PHARMACIST STEVE

Misdiagnosing Causes and Casualties in the Opioid War

http://reason.com/blog/2017/10/18/misdiagnosing-causes-and-casualties-in-t

“The opioid crisis is an emergency,” declared President Donald Trump in August. “And I am saying officially right now that it is an emergency, a national emergency. We are going to spend a lot of time, a lot of effort, and a lot of money on the opioid crisis.”

As of this week, President and his advisors have not yet completed the paperwork for an official national emergency declaration. So how much of a crisis is the “opioid epidemic”?

In 2015 some 33,000 Americans died from overdosing on various synthetic opioids. Some researchers forecast that as many as 500,000 Americans could die of opioid overdoses in the next decade. The drugs most associated with overdose deaths are prescription pain pills like oxycodone, along with black market heroin and fentanyl.

Lots of media reports have made pharmaceutical manufacturers, distributors, and “pill mill” physicians the chief villains in the rise of overdose deaths. “The Drug Industry’s Triumph Over the DEA,” published earlier this week by The Washington Post and CBS’ 60 Minutes, is one such “exposé.”

While it is true that some unscrupulous phyisicians and pharmacies have overprescribed opioid medications, Josh Bloom, director of Chemical and Pharmaceutical Sciences for the American Council of Science and Health provides a helpful guide to some of the deceptive claims being peddled by drug warriors. Specifically, Bloom decodes Andrew Kolodny’s “The opioid epidemic in 6 charts,” over at The Conversation.

Kolodny, executive director for Physicians for Responsible Opioid Prescribing, cites data from the National Institute on Drug Abuse showing that more 60,000 Americans died of drug overdoses in 2016. Bloom suggests that that assertion misleads readers into thinking that those deaths are mostly the result of taking prescription opioids.

The actual number of deaths associated with overdosing on prescription opioids was around 17,000 last year. And as Bloom points out, most of those overdose deaths occurred in conjunction with benzodiazepines (like Valium and Xanax) and black market heroin and fentanyl.

A recent Center for Disease Control Morbidity and Mortality Weekly Report focusing on drug overdose deaths in Ohio found that 90 percent of the decedents tested positive for fentanyl, 31 percent for cocaine, 27 percent for benzodiazepines, 23 percent for prescription opioids, and 6 percent for heroin. Once these are taken into account, Bloom estimates that “the number of deaths from opioid pills alone will be much lower, perhaps in the neighborhood of 5,000.”

Bloom also objects to Kolodny’s observation that the “effects of hydrocodone and oxycodone on the brain are indistinguishable from the effects produced by heroin.” Both prescription opioids and heroin operate on the same receptors in the brain, but hydrocodone and oxycodone are four and two times less powerful, respectively, than heroin. And they are 200 and 100 times less powerful than fentanyl.

Long-term use of prescription “opioids are more likely to harm patients than help them because the risks of long-term use, such as addiction, outweigh potential benefit,” Kolodny says. Bloom counters that the “absence of evidence is not evidence of absence.” His main argument is that Kolodny cannot make his claim for the simple reason that no long term studies on the effects of opioids to manage chronic pain have been conducted.

In any case, Bloom cites 2010 research that the risk of addiction is below one percent for patients who use prescription opioids for short term pain control. A 2013 review similarly reports the risk of addiction is below one percent and concludes, “The available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence.”

A 2015 review article in the Annals of Internal Medicine reported that “reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date.” However, the Annals reviewers were less sanguine than Bloom about prescribing opioids to treat pain. “Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction.” The Annals review also notes that various studies found the prevalence of prescription opioid addiction ranging from 2 to 14 percent.

Some pharmaceutical companies, Bloom acknowledges, helped fuel the opioid problem by falsely claiming their medicines were less addictive and less subject to abuse than other pain medications. For example, Purdue Pharma, the manufacturer of Oxycontin, admitted it had misled physicians and paid in a fine of $653 million in 2007.

But given that most of the opioid deaths now result from consuming illicit drugs, Bloom argues Kolodny’s effort to blame the problem on drug companies is now irrelevant.

Kolodny rejects the claim that the reformulation of prescription opioids after 2010 to make them more difficult to snort or inject pushed many users to black market heroin and even more dangerous substances in search of highs. Bloom points out that after 2010 the number of deaths attributed to prescription opioids flattened while those from heroin and fentanyl increased almost five-fold.

Bloom decries what he calls the “opioid pain refugee crisis,” in which new federal rules restrict patient access to effective drugs to control severe pain. In 2012, the Institute of Medicine at the National Academy of Sciences issued a study, Relieving Pain in America, that reported: “Chronic pain affects about 100 million American adults—more than the total affected by heart disease, cancer, and diabetes combined. Pain also costs the nation up to $635 billion each year in medical treatment and lost productivity.”

“We do not question that opioid misuse is a serious and growing public health problem,” writes Arthur Lipman, editor of the Journal of Pain & Palliative Care Pharmacotherapy. “We do not, however, accept the simplistic solution of limiting opioid use that is advocated by many commentators as being rational. Although opioid overprescribing and access undoubtedly contribute to the problem, opioids are still seriously underprescribed for and unavailable to many legitimate patients with moderate to severe pain who need these medications to function adequately.”

While Kolodny argues for substantially increasing restrictions on patient access to prescription opioids, he also urges federal and state governments to “ensure that millions of Americans now suffering from opioid addiction can access effective addiction treatment.”

Instead of pursuing the failed Drug War policies of restriction and prohibition, one good way for President Trump to “spend a lot of money” to help those opioid users who do become addicted is to increase access to medication-assisted therapy programs as recently suggested by my Reason colleague Mike Riggs.

Filed under: General Problems