The Washington Post recently received access to a database maintained by the Drug Enforcement Administration that tracks the manufacture and distribution of every prescription opioid in the country. It reported that 76 billion pills were distributed throughout the US between 2006 and 2012, with higher volumes shipped to the areas that were most hard hit with opioid-related overdose deaths.
This is being offered as proof that the overprescribing of prescription opioids caused the overdose crisis. But this flies in the face of other powerful evidence. Research reported in the Journal of Pain Research last February that examined data from the National Survey on Drug Use and Health as well as the Centers for Disease Control and Prevention show there is no correlation between the number of pain pill prescriptions and “past-month nonmedical use” or past-year diagnosis of “pain reliever use disorder” among adults. This was corroborated by a study published by the Cato Institute the same month.
Research from the University of Pittsburgh shows overdose deaths from nonmedical use of licit and illicit drugs have been on a steady exponential increase since the 1970s, with no evidence of slowing. The only changes over the decades pertain to the particular drug in vogue during any period. In the early part of this century, the drugs in vogue were diverted prescription opioids.
To be sure, the lure of easy money offered by a black market fueled by drug prohibition brings out the worst in people, and doctors and pharmacists were no exception. Some doctors and pharmacists leveraged their professional licenses and teamed up with regional drug dealers to supply nonmedical users with large quantities of their preferred drug. But the blame for such behavior should be placed where it belongs: drug prohibition.
Those unethical health care providers were the exception, not the rule. And they were providing drugs to mostly nonmedical users, sometimes under the guise of providing patient care. Meanwhile, the nonmedical use of prescription opioids peaked in 2012, as heroin became cheaper and more available than diverted pain pills. The prescription of high-dose opioids peaked in 2008 and the number dropped more than 58 percent by 2017. Yet the overdose rate accelerated as the prescription numbers decreased, because nonmedical users migrated to more readily available heroin and fentanyl. By 2015 there was already evidence that heroin was becoming the new drug in vogue, as up to one-third of heroin addicts undergoing rehab stated they initiated drug use with the opioid heroin.
The CDC released preliminary estimates of 2018 opioid-related overdose deaths July 17, and they suggest the death toll may be tapering off slightly, down to 47,590 from roughly 49,000 in 2017. One aspect of these numbers the media failed to report was that 67 percent of those deaths involved illicit fentanyl, one-third involved heroin, and just under one-third also involved cocaine. About one-fourth of opioid-related overdose deaths involved any prescription pain killer, and more than three quarters of them also involved heroin, fentanyl, cocaine, or tranquilizers.
The overdose problem has never been a product of doctors treating patients for pain. It has always been a product of (a growing population of) nonmedical users accessing drugs in a dangerous black market fueled by drug prohibition. While the possible downturn or leveling off in the mortality rate is encouraging, this can largely be attributed to the adoption of harm reduction measures, such as naloxone distribution and needle-exchange programs, which need to be more widely-adopted.
The number of opioids prescribed greatly increased during the early part of this century, as doctors were–rightly–encouraged to be more concerned with alleviating pain and patients were–rightly–assured that opioids in the medical setting have a low overdose and addiction potential. That meant more pain pills were available for diversion to the black market for nonmedical use. And, as mentioned above, there were some doctors and pharmacists who were unethical and unscrupulous. But, at the end of the day, there is no correlation between the number of pills prescribed and the incidence of nonmedical use or use disorder.
The continued obsession about the number of pain pills being prescribed causes patients to go undertreated for their pain and will not make one IV drug user pull the needle out of their arm.