The nation’s opioid crisis is real and it is serious. As Christopher Caldwell recently pointed out, “those who call the word ‘carnage’ an irresponsible exaggeration are wrong.” And so, too, are those playing politics with the crisis. Even beyond the politicization—or, perhaps, because of it—there is still a great deal of misunderstanding as to what is driving this crisis.
As for the first problem, the politics: Senator Claire McCaskill (D., MO) has announced that she is initiating an investigation of several opioid manufacturers, and is requesting “reams of information” from them. But note the one manufacturer she did not target and from which she did not request information—Mallinckrodt. Mallinckrodt, after all, is headquartered in Missouri, her own state. Odd, that. And it’s not as if Mallinckrodt is a bit player in the manufacture and sales of opioid drugs. Indeed, “it is one of the nation’s largest” producers, responsible for nearly 20 percent of the market share of opioid prescriptions. The companies McCaskill has targeted are responsible for a total market share of 5.25 percent combined. Odd, that. If she were serious about investigating pharmaceutical companies, she most certainly would be investigating the one based in her own home state which also happens to be the one responsible for most opioid sales in America.
But all of this is not even the beginning of the beginning in addressing America’s opioid crisis. For when political leaders like Senator McCaskill are not playing politics with the issue, they are too often misunderstanding it. Some of that is not their fault.
Part of the problem in addressing the opioid crisis is that the terminology can be confusing or misleading. People hear “opioid” or “prescription opioid” or “fentanyl” and begin to lump the problems all together as a crisis driven by legitimately prescribed drugs. No doubt, that is a part of the problem, but it is nowhere near the biggest part of it. Take a look at the best statistics available (taken from the Office of National Drug Control Policy and the CDC):
- In 2015, there were 33,091 opioid overdose deaths.
- Heroin deaths constituted 12,990 of those deaths.
- Synthetic opioids (mostly illegal fentanyl) constitute another 9,580 deaths.
Because opioid deaths usually involve the use of more than one drug, percentages and raw numbers will not neatly add up to 100% or the 33,091 deaths. As the White House Website puts it: “A portion of the overdose deaths involved both illicit opioids and prescription opioids.” But what we can see from the above is that over 68 percent of the problem is from the use of illegal drugs. Or, as the CDC put it in December of 2016: “[T]he increase in opioid overdose death rates is driven in large part by illicit opioids, like heroin and illicitly manufactured fentanyl, a synthetic opioid.”
As for the prescribed opioids, the majority of overdose deaths from those come from the diversion and illegal distribution of them. As the CDC notes: “Most people who abuse prescription opioids get them for free from a friend or relative.” The people “at highest risk of overdose” “get opioids using their own prescriptions (27 percent), from friends or relatives for free (26 percent), buying from friends or relatives (23 percent), or buying from a drug dealer (15 percent).” Thus, for the population that overdoses from opioid prescriptions, 64 percent abuse them from a diverted or illegal source. In other words, the abuse of opioid prescriptions that leads to overdose deaths involving a patient acquiring a legal prescription and misusing that prescription on himself is less than 30 percent of the prescription problem and constitutes about 15 percent of the overall opioid overdose problem.
This is backed up, as well, by the most recent testimony of the Director of the National Center for Injury Prevention and Control at the CDC, Dr. Debra Houry. Just last month, she testified to Congress stating,
Although prescription opioids were driving the increase in overdose deaths for many years, more recently, the large increase in overdose deaths has been due mainly to increases in heroin and synthetic opioid (other than methadone) overdose deaths, not prescription opioids. Importantly, the available data indicate these increases are largely due to illicitly manufactured fentanyl.
Again, the main driver of our current crisis is the use and abuse of illegal drugs, not legally prescribed drugs. Indeed, there is some common sense to this. Almost anyone who has had a surgical procedure was likely given a legal opioid like fentanyl. As one prominent anesthesiologist recently wrote: “To an anesthesiologist, fentanyl is as familiar as a Philips screwdriver is to a carpenter; it is an indispensable tool in my toolbox. It is the most commonly used painkiller during surgery. If you’ve had surgery, it is more likely than not that you have had fentanyl.” And yet the vast majority of people who have had surgical procedures do not have substance abuse or opioid abuse problems.
