The ongoing battle to control opioid addiction has not gone well, to say the least. Many of the government’s efforts, mostly from the Centers for Disease Control and Prevention (CDC), have been unproductive. Some have been counterproductive, medically and scientifically flawed, punitive, and perhaps most frightening, have usurped control of patient care from physicians.
Our government is now, in effect, dictating what constitutes acceptable prescribing of controlled substances, mostly opioid painkillers. That is both unprecedented and disturbing, and patients who need potent pain medications are suffering.
As Milton Friedman used to say to his colleagues, “only in government do we respond to a program that’s failing by throwing more money at it.” The omnibus spending bill, signed by President Donald Trump, will provide an additional $3 billion specifically for the over-hyped “opioid epidemic.”
Faulty Policy Based on Biased Data Analysis
Misconceptions about the nature and extent of opioid addiction are common. For example, in his statement after he signed the omnibus spending bill, Trump said: “People go to the hospital for a period of a week and they come out and they’re drug addicts.” Neither that scenario nor the nuances of the government’s statistics are accurate.
The CDC and those who accept its party line have steadfastly maintained that roughly 60,000 people die each year from drug overdoses. Most people probably assume that number represents opioid overdoses. But that isn’t true, as is evident from even a cursory look at the agency’s own data.
The 60,000 figure refers to overdoses of all drugs combined—prescription, over the counter, licit and illicit. Yet the agency continues to repeat this number, making little effort to clarify what it really means. A recent article by four CDC staffers goes partway, stating that “63,632 persons died of a drug overdose in the United States; 66.4% (42,249) involved an opioid.”
Even that number is greatly inflated, since it includes both prescription pills, such as Vicodin, and street drugs like heroin and illicit fentanyl and its analogs. This is the CDC’s most egregious “accounting” error: Heroin and fentanyl together account for about two-thirds of the opioid overdose deaths, but these street drugs in no way belong in the same category as Vicodin—they are far more potent and dangerous, not to mention illegal.
By lumping together the two dissimilar groups, the CDC can technically claim that more than 40,000 people die each year from opioid overdoses, once again implying that this number refers to prescription medication. It does not. The real number is likely in the 10,000-15,000 range.
But even that number is inflated. The CDC’s own data shows that in 2015 half of the overdose deaths involving prescription opioids also involved a benzodiazepine, such as Valium. Other published data has shown that alcohol and methamphetamine are often involved as well.
Thus, it can reasonably be assumed that the number of deaths from opioid pills alone is probably about 5,000, roughly as many people who die each year from bicycle and bicycle-related accidents. Yet, we don’t hear scaremongering alerts about a bicycle accident epidemic.
These distorted figures are important, and for reasons other than simple headline-grabbing.
The Consequences of a Persistent but False Narrative
News organizations have unquestioningly repeated the CDC figures and thereby have helped shape the current narrative—that doctors prescribed too many OxyContin pills in the 1990s and pain patients became addicted. But this narrative, although plausible, is not supported by the evidence.
Addiction in pain patients is rare. Many high quality reviews conclude that the addiction rate even of patients who have required long-term opioid medication for severe pain due to injury or illness is less than one percent. Today’s death toll from opioid use is largely the result of abuse, not medical use, of these drugs.
One Size Fits None: Opioid Pharmacology
Clinicians know that individual patients differ significantly in their response to specific opioid analgesics such as codeine or morphine. This can be explained by genetic variation in the number or characteristics of opioid receptors; differences in their ability to bind to and metabolize the drugs; and medical conditions such as reduced liver or kidney function. This explains why, in similar clinical situations, the dose of morphine needed to control pain can vary as much as 15-fold.
Thus, the need for higher doses of opioids may not be drug-seeking behavior or tolerance from past use of opioids, but may be a function of innate biological differences between people.
Compared with the general population, patients with chronic pain who require high doses of opioids to achieve pain relief often have high levels of enzymes called cytochrome P450, which are critical in the metabolism of drugs. In some cases this results in some people being “ultra-rapid metabolizers” of codeine to morphine (the actual pain-reliever in the body), which can result in toxic or even lethal levels of the latter.
Conversely, some people have genes that produce an underactive enzyme that poorly metabolizes codeine to morphine, so they may be resistant to the analgesic qualities of codeine and be unable to obtain pain relief from it except at very high doses. That has important public policy implications, because new limitations on the amount of opiates that can be prescribed and dispensed could prevent such patients from getting the amount of drug they need.
Fighting the Wrong War
Since bureaucrats and elected officials discovered they were confronting an unwinnable battle against addiction, in the name of appearing to be trying to solve an insoluble problem they declared a new enemy: opioid pills. Two-thirds of states have enacted laws that limit the prescribed duration and/or dose of these pills, decisions that should be made by physicians.
Worse still, in an effort to appear “tough,” governors are tripping over each other to outdo one another. In some states, there are now mandatory restrictions on opioids even for post-surgical patients with slow, painful recoveries. And pity the poor patients whose genes cause them to need higher doses.
Once the false narrative is peeled away, the policy flaws and the suffering they cause become evident. Deaths from appropriate and responsible use of opioid pain medications are, in fact, relatively uncommon, but the politicians and bureaucrats soldier on. Their one-size-fits-all legislative and regulatory remedies are doomed to fail and can inflict tremendous inconvenience and pain on patients along the way.
Josh Bloom holds a Ph.D. in organic chemistry and is the Director of Chemical and Pharmaceutical Sciences at the American Council on Science and Health. Henry I. Miller, a physician and molecular biologist, is the Robert Wesson Fellow in Scientific Philosophy and Public Policy at Stanford University’s Hoover Institution.