Federal policymakers are finally starting to rethink their failed opioid policies that are based on the mistaken narrative that America’s overdose crisis is the direct result of doctors overtreating their pain patients with opioids, condemning them to a life of addiction. Now the streaming service Hulu comes out with a new miniseries, based on the 2018 book Dopesick, threatening to breathe new life into this false and dying narrative.
Beth Macy’s 2018 powerful book, along with 2019’s Dreamland by Sam Quinones, caused policymakers to adopt the false narrative that America’s overdose crisis is the direct result of doctors over‐treating their pain patients with opioids and turning them into “addicts.”
State and federal policymakers embarked on a concerted effort to reduce opioid prescribing, hoping this would stem the rising tide of overdose deaths. Prescriptions of opioids per 100 persons have dropped nearly 50 percent since 2012. Almost simultaneously the overdose rate has surged from roughly 40,000 in 2012 to 93,000 in 2020. Meanwhile, pain patients suffer from pain and mental anguish—especially veterans—as doctors abruptly taper or deny opioids to treat their pain.
Government data show no evidence of any correlation between the number of opioids prescribed and the non‐medical use of opioids or of opioid addiction. And researchers at the University of Pittsburgh provide clear evidence that overdoses from non‐medical drug use have been growing exponentially since at least the 1970s, long before the Food and Drug Administration approved OxyContin in 1996, with different drugs predominating among the overdoses at different points in time.
In the late 1990s and early 2000s the drugs of choice for non‐medical users were “diverted” prescription opioids like OxyContin. By 2012, as opioid prescribing started dropping, making fewer prescription pills available for diversion to the black market, non‐medical users moved to heroin. In 2020, 83 percent of opioid‐related overdose deaths involve fentanyl and its analogs.
As my co‐authors and I pointed out in the Journal of Pain Research in 2019:
Americans increasingly have been engaging in the non‐medical use of licit and illicit drugs since the late 1970s. Some of this drug use may represent self‐medication in response to anxiety, depression, alienation, and despair. The rising incidence of drug‐related deaths among nonmedical users also indicates that they are facing bigger risks today, probably because potency has become more difficult to predict and possibly because doses have increased and drug mixtures have become more reckless. However, policymakers and the media tend to favor simple explanations and solutions for complex problems, and the opioid overprescribing narrative is no exception. However, as Mencken observed, “There is always a well‐known solution to every human problem” that is “neat, plausible, and wrong”. The standard explanation of the overdose crisis is wrong, and the policies it has inspired are not only ineffective, but harmful.
The standard explanation of the overdose crisis is also based upon a tendency to conflate physical dependency on a drug with drug addiction. There is a big difference, as I point out here.
Physical dependence represents an adaptation to the drug such that abrupt cessation or tapering off too rapidly can precipitate a withdrawal syndrome, which in some cases can be life‐threatening. Physical dependence is seen with many categories of drugs besides drugs commonly abused. It is seen for example with many antidepressants, such as fluoxetine (Prozac) and sertraline (Zoloft), and with beta blockers like atenolol and propranolol, used to treat a variety of conditions including hypertension and migraines. Once a patient is properly tapered off of the drug on which they have become physically dependent, they do not feel a craving or compulsion to return to the drug.
Some also confuse tolerance with addiction. Similar to dependency, tolerance is another example of physical adaptation. Tolerance refers to the decrease in one or more effects a drug has on a person after repeated exposure, requiring increases in the dose.
On the other hand, addiction is defined as compulsive behavior despite harmful consequences. Many experts view it as a behavioral or learning disorder as opposed to an organic brain disease. Regardless of the etiology, as Drs. Nora Volkow and Thomas McLellan of the National Institute on Drug Abuse pointed out in this New England Journal of Medicine article, when people are placed on opioids for the treatment of pain, addiction is very uncommon, “even among those with preexisting vulnerabilities.”
Based upon a “neat, plausible, and wrong” narrative, policymakers cast in stone the then‐controversial Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, etching into policy what the CDC explicitly stated was not “settled science,” but what were meant to be general rules of thumb to aid practitioners, and would be:
[V]oluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.
Most of the CDC guidelines were based on “type 4 evidence,” which the CDC defined as, “clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations.”
Policymakers have gradually become aware that their ham‐handed approach to the overdose crisis, based upon a flawed and simplistic narrative, is doing more harm than good. Patient advocacy groups increasingly object to the undertreatment of their pain, and the way in which the flawed narrative stigmatizes them as people with “addictive personalities” who are “drug seekers.” They plead with policymakers to drop the narrative and follow the science.
Aware of the misinterpretation and misapplication of its 2016 guidelines, the CDC issued an advisory in April 2019. The agency announced in December 2019 that it planned to update its guidelines. And the FDA held a “public workshop” last August entitled, “Morphine Milligram Equivalents: Current Applications and Knowledge Gaps, Research Opportunities, and Future Directions.”
Daily morphine milligram equivalent caps are a part of the guidelines that states codified. The stated purpose of the workshop is to “provide an understanding of the science and data underlying existing MME calculations for opioid analgesics, discussing the gaps in these data, and discussing future directions to refine and improve the scientific basis of MME applications.” (emphasis added)
Purdue Pharma and other drug makers may have been untruthful and overly aggressive in marketing prescription opioids. I am not here to defend their practices or absolve them of any guilt. But if the last 20 months of the COVID-19 pandemic have taught us anything, it should be that biological science is rarely settled, it is usually nuanced, and that neat and simple explanations are usually wrong. Just when those responsible for our misguided opioid policy are coming to this realization and reevaluating their approach, Hulu releases a miniseries that is sure to fuel the passions and might cause them to backslide.
# Reprinted with permission. Dr. Singer's October 11 blog on the Cato Institute site can be read here.
