By Richard A. Lawhern, Ph.D.
Anybody who reads a newspaper or watches evening news has heard the screaming headlines: “60,000 Drug Overdose Deaths” (or similar numbers). When reporters seek maximum sensationalism, we hear deaths by overdose summed over 10 years or compared to casualties in the Vietnam War. 500,000 drug deaths is a much more impressive number — even though it’s mostly hype.
Unfortunately for all of us – and for US public policy makers — such numbers misrepresent more than they illuminate [Ref 1]. Public policy concerning opioid addiction which is based on such inflated numbers will inevitably fail spectacularly, just as the “War on Drugs” did in the 1980s.
When we boil off the hype, we find that the “real” numbers of yearly deaths where a pain killer prescribed to a pain patient might have been involved is much smaller — like maybe 7,000 instead of 60,000 in 2016. About half of drug-related deaths don’t involve opioids at all (thousands of deaths from heart failure or liver toxicity are attributed to Ibuprofen or Acetaminophen). Among the remaining 33,000 deaths last year, most involved multiple street drugs and alcohol – something we rarely hear except as a footnote. The drugs most often detected by county medical examiners in 2016 were illicit fentanyl, heroin, morphine stolen from hospital dispensaries and methadone diverted from community drug treatment programs. So-called “prescription” drugs come in fifth – but many of those drugs weren’t actually prescribed to patients. [Ref 2-4] They were diverted to the street by theft from pharmacies and home medicine closets. Under prevailing CDC rules for mortality data collection, any death where an opioid is detected among other factors is labeled “opioid related” [Ref 5]. When Massachusetts traced opioid related deaths into their State prescription tracking database, only 8% of OD victims had a recent prescription. When a reporter breathlessly reports deaths by “opioid overdose” without clarifying sources or types of drugs, they’re essentially committing journalistic fraud.
We also hear tragic stories about young adults who overdose and die following a sharp descent into addiction. Many of them, we’re told, start down this path by being prescribed opioid pain killers for a few days or weeks after a sports injury or automobile accident. Without doubt, such stories are tragic and the families are devastated. The problem is that such stories aren’t representative or typical [Ref 4].
90% of drug addicts first begin abusing drugs and alcohol in their teens or 20s. According to the National Survey on Drug Use and Health, “…75% of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.” The typical new addict is a young white male with a history of family trauma, sustained unemployment, and mental health issues. [Ref 6]
So who is the typical chronic pain patient? According to the National Academies of Medicine, over 100 million US citizens now suffer moderate to severe pain. Of these, an estimated 18 million are prescribed opioids during any given year, and perhaps 2.7 to 3.3 million will be managed on opioids for longer than 90 days. [Ref 7]
Causes of long-lasting severe pain are multiple and complex. Some chronic pain seems to emerge “of itself” for no presently understood reason, while other cases follow from injury or diseases. It might not be helpful to imagine a “typical” pain patient, due to the multiple overlapping conditions involved. However, broad trends are well known [Ref 8-9].
– Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of 20-64 experience back pain. Many other chronic pain conditions also affect older adults [Ref 8].
– Women are more likely to experience pain than men (~60% vs 40%) and to experience more intense pain. Likelihood of pain increases with age, with new cases reaching a plateau or decreasing after Age 60. [Ref 9]
– Non-white and poor people experience more — and more severe — pain than well educated white elites.[Ref 9]
– For certain types of painful disorders such as facial neuropathic pain, Complex Regional Pain Disorder or Fibromyalgia, the typical patient is a woman in middle age or later. [Ref 10, 11]
When the known risk factors for addiction are compared with statistics on chronic pain, it becomes clear that attribution of the US “opioid crisis” to over-prescription of opioid pain relievers is unjustified. The great majority of addicts begin as male adolescents from troubled or disadvantaged socio-economic backgrounds – a population that is medically under-served. Few teens will see a physician for pain severe enough to justify prescription of an opioid for longer than a few days, and most such visits involve dental surgery. By contrast, a significant majority of chronic pain patients are women of middle age who have a very low risk of opioid addiction.
The demographics simply do not work.
The contrasts between addicts and chronic pain patients are strongly reinforced by the few available studies of the long-term effectiveness and risks of opioid treatment for common pain conditions. Not many of these studies have been conducted. But one which stands out is a 2010 Cochrane Review [Ref 13]. Key results of this review are worth repeating here: “We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants….” “Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome….”
“Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.” As a parenthetical note, we do not know in detail, the reasons for “discontinuance of opioid therapy due to inadequate pain relief”. But one of those reasons seems likely to be under-treatment of people who poorly metabolize opioids. [Ref 12]
The President’s Commission on Combating Addiction and the Opioid Crisis released its report in early November 2017. Although some aspects of the report seem positive, it is deeply flawed overall by its clinging to the false narrative that medically managed prescriptions in some way provide a “gateway” to addiction. Some of the Commission’s recommendations will almost certainly drive more physicians out of pain management practice and more patients into agony through desertion or denial of adequate medication. [Ref 14] Perhaps the only saving grace for chronic pain patients in the Commission report, is a recommendation for expansion and clarification of the 2016 CDC Guidelines on prescription of opioids to chronic pain patients. If this project is approached honestly and led by pain management specialists instead of addiction psychiatrists, almost the entirety of the CDC guidelines must be thrown out and done over. There is wide agreement among medical professionals that the published Guidelines are biased against opioid pain relief, scientifically unsupported and seriously incomplete [Ref 12].
