By R Carter
When dealing with a complicated problem, everyone knows context matters and few things are any more complicated than the current issue of drug addiction and the manner in which it has been linked to pain management with opiates. Today in the minds of many, the two subjects are literally one and the same, with a bottom line of trying to save us all from addiction to opiates.
If your like most people you’ve read the headlines and followed government’s efforts. Yet while government sounds compelling, there’s probably been a lingering doubt that there’s more to the opiate crisis than what you’re told.
This happens to be the position held by those in the chronic pain community. There is deep resentment within those ranks for the manner in which government ignores their letters and phone calls calling for a voice in how decisions are made. With more than two million chronic pain patients taking opiates daily, in order to remain functional productive members of society, most see the government’s response as an assault on their livelihoods and families, for others it is an assault on their lives. With some who have been force tapered or terminated from pain medications, taking the route of suicide, it’s hard to ignore such claims from the chronic pain community.
The charts in this post are intended to reflect how polydrug use, more than any other behavior, is responsible for the spike in overdose deaths. Even when combined with prescribed opiates, polydrug use with illegal substances remains the leading cause for overdose deaths. It’s this behavior which separates the two million chronic pain patients taking opiates from the drug abuse and overdose phenomena.
In this post I dive deeper into data published by the Ohio Department of Health. I’m using the same overdose data they use to inform and frighten us with. I’ll pull back the curtain a bit and show the reader what’s going on with other drugs of abuse. By doing so I hope to show how the opiate crisis is more than a prescribing problem with physicians, one which is far larger than pain patients taking opiates. While government continues to emphasize prescription opiates as the cause, I try to persuade the reader that such a scenario is more fiction than fact and provide corrective steps which could lead to better regulations for all concerns.
The data for this post, like data from all states, eventually gets shared with the CDC. I hope to show the reader that context is critical when drawing conclusions, especially for regulations which can imprison doctors and deny needed medical care to millions of Americans.
The NIH estimates that 95% of all overdose poisonings involve multiple substances. Even when attributed to prescription opiates, an overdose usually involves as many as six drugs, yet the rush to judgment on prescription opiates ignores such facts.
|The current context sold to the American public|
The 2016 CDC Guidelines for Chronic Pain Management has left many, both in and out of healthcare, scratching their heads in disbelief. How could data collected for short term, acute pain of opiate naïve patients, be in any way related to long term, chronic pain in opiate tolerant patients? The two groups literally represent opposite ends of a spectrum. Yet this is the pseudoscience which public health, legislators, state medical boards, private clinics and hospitals have accepted as fact.
The war on opiates started in 2010 as a war on opiate overdose deaths, but even then the blame was laid at the feet of physicians for over prescribing, based only on data for the number of opiate prescriptions written. At the same time an effort to connect the dots between prescribers and overdose victims began. Government agencies have tried to cross reference death certificate data from NVSS (National Vital Statistics System under the CDC ) with other sources such as AAPCC (American Association of Poison Control Centers) the NIS (National Inpatient Sample), the SAMHDA (Substance Abuse and Mental Health Data Archive) and others, all with mixed and incomplete success.
The Federal government defines the minimal standards for collecting death certificate data, but it’s the responsibility of states to actually do the work on their own budgets. Until all states can adopt such standards, changes at a Federal level remain delayed for up to a decade or longer. The last major update to the death certificate record occured in 2003. Since states bare the cost, states can also respond beyond the minimal standards and some do, collecting details which allow context, color and depth where none exists at a Federal level.
The charts used in this post will make use of this additional data from the State of Ohio to make it’s case for why context matters when drawing conclusions and passing regulations.
|Where the data gets skewed or should we say, screwed|
Data reported by the CDC is the lowest common denominator; it has to be, otherwise it wouldn’t reflect our nation as a whole. This makes CDC data inadequate for how it is used it’s not granular enough to separate legally prescribed opiates from illegal street drugs, even with toxicological results. To have accurate reporting on prescription opiate, data must be cross referenced with PDMP data. Without PDMP data it all gets lumped together as one kind of data, which is what we see reported by the CDC.
For example, Heroin is converted to morphine thirty minutes after injection, and most Heroin is cut with Fentanyl, both of which are indistinguishable from prescribed versions of the same drugs. Inconsistencies created by a lack of standards for completing a death certificate also create aberrations and gaps, making the data inaccurate and misleading.
At the 2018 ASTHO (Association of State and Territorial Health Officials) meeting, they outlined a number of key problem areas in the completion of a death certificate. These problems reveal how unreliable and misguided the current form is for how it is being use. (See this link for a full report).
The problems identified were:
- Inadequate interoperability across systems used to support death certification.
- A lack of computers in all offices, also outdated hardware and software.
- Inability to access or share data from other system such as PDMP’s, Crime Labs and EHR’s.
- Inability of toxicology labs to access PDMP or crime lab data.
- Toxicology testing techniques and methods which are not keeping pace with emerging illicitly manufactured synthetic opioids i.e. Fentanyl and analogs, counterfeit hydrocodone, oxycodone and others.
- Developing and adopting toxicological standards for all states.
- Training and education for coroners, death investigators, and medical examiners is lacking.