Yes, there is a popular reverse gateway theory regarding heroin abuse—i.e., that high percentages of heroin users started by abusing prescription opioid drugs. But that is misleading and, indeed, looks at the problem from the wrong direction.
As Dr. Robert DuPont from the Institute for Behavior and Health has put it:
[W]hile 80% of heroin users used a prescription opioid before they first used heroin, the vast majority, over 96%, of people who have used a prescription opioid non-medically [i.e., illegally] have not transitioned to using heroin. Five years after the initial nonmedical use of a prescription opioid, only 3.6% ever used any heroin. Among prescription opiate users, the people most vulnerable to switching to heroin are those who are also abusers of other drugs including alcohol.
In other words, the vast majority of prescription opioid patients do not transition to the use of an illegal drug like heroin.
Other data bear this out, as well. For example, according to an important article in the January 2016 issue of The New England Journal of Medicine, it was found that “[A]lthough the majority of current heroin users report having used prescription opioids non-medically before they initiated heroin use, heroin use among people who use prescription opioids for non-medical reasons is rare, and the transition to heroin use appears to occur at a low rate.”
The numbers and factors detailed here are not meant to diminish or emphasize any serious or particular effort to address the variety of opioid issues contributing to the present crisis but, rather, to detail the full picture of the problem in sharp relief. Playing politics with this crisis will get us nowhere and waste a lot of time, energy, and resources. Public confusion about what is leading the epidemic and behind the majority of cases driving the crisis is another problem altogether, made worse by playing politics with it. It is time, past time, to get serious about this issue and take it on in a serious manner.
There are a great many efforts aimed at dealing with pill mills and irresponsible and rogue sales of prescription opioids. That is all to the good. But those efforts will not solve the problem or even get to the roots of the largest parts of it. A responsible and successful prevention campaign is needed and must be combined with serious drug education policies and messages along with a greater border and law enforcement effort. For concerned Americans, first and foremost, it is our duty to become educated about the issue.
Thank you for this eye-opening post. For those of us who actually assess and treat people with pain and/or addictive disease your data is dead on. Only a small percentage of those who are prescribled opioids for legitimate medical purposes become addicts, e.g., study in 2009 revealed that less than 4% became addicted to their pain medicne. Yet the bigger poinit in all of this is understanding the science behind who’s at high risk for addicton and who is not. There is mounting evidence that approximately 30% of Americans have a Dopamine deficiency. Simply put, they have less neurobiological assets associated with reward, pleasure and contentment. In certain environments and at certain developmental stages these individuals are at great risk for addiction. Lastly, more funding basic science research and training for doctors to provide “individualized care” is essential, if we are to help those who truly suffer with pain, while effectively preventing and treat Substance Use Disorders.
Here’s the opinion from the CDC….”We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled,2 yet there has not been an overall change in the amount of pain that Americans report.3,4 Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999.5″
It’s difficult to sympathize with those who died abusing opioids. The real victims are their families and communities who bore the brunt of their abuse. How many millions of Americans are victimised daily so these folks can feed their addictions? In truth, all of us. Either they steal from us to buy illegal heroin or we pay for their prescribed pain killers. Rarely is there a Rush Limbaugh type who pays for their own habit. The government picks up the tab for most and insurance covers the rest so we pay through higher taxes or premiums.
So Senator McCaskill has it wrong. It isn’t that pharmaceutical companies work hard to make these drugs readily available. It’s that third party payers make it easy for these drugs to be readily paid for by someone other than the abuser. Sure there will always be junkies willing to steal to feed their habits. But having to pay for the drugs would deter many folks, especially friends and family from feeding the abuse.
For folks with real chronic pain, opioids are real life saving drugs. Until we can find a non-addictive replacement, it’s morally imperative we keep them available. But that doesn’t mean society should pay for them.
30 tabs of 30mg of generic codeine costs $5. Bag of heroin costs about $5 now.
The increase in illegal drug addictions which include Heroin has greatly increased since the US Southern border has been left open by the previous administration. Heroin and methamphetamines have been coming across the border in massive quantities due to the lack of enforcement. With heroin being as cheap as it is why would any addict rely on expensive pharmaceuticals while heroin is as cheap as it has ever been? This is nothing more than the effect of having an open Southern border for the last 8 years. We have no one to thank but the Obama administration and it’s open border policies.
