DDP Newsletter March 2018 Vol. XXXIV, No. 2
The body count from the “epidemic” of “opioid overdoses” is increasing, cutting U.S. life expectancy for the second year in a row (https://tinyurl.com/y9k2a8wz). Legislators are responding in a crisis atmosphere to cries to “do something.” Arizona legislators were pressured to vote 3 days after an emergency proposal of a law that does not take effect until 2019: No time to hear expert testimony, but the law still passed unanimously.
The narrative is that greedy, evil drug manufacturers deliberately understated the risk of addiction and encouraged liberal use of opioids in both acute and chronic pain patients. Ill-trained, gullible physicians over-prescribed. Trusting, naïve patients took a few pills for a sprained ankle and became hooked into life-long addiction.
During the pain decade of the1990s, opioid prescribing increased in response to the “epidemic” of chronic pain. Doctors were encouraged to overcome “opiophobia” and told that when used properly drugs seldom caused addiction. A study of 568,000 patients who filled a post-operative prescription for an opioid identified “misuse” in only 0.6% (BMJ 2018;360:j5790). Systematic Cochrane reviews conclude that “opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence” (cited in https://tinyurl.com/yd3l97mo). In 2016, the CDC estimated a 0.7% rate of abuse or dependence with lower doses and 6.1% with higher doses (tinyurl.com/gqfdmov).
The AMA, however, now asserts that 75% of heroin users in treatment had their addiction start with pain pills, and this is the view cited by legislators. Radio ads urge people to clean out their medicine cabinets—a pain pill that has been lurking in there for 10 years might destroy an innocent young person’s life.
As use increased, so did deaths attributed to prescription opioids, but gradually, with an average annual increase of 2.6% between 2007 and 2013 (Lilly, J Am Phys Surg, spring 2018, https://tinyurl.com/yaqhxuhv). The government launched a war on pain doctors, with an 800% increase in physician prosecutions between 2000 and 2003 (https://tinyurl.com/y8nxmya3).
State laws are limiting the number of pills that doctors can prescribe, and every state now has a Prescription Drug Monitoring Program (PDMP) to track every prescription. The National Committee for Quality Assurance (NCQA) proposes a quality measure to flag physicians as engaged in bad practice if they allow doses to remain high, regardless of how a patient is doing (https://tinyurl.com/y8xtj2fq). In Tennessee, 308 Health Department-certified pain clinics were closed in one day; 120,000 patients went through opioid withdrawal, and some died, writes Councill Rudolph, M.D. Similar laws were passed in Florida, Alabama, North Carolina, and Missouri; 6 million Americans were suddenly left without treatment. Some resorted to the black market. Some committed suicide.
Since 2000, more than 200 lawsuits have been filed against drug manufacturers. Although Purdue Pharma paid a settlement of $600 million, a winning formula for a tobacco-type bonanza has not yet been found. A new tactic, the federal government suing for restitution for the cost of repairing social damage, looks promising, as it avoids the defense of the responsibility of consumers and prescribers (NEJM 12/14/17).
The Food and Drug Administration (FDA) promotes abuse-deterrent formulations (ADFs) of opioids and allows manufacturers to use then to “evergreen” their patents, greatly increasing their profits. All OxyContin now on the market is of the ADF variety, causing added harm to addicts who try to misuse these products. Jeffrey Singer, M.D., compares this with the government’s requirement to denature commercial alcohol during Prohibition. Abuse-deterrent alcohol caused blindness due to methanol, and an estimated 10,000 deaths (tinyurl.com/ycb3wzym).
The Drug Enforcement Administration (DEA) sets manufacturing quotas for opioids. It ordered a 25% reduction in 2017, and another 20% reduction this year. FDA regulations and market forces have reduced the number of manufacturers of some drugs to one or two, and an entire plant can be shut down due to a minor infraction. Resulting shortages mean frequent undertreatment of severe pain in hospitalized trauma, post-operative, and cancer patients, writes surgeon Jeffrey Singer, M.D. (https://tinyurl.com/y8xvaqtr).
Prescriptions are now down 41% from their peak in 2010. The Trump Administration has set a goal of decreasing prescriptions by a third (https://tinyurl.com/y9v4kdou).
So, what has happened to death rates? They turned sharply upward, starting in 2013. Deaths from “pain relievers (Opioids [ICD-10 codes] T40-T40.4)” increased 43.6% in just one year, from 22,598 in 2015 to 32,455 in 2016, according to the National Institute on Drug Abuse (NIDA). The reason is obscured by NIDA’s failure to distinguish legitimate prescriptions from black-market sales (Lilly, op. cit.). The spike in deaths is exclusively from illicit heroin and fentanyl, not from legal drugs.
An additional complication is a surge in other illicit drugs. Many “overdoses” would more accurately be called “mixed drug intoxications” (Reason, April 2018). In 2016, 97% of overdoses in N.Y. City involved multiple drugs—cocaine in 46% (tinyurl.com/y9y7ljy9). What did happen around 2013 to account for the precipitous increase in drug- overdose deaths from 2013-2016? Daniel Horowitz points to two factors: ObamaCare’s expansion of Medicaid, and Obama’s immigration policy.
Medicaid expansion states account for 13 of the 15 states with the highest opioid overdose rates. Medicaid recipients obtain their drugs virtually free and often sell them on the street at a huge profit (https://tinyurl.com/yc6xkpme). While many promote more funding for Medicaid to pay for addiction treatment, a new Senate report details how Medicaid is fueling the epidemic (IBD 1/22/18, https://tinyurl.com/yauw584e).
The 540% increase in deaths from illicit opioids began about a year after the Obama Administration enacted DACA (Deferred Action for Childhood Arrivals), abolished the 287(g) program of cooperation between federal, state, and local immigration officials, and began implementing amnesty in June 2012, writes Daniel Horowitz (tinyurl.com/y7u6db7p). Some 300,000 illegal entrants from Central America have been resettled in communities dispersed throughout the U.S. The unaccompanied “children” (UACs) include many members of the MS-13 gang, noted for its homicidal violence. The Dept. of Homeland Security (DHS) estimates that as many as 30% of the UACs in custody have gang ties. The DEA states that 80% of the illicit opioids sold in the U.S come from Mexican and Central American drug cartels, disseminated by gang traffickers and illegal alien smugglers, who are protected by sanctuary cities. Obama released about 2,000 drug traffickers from federal prison during his last two years in office (tinyurl.com/ycfnbvl6).
“The drug cartels have launched chemical warfare against us—and we are helping,” Horowitz writes. First responders have required Narcan after exposure to a fentanyl overdose victim. One fentanyl derivative, the elephant tranquilizer carfentanil, is 10,000 times more potent than morphine and requires a hazmat team to handle it.
REGISTER NOW FOR 36th ANNUAL MEETING
We are looking forward to another all-star meeting in Las Vegas Aug 24-27. See enclosed program and watch ddponline.org for updates. Note July 27 cut-off for hotel reservations, and special requirements for Front Sight and the National Security Site.
DDP, 1601 N. Tucson Blvd. Suite 9, Tucson, AZ 85716, 520.325.2680, www.ddponline.org. Follow us on Twitter @d4dp.