26 March 2018,

Over at Reason, Jacob Sullum has written a much-needed corrective to the prevailing narrative about opioid addiction — that there is a widespread problem of “accidental addiction” among pain patients. It’s a destructive narrative, because it makes it more difficult for people in real pain to find doctors willing to treat them.

From Sullum:

Contrary to the impression left by most press coverage of the issue, opioid-related deaths do not usually involve drug-naive patients who accidentally get hooked while being treated for pain. Instead, they usually involve people with histories of substance abuse and psychological problems who use multiple drugs, not just opioids . . .

But the truth is that patients who take opioids for pain rarely become addicted. A 2018 study found that just 1 percent of people who took prescription pain medication following surgery showed signs of “opioid misuse,” a broader category than addiction. Even when patients take opioids for chronic pain, only a small minority of them become addicted. The risk of fatal poisoning is even lower—on the order of two-hundredths of a percent annually, judging from a 2015 study.

Despite such reassuring numbers, the government is responding to the “opioid epidemic” as if opioid addiction were a disease caused by exposure to opioids, a simplistic view that ignores the personal, social, and economic factors that make these drugs attractive to some people. Treating pain medication as a disease vector, the government has restricted access to it by monitoring prescriptions, investigating doctors, and imposing new limits on how much can be prescribed, for how long, and under what circumstances. That approach hurts pain patients by depriving them of the analgesics they need to make their lives livable, and it hurts nonmedical users by driving them into a black market where the drugs are deadlier.

A large majority of opioid-related deaths now involve illicitly produced substances, primarily heroin and fentanyl. As usual, the government’s efforts to get between people and the drugs they want have not prevented drug use, but they have made it more dangerous.

According to a 2014 analysis of data from the National Survey on Drug Use and Health (NSDUH), 54 percent of nonmedical users got prescription opioids for free from friends or relatives. Another 16 percent bought or stole pills from friends or relatives, while 4 percent bought them from strangers. About 6 percent mentioned other sources, including online purchases, forged prescriptions, and theft from doctors’ offices or pharmacies. Just 20 percent of nonmedical users said they obtained opioids through prescriptions written for them.

Although some people who now obtain opioids indirectly may have had prescriptions at some point, these results undercut the notion that nonmedical users typically start as bona fide patients. Even among the heaviest users, just 27 percent had prescriptions at the time of the survey, and it is not clear how many of those were legitimate at the outset. In most cases, says Sidney Schnoll, a physician specializing in addiction and pain treatment who works for the consulting firm Pinney Associates, “These are people who were drug-seeking. They are not people who went to a physician, got a prescription, and suddenly became addicted to the drug.”

. . . A study reported in The BMJ this year tracked 568,612 opioid-naive patients who took prescription pain medication following surgery and found that 5,906, or 1 percent, showed signs of “opioid misuse” during the course of the study, which included data from 2008 through 2016. Although some studies have described “rates of misuse, abuse, and addiction-related aberrant behaviors” as high as 26 percent among chronic pain patients, Volkow and McLellan reported, “rates of carefully diagnosed addiction” average less than 8 percent.

Fatal overdoses among patients are even rarer. A 2015 study reported in the journal PLOS One followed chronic pain patients treated with narcotics for up to 13 years and found that one in 550 died from an opioid-related overdose, which is a risk of less than 0.2 percent over the course of the study. A 2015 study of opioid-related deaths in North Carolina, reported in Pain Medicine, found 478 fatalities among 2.2 million residents who were prescribed opioids in 2010, an annual rate of 0.022 percent.

Despite what you may have read elsewhere, the Drug Enforcement Administration hasn’t exactly been going easy on doctors who overprescribe. In the 1990s and 2000s, the agency targeted lots of doctors with highly publicized investigations. (I know this because I wrote about some of them.) The intent of these investigations — and the news conferences and media releases that went with them — was to scare doctors away from prescribing opioids. It worked. A lot of competent and conscientious doctors left pain treatment.

But the pain their patients were experiencing didn’t go away. The demand for relief persisted. Unfortunately, but not at all surprisingly, that demand was filled by less scrupulous, less careful “pill mill” doctors willing to write prescriptions for addicts and legitimate patients alike, with about the same amount of care and attention for either. (The government and anti-opioid interests also tend to conflate addiction with dependence, which is a separate problem. Diabetics, for example, are dependent on insulin. They aren’t addicted to it.)

The basic problem here is that drug cops shouldn’t be dictating medical policy. If doctors are overprescribing, medical licensure boards should intervene. But as we saw for decades with the medical use of marijuana, when it comes to controlled substances, drug warriors don’t see nuance. They tend to view intoxicating drugs with a Puritan fervor. The research suggests that one way to get more people off opioid painkillers, for example, would be to ensure better access to medical marijuana. The current U.S. attorney general isn’t having that. He advises people suffering from chronic pain to take an aspirin instead.

We need rational, evidence-based opioid policy that balances the the medical needs of people in pain with the government’s interest in preventing addiction and overdose deaths. Right now, the latter is dominating the debate. Worse, it’s not at all clear that limiting access to prescription opioids actually prevents addiction and overdose.

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