Harrumph! There should be a Use as Directed warning on opioid packaging.
Hilarious. Right on!
We’re learning more about the neurobiology of opioids. They suggest that the problem is even worse than Seth thinks.
Here are some highlights:
•More than a few days of use of opioids sensitizes the nervous system to pain, creating a vicious cycle with pain.
•Opioid withdrawal tends to cause full body pain even in individuals who have no other medical cause for pain.
•Tolerance develops to the analgesic effect of opioids, which generally results in the pain patient needing higher doses of the drug.
•Opioids also suppress the respiratory drive; tolerance to this effect develops to a much smaller extent than does analgesic tolerance.
•This means that a patient taking prescribed doses of opioids has a depressed respiratory drive, which compounds the adverse health effects of from sleep apnea and other conditions.
•It is likely that this depressed respiratory drive can cause or contribute to death, but since the patient might well be taking the prescribed dose, it will not be considered an “overdose.”
•When a person has a painful condition and withdraws from opioids, their condition-related pain gets worse.
•Withdrawal from opioids without triggering this problem needs to be done extremely slowly, over months to years. Few physicians have the skill or inclination to supervise this process – which is not always successful anyway.
You wrote 5 months ago however if you can site references it would be appreciated. Hope it was’nt the CDC or PROP…
I was on ‘opioids” for years due to back pain. Wife had them prescribed for her arthritis. Then came the “Hammer”. The small amounts prescribed did practically nothing to really alleviate our pain. I would say i had an initial reduction of pain about 30% and that rapidly dropped off to about 10%. I asked for a larger dose. They gave it to me. But, that barely helped. After five years I was taking them solely to hold off the pain of NOT taking them. It’s true. If you stop, your pain really increases far worse than when you started.
Then came the drug testing to make sure I was actually taking them and not selling them. I’m no criminal but they treated me as one.. And the Drug “gestapo” suddenly came! Demanding questions and a threat to my constitutional rights to own guns, to drive a car, etc. If you are taking regular prescribed opioids, even small doses and get stopped while driving and the cops find traces of them in your system, you can get charged with a felony! I was going to actually have to give up my driver license!
To H with opioids,
I asked for a withdrawal program. But, none was available on my insurance. I had to go cold turkey, which I did. It took me ten days and during that time, I came both close to suicide and close to attacking anyone near me. You can not believe how tough that was. No help at all from the docs. Withdrawal is pure hll! Then I reported to the Dr.I no longer needed the pills. “What!”- Yeah! suddenly they treated me even more like a criminal. and, yet- to my amazement -they refused to stop sending them to me! I tried to return them. Guess what? No way. There is no system designed for a patient to give them back. I was advised to go to the police and turn them in. Fk that! Cops are just waiting for a fool to walk in and admit they have controlled substances. NO WAY! Also, Dr’ said- Do not flush them down the toilet, they damage the ecology.” I was afraid to bury them for danger of kids or pets finding them. So, I dumped ’em in the commode and flushed anyway.
I won’t do that sht again! Then poor wife had to go through the same thing. Fortunately, I was there to help and we got her through it. Dr.s were amazed we did it on our own. And they then said, like idiots, we should have asked for their help. Jesus Christ!! We did! No help was available at all!
The government screws up everything they touch. It would have been easier to get our drugs on the black market and go to experienced drug dealers for help.
Anyway. Won’t do that sht again! If you can grit through your pain, do it. It’s far better than getting yourself involved with screwball Doctors and insurance companies obliged to work with even goofier government regs. Besides, the weak assed drugs they offer are completely useless in really helping ease your pain. And they super screw up your body–constipation, edginess, the fear of running out of the drugs, the hassle to deal with the prescriptions, the fear of driving and getting stopped, and all the pure bull sht! And the benefit to real pain reduction is practically nothing! Tylenol works just about as well in the long run.
If they would give you something that really worked on the pain, yeah, it would probably be worth it. Hysterically, I found that the one drug the Dr.s abhore and are constantly warning against, alcohol, works ten times better. And I don’t need a prescription to get it. When my back really starts singing, I just get me a big bottle of vodka and lay up with it for a few days. Works great! Do not drive while using it, of course!
