It's the Fentanyl, Stupid. But Politicians Still Target Pain Pills.

In 2018 Sen. Elizabeth Warren (D-MA) and five other lawmakers wrote a letter to the DEA urging the agency to hurry up and finalize a new regulation that would permit pharmacists to partially fill opioid prescriptions, to reduce the number of unused opioids in circulation, as a way to presumably address the "epidemic" of drug overdose deaths. 

But it's now 2020 and we are supposedly more educated and enlightened about the so-called "opioid epidemic" (1). So, one might expect that the persistent but distorted mindset – that pain pills are responsible for the rash of overdose deaths – would have been filed away under "stupid s### we used to believe." One would be disappointed. It hasn't been filed away and it's not likely to be anytime soon.

Last week Warren, Rep. Katherine Clark (D-MA), and others (2) once again called out the DEA for "dragging its feet" by not finalizing the partial fill regulation. 

The lawmakers wrote “More than 50,000 Americans died in 2019 due to an opioid overdose — with tens of thousands more likely experiencing a nonfatal overdose," once again propagating a longstanding lie that analgesic drugs like oxycodone and hydrocodone are the primary contributors to our "epidemic." 

On the surface, it would seem that the new regulation would be harmless, possibly even helpful. For example, it would enable someone with a prescription for 20 Vicodin tablets to tell the pharmacist "Gee, I don't really need 20, just give me 15 (1)." (As if that's ever going to happen in this universe.) What is far more likely is for the pharmacist to say "you only need 15, not 20" which isn't the least bit difficult to believe since pharmacists have been haphazardly imposing their own limitations prescriptions for years :

"As a patient advocate and healthcare writer who is very active in social media, I see reports from thousands of patients who have been denied a refill of valid prescriptions for opioid pain medications.  This is particularly true for prescriptions at high doses.  And it is a trend reinforced by insurance providers and pharmacy chains as policy without scientific support. It's pretty obvious that Elizabeth Warren and her colleagues literally don't know what they are talking about."

Richard "Red" Lawhern, Ph.D., Co-founder of the Alliance for the Treatment of Intractable Pain, and a member of the ACSH Scientific Advisory Board

Worse still is that regulations like the ones Warren is pushing for reinforce the "must limit pills" mantra, which has done nothing but cause more patient suffering and, perversely, more overdose deaths. Need some evidence? Happy to oblige. 

I've written many times (most recent) that the term "synthetic opioids" should not be used. It is misleading and probably intentionally so because it is not "synthetic opioids" that are killing people; it's illicit fentanyl and its analogs, Don't try to disguise the truth using wordsmanship. That's not playing fair. 

We can see just this in the most recent annual CDC report. I'll break this down later but for now, just look at the last column because it tells one chapter of the story of what is really happening in the US. There's that insidious term "synthetic opioids" again. It may obfuscate the truth from a casual observer, so let's "unobfuscate" the data. Note the fine penmanship.

Source: NCHS Data Brief, Number 356, January 2020 (CDC)

I've taken the liberty of enlarging the most relevant part of the table so that those of you who don't have x-ray vision might be able to read it. Let's look at what happened between 2014-18 during which time prescriptions for opioid analgesics decreased by 32%.

The column on the left shows that overdose deaths involving any opioid increased by 50% over the five-year span despite a 32% drop in scripts. So much for the concept that writing fewer prescriptions for pills will result in fewer opioid overdose deaths. It resulted in more, as drug abusers and undertreated patients switched from less dangerous prescription drugs to deadlier street drugs. You can see this in the next column.

Death involving heroin rose by 42% during that time. The middle column again tells us that deaths involving so-called "natural and semisynthetic opioids" (2) were unchanged over this time interval. This is one of two key stories that correctly define the "opioid epidemic" in the US – the torment of pain patients for no good reason. That's not something you're going to hear on from politicians, is it? 

Skip methadone – the fourth column – I don't even know why it's included. But pay special attention to the column on the right because this is the second key story. Between 2014 and 2018 overdose deaths skyrocketed as Illicit fentanyl from China began to infiltrate the US. By 2018 fentanyl was by any measure the primary killer – the drug that caused more deaths than any other (4). In those five years, fentanyl-related deaths soared by more than five-fold and they have risen since then.

During a time in which pain patients were being force-tapered from their medicines against their will or cut off completely, the US saw about 18,000 more deaths from illegal opioid drugs while the rise in deaths involving pain pills was approximately zero. Nice work, folks. Maybe Warren's plan to dispense even fewer pills will help prevent more deaths, but I doubt it...

Duh. Image: Amazon.com

Data for the first half of 2019 is just more of the same, but don't you just love the graph?

Deaths involving prescription opioids were absolutely swamped by those of four street drugs. Graph: Pain News Network, CDC

The above graph really brings the message home. Illegal street drugs were involved in almost 84% of overdose deaths, yet we continue to torture people who were functioning well for years taking (sometimes) high opioid doses but are now confined to bed with unremitting pain and fantasies of suicide. What a mess.

Finally, perhaps Sen. Warren might want to return to Massachusetts for a visit and some fact-finding. Part of her letter states... 

"More than 10 million people aged 12 and older reported abusing an opioid in the past year, with over 50 percent of those who abused a prescription pain reliever reporting that they obtained it from a friend or family member, and just 37 percent as a prescription from their doctor.

I'm not sure where Sen. Warren got her information, but a 2019 study of her own state concluded that between 2013-15 only 1.3% of overdose victims had a prescription. Quite a discrepancy.

Although the pain community has begun to fight back little has changed over the past five years. Lawmakers and bureaucrats continue to fight the wrong enemy. The result is more suffering and more death. These data show that there cannot possibly a different outcome. Shameful. 

NOTES:

(1) Pharmacists may not dispense partial prescriptions unless there is not enough supply. Then they can do partial refills. 

(2) The other signatures on the letter were from Sen. Dianne Feinstein (D-CA), Rep. Steve Stivers (R-OH), and Senator Shelley Moore Capito United States Senator (R-WV).

(3) More ridiculous nomenclature. Semisynthetic is a synthetic derivative of one of the "natural" chemicals in poppy. It is meaningless and confusing. For example, heroin is semisynthetic while morphine is natural. Codeine is natural but oxycodone is semisynthetic. This ridiculous classification is antiscientific and confusing. It makes not one iota of difference whether a drug is obtained from a plant or made in a lab. Only the chemical structure and properties of the drug matter. 

(4) That is, except for alcohol, which causes 88,000 deaths per year. Why no crisis?