. He's no longer able to use his crutches except very short distances and primarily uses a wheelchair.
http://vancouversun.com/news/local-news/daphne-bramham-patients-with-ch…

Is Assisted Death the Best We Can Offer Chronic Pain Sufferers?
Daphne Bramham
I think you will agree it’s frightening that this question could even be asked in a major newspaper.
http://vancouversun.com/opinion/columnists/daphne-bramham-is-assisted-d…

The War on Opioids Has Become a War on Patients
Jeffrey Singer, MD
https://www.cato.org/blog/war-opioids-has-become-war-patients

Cathy Heyworth Harris
1 week ago

I suffer from CRPS or Complex Regional Pain Syndrome, a neuro-inflammatory disease that rates as one of the highest pain diseases on the McGILL pain scale, more pain than natural childbirth without medication. An attack is 300+++ pain, which won't stop without pain medication intervention, which sometimes won't work for days. It is a very rare, misunderstood, not believed disease by doctors and ER personnel, and is known as the 'suicide' disease. Research it. What am I suppose to do when I am denied pain control for the worst pain disease known on the planet, first documented during the Civil War? I was diagnosed after left elbow ulnar nerve decompression surgery with casting, classic CRPS Stage 2 criteria. Yet it is almost impossible for me to now get adequate pain control as the policies under the current Presidential administration and Congress clamp down on opioids and other pain medications. Will my only solution be to kill myself when I have nothing left when my next attack finally happens as CRPS eventually spreads to your entire body and organs? This is what America wants me to do, kill myself, as all my options finally run out as they cut off all chronic pain sufferers from pain medication, like people dying from cancers? What happened to compassion in America?

Red Lawhern
6 days 20 hours ago

Thank you Dr Satel. If I may, I would suggest a few nuances to your otherwise well researched article.

I suggest that although the increased availability of diverted opioids may have been "a" factor in the increase seen in opioid overdose related deaths, it has never been "the main cause" of such deaths.

Analysis of the CDC Wonder database data reveals that the relationship between opioid prescribing and opioid-related overdose deaths has never been strong. In State by State data for 2006, there is a range of 300% in prescribing rates, but only a 60% rise in OD rates -- and the ratios of the two vary widely from State to State. Even that weak trend disappeared in 2016. There is no reliable cause and effect relationship.
The National Drug Survey informs us that perhaps 70% of all addicts report their first experience with opioids was with prescription drugs -- but 90% were people who never saw a doctor. Likewise, at least two of the four studies used by CDC writers to unfairly condemn opioid prescribing were conducted in patient populations where non-medical use of opioids is common (emergency room admissions).

Published studies in 2016 and 2017 demonstrate that rates of diagnosis for opioid abuse are less than 0.6% among post-surgical patients prescribed opioids for pain -- probably MUCH less, since many doctors who enter such diagnoses are not well trained in either addiction or the diagnosis of chronic pain caused by failed surgery. Fewer than 1% of post-surgical patients continue prescriptions beyond 13 weeks, and rates of diagnosed abuse are only weakly sensitive to prescription doses from 20 to over 120 morphine milligram equivalent per day.

I write as a non-physician subject matter expert in chronic pain and public policy for opioid analgesics. I "touch" over 60,000 chronic and intractable pain patients in social media almost every day.

Nancy Hodgeson
6 days 18 hours ago

In the late 1990s and into the 2000s, prescription opioids were indeed the main cause of overdose deaths (at least when those pills were combined with alcohol and Valium-type drugs)," My boyfriend and I are fighting for all pain patients and I agree that when alot of pills and alcohol are combined, overdoses occur. Howvere and my apologies if I misunderstood you comments " In the late 1990s and into the 2000s, prescription opioids were indeed the main cause of overdose deaths (at least when those pills were combined with alcohol and Valium-type drugs)," the main reason for overdoses RIGHT NOW that are still being blamed for overdoses are Valium type drugs. I am assuming that that includes medications like Klonopin. that you were referring too. Do you think people who take benzodiazepines are to blame? I do not drink, took my medications as directed 15mgs a day of percocet, and 2mg of a benzodiazepines , Klonopin. I have PTSD, Bipolar, and a Panic disorder before the accident, (I was hit by an 18 wheeler). I think blaming people who take psychiatric drugs and making them choose between there benzodiazepine or thier pain medicatriations is discrimination. However everyone is being discriminated against now, so I we fight, go to rallys, and to fly up the FDA public meetings. I am was told I had to make a choice between the pain medication or my psychiatric medicatons that have kept me stable for over a decade and did not give me troubles AT ALL when I took them with my perocet. I am just trying to find out if I am being blamed for the overdoses back then. Valium is a sedative. I do not know what class it is in, but I think you were referring to people who take them and other medications like benzo's. I was just wondering if you meant us or if other's had to choose like my clinic did. Thank you. This question does not include the abuse of them and alcohol, unless others think psychiatric patients all drink and abuse drugs as is the stereotype on TV and the stigma SOME people feel.

Linda Cheek
6 days 10 hours ago

But in order for the truth to reach the American people and the legislators ignoring what the DOJ is doing to innocent physicians and patients, it is important for people to understand the REAL cause of drug abuse and addiction. It is on my website, www.doctorsofcourage.org, as a shortened video and as a full-length purchasable DVD. If one person from each district in each state would purchase a DVD and 2 people from each state, and send them to their respective legislators, we could end this fiasco real fast.

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