Thank you for sharing your story. You & your wife both showed a great deal of courage to go through withdrawal cold turkey. Not sure it’s for everyone. I have heard it can kill you. Wish you two the best from now on. God bless.
Appreciate your kind words. The current system is so balled up it is basically a terrible danger to the patients. The thing I have learned since is there are some really excellent drugs out now to really control pain. They are highly restricted because the gvt does not want them on the street. So people suffer terribly for no reason other than gvt does not want to do the job they were intended for int he first place, which is simply enforcing the law. The law is jumbled up now to be so complex every felony arrest can cost the gvt millions by the time they go from arrest to trial to final day of incarceration. So they try enforcement by ever stricter prohibition which really only makes the whole thing worse for everyone.
The 33 year old son of good friends died of a heroin overdose last year. He had become addicted to narcotics after a back injury. Somewhere along the way, he turned to heroin when the Drs wouldn’t prescribe for him any longer. Heroin is cheap. 0.2g bag is $5-$10.
His parents, brother, and sister were/are devastated.
Glad you saved yourself – and your wife.
These drugs have a purpose and a use. But, the government has totally ruined the way they can be useful and has done nothing but make them a devastation and ruin thousands of lives. You should hear how my law enforcement friends talk about them. To them, they are pure job security. I tell them; Some day you will need help with pain. Then you will see for yourself.
I’m very sorry to hear about your friend’s son. I’ve had two friends who survived Vietnam with horrible wounds and you would not believe the agony they went through because the gvt simply pulled the pain killers out from under them. And here the government has laws against torturing enemy combatants. And yet they have absolutely no regard for how the policies and laws they make up on drugs cause unimaginable agony for our very own vets. It’s unbelievable.
This video explains it well!! https://www.youtube.com/watch?v=6UyPlF66KME
The Neurobiology of Opioid Abuse. Mu-opioid receptors are the target of heroin and other prescription opioids, which is the underlying neurobiology responsible for endemic addiction morbidity and mortality in the US. Mu-1 Opioid Receptors are not only in the brain. Constipation, for example is a common side effect of opioid abuse, becasue MU-1 Opioid receptors are abundant in the lower GI system.
Opioids in the Brain
The opioid system consists of three receptors, mu, delta, and kappa. Opioid receptors are activated in response to natural rewarding stimuli and by drugs of abuse, which causes neuroadaptation of opioids and their receptors as addiction develops.
Charbogne and colleagues (Journal of Biopsychiatry, 2016) report that Naloxone reversible, Mu opioid receptors (MORs) mediate analgesic, euphorigenic, and other biological effects of opioids. Yet the aberrant activation and modifications of the mu opioid system associated with drug craving and relapse are not well understood.
Behavioral analysis of OPRM1 mice shows that this population does regulate locomotor and motivational effects of heroin. These receptors do not contribute to heroin-positive reinforcement. Beyond a well-established role in reward processing at the level of local ventral tegmental area neurons, MORs moderate motivation for appetitive stimuli and motivation to obtain heroin and food reward, revealing a yet unreported role for MORs within addiction circuits. Several brain areas responsible for MOR-mediated reward have been identified. Yet more research is needed to establish the key underlying molecular function of the system and to locate neural sites where opioid peptides and receptors contribute to the onset of addictive disease.
Why Does This Matter?
We wonder why do some people exposed to prescription opioids become addicts quickly, others slowly and others never do. We also have wondered about individual differences in opioid medication response, toxicity, addiction, and relapse. Genetic association studies reveal that the OPRM1 A118G genotype (found in up to 30% of Caucasian and 60% of Asian populations) increases the risk of heroin addiction. Accordingly, more genetic research is needed to further elucidate our understanding of the biology of addiction and for the development of therapeutic interventions to treat the disorder.
Reference
Charbogne P, Gardon O, et al. Mu Opioid Receptors in Gamma-Aminobutyric Acidergic Forebrain Neurons Moderate Motivation for Heroin and Palatable Food. Biol Psychiatry. 2016 Dec 26. pii: S0006-3223(16)33156-0. doi: 10.1016/j.biopsych.2016.12.022.