- Death certifiers need specific guidance on how to complete the death certificate.as well as standardized rules for completion. Too many death certificates have missing data are incomplete or vaguely generalized.
- Drug Intoxication Deaths which have more than One Drug Present don’t reflect such findings.
To get around these problems the CDC uses a computed value (NCHS Automated Coding System) to make a guess at whether or not a death certificate’s cause of death reflects a drug overdose death. Yet no one outside the CDC knows exactly what criteria goes into this guess work or how reliable it is, given the rapidly changing scenarios around drug overdose deaths.
Figure 1 uses the same criteria and filters used by the CDC to report prescription opiate overdose deaths, except this chart use data from Ohio only. The ICD-10 codes used in these charts can be reviewed in this link, the official document published by the World Health Organization can be viewed on this link WHO-ICD10 Codes. These totals in Figure 1 are often those published in government press releases and attributed to prescription opiates. As you will see in the next two charts, they do not reflect the true facts when cross referenced with PDMP data.
Figure 2 is a special chart prepared by the Ohio Department of Health which includes data from death certificates and is cross referenced with PDMP data which excludes Heroin and Fentanyl. Ohio law allows sharing PDMP data with other state agencies, as do another eight states including WA, TX, KS, IL, IN, WV, FL and ME, see this document published by the CDC. Data has been backfilled from existing records prior to 2016, as is implied on Ohio websites.
Figure 2.5 includes Fentanyl and Analogs plus prescription opiates, cross referenced with Ohio’s PDMP data. The noticeable spike in overdose deaths which appears will be reflected in subsequent charts for polydrug use and years 2014 – 2019. The spike is not an increase in prescribing and may reflect a large number of individuals turning to the black market once restrictions began taking effect around the same time based on reports from law enforcement documenting an increase in illicit Fentanyl also appearing at the same time. As of 2019 law enforcement and street drug users coming out of treatment, report most black market drugs are now cut or laced with Fentanyl as black market entrepreneurs attempt to enhance a customers physical dependence on these substances and or cut costs and raise profits.
All remaining charts do not use PDMP data.
It’s known that most overdose deaths include multiple drugs yet the CDC fails to provide any context as it relates to prescription opiates. This failure could be coincidence as the CDC only publishes the lowest common denominator of data collected by all states. Since most states don’t allow sharing data between PDMP’s and Vital Statistics, the numbers for overdoses deaths includes both legal and illegal sources similar to those in Figure 1.
This grossly misleading fact is not addressed in public reports issued by the CDC or any other government agency. This can only be viewed as deliberate when it is a well understood fact at both a state and federal levels.
Further complicating the totals on polydrug use are black market sources which have become quite sophisticated at producing counterfeit drugs which are indistinguishable from those produced by legitimate manufacturers. While methods exist for discovering trace elements which would identify these sources, most states don’t perform this type of testing, despite recommendation from ASTHO.
Instead this becomes a license to misrepresent facts and politicize the data, resulting in the incarceration of physicians and prescribing restrictions placed on doctors and patients. This distortion of facts has allowed some without ethical boundaries to attack innocent doctors with claims of over prescribing.
Prescribing limits set by medical boards have become a tool for eliminating a competitor from practice or from a position of influence. There are several accounts of this, occurring with greater frequency. Examples would be Mark Isben and more recently Dr. David Neff who was the head of Michigan’s Medicaid program.
As dramatic as the opiate crisis may seem, another may be playing out alongside it, one which may be based on white collar corruption, for the sake of power, influence or financial gain.
|Polydrug use and its impact on drug overdose data|
Current prescribing guidelines in every state require routine drug screens and when noncompliance is found, patients are discharged from medical care and reported. Physicians who fail to comply with these guidelines are prosecuted without exception.
With physicians monitoring patients by using urine drug screens and PDMP data, polydrug use is a behavior, which for the most part, is limited to street addicts and recreational drug users. It’s the only rational answer for why overdose death rates continue to climb. Still, a system of no tolerance for physicians, restrictions on prescribing and tight control over production, prescribing and dispensing, hasn’t been in effect long enough to make it a far gone conclusion that all these measures will likely produce the desired results.
If prescription overdose death rates continue to drop through 2022, cross referenced by PDMP data, then regardless of the overdose rate for polydrug use, regulators will be forced to reevaluate current restrictions. Anything else would be viewed as anything, but an attempt to right a wrong that will improve the health of Americans.
The remaining charts look at Prescription Opiates not cross referenced with PDMP data and are typical for those reported by the CDC. These reports stand in stark contrast to the two previous charts, Figures 2 and 2.5, which are cross referenced with PDMP data.
This fact reveals how deeply skewed CDC data is, which should set off alarms for those watchdog groups and healthcare officials who monitor government regulatory efforts.
In these remaining charts, for a substance to be included on a chart, it must be hand written onto the death certificate. Meaning the physician recording the data has confirmed the substance through toxicology.
Figure 3 represents legally prescribed opiates plus illicitly obtained prescription opiates, plus Heroin cut with Fentanyl.
Figure 4 represents the same groups of opiates as Figure 3 plus alcohol.