Whether the US Government will permit the correction of its sorry record of distortions and mistakes in the so-called “opioid epidemic” remains to be seen. But it is now clear that the demographics of addiction and chronic pain only marginally overlap. Effective public policy cannot be based on the fiction that doctor-prescribed pills are the problem. Pill counting is not a viable solution [Ref 15]. Americans deserve pain management practices based on facts rather than sensationalism.
About the Author: Richard A (“Red”) Lawhern, Ph.D. is a non-physician writer, research analyst, patient advocate, and website moderator for chronic pain patients, families, and physicians. His wife and daughter are chronic pain patients. His 20 years of experience has produced articles and critical commentaries at the US Trigeminal Neuralgia Association, Ben’s Friends online communities for patients with rare disorders, US National Institutes for Neurologic Disorder and Stroke, Wikipedia, WebMD, Mad in America, Pain News Network, National Pain Report, the American Council on Science and Health, the Global Summit for Diagnostic Alternatives of the Society for Humanistic Psychology, Psychiatric News and Psychology Today
1. Schatman, ME, Ziegler SJ, “Pain management, prescription opioid mortality, and the CDC: is the devil in the data?” Journal of Pain Research, October 5, 2017. https://www.dovepress.com/pain-management-prescription-opioid-mortality-and-the-cdc-is-the-devil-peer-reviewed-article-JPR
2. Bloom, Josh, “Heads in the Sand – The Real Cause of Today’s Opioid Deaths”, American Council on Science and Health, August 16, 2017. https://www.acsh.org/news/2017/08/16/heads-sand-%E2%80%94-real-cause-todays-opioid-deaths-11681
3. Boyles, Salynn, “Mass. Study: Illicit Fentanyl Involved in Most Opioid Fatalities” Medpage Today, April 13, 2017, https://www.medpagetoday.com/Psychiatry/Addictions/64558
4. Sullum, Jacob, “Opioid Commission Mistakenly Blames Pain Treatment for Drug Deaths” Reason Magazine November 2, 2017, http://reason.com/blog/2017/11/02/opioid-commission-mistakenly-blames-pain
5. Molohon, Denise, “How the CDC Misclassifies Opioid Overdoses” Pain News Network, January 12, 2016, https://www.painnewsnetwork.org/stories/2016/1/12/how-the-cdc-misclassifies-opioid-overdose-deaths-1
6. Szalavitz, Maia, “Opioid Addiction is a Huge Problem, but Pain Prescriptions Are Not the Cause”, Scientific American, May 10, 2016. https://blogs.scientificamerican.com/mind-guest-blog/opioid-addiction-is-a-huge-problem-but-pain-prescriptions-are-not-the-cause/
7. Martin, Steven A; Potee, Ruth A.; Lazris, Andrew, “Neat, Plausible, and Generally Wrong – A Response to the CDC Recommendations for Chronic Opioid Use”, Medium, September 7, 2016, https://medium.com/@stmartin/neat-plausible-and-generally-wrong-a-response-to-the-cdc-recommendations-for-chronic-opioid-use-5c9d9d319f71
8. American Academy of Pain Medicine “AAPM Facts and Figures on Pain”, [Current edition accessed November 11, 2017] http://www.painmed.org/patientcenter/facts_on_pain.aspx
9. Grol-Prokopczyk, Hanna, “Socioeconomic disparities in chronic pain based on 12-year longitudinal data”, International Association for the Study of Pain, PAIN, Vol 158 No 2, February 2017
10. Lawhern, Richard, Living With TN – A Ben’s Friends Community for Patients With Rare Disorders, March 15, 2012, archived at http://www.lawhern.org/DemographicsFacialPain.docx
11. National Institutes for Neurological Disorders and Stroke, “Complex Regional Pain Syndrome Fact Sheet”, [Accessed November 11, 2017] https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Complex-Regional-Pain-Syndrome-Fact-Sheet
12. Lawhern, Richard, “Warning to the FDA – Beware of Simple Solutions in Chronic Pain and Addiction”, National Pain Report, June 1, 2017.
13. Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM, “Long-term opioid management for chronic noncancer pain” The Cochrane Library, Wiley & Sons Publishers, 2010.
14. Bloom, Josh, “Grading the President’s Commission on Combating Addiction And the Opioid Crisis”, American Council on Science and Health, November 3, 2017, https://www.acsh.org/news/2017/11/03/grading-president%E2%80%99s-commission-combating-drug-addiction-and-opioid-crisis-12078
15. Tadeschi, Bob, “A Civil War over Pain Killers Rips Apart the Medical Community – and Leaves Pain Patients in Fear” Stat News, January 17, 2017. See particularly, the hundreds of comments from pain patients themselves. https://www.statnews.com/2017/01/17/chronic-pain-management-opioids/comment-page-4/#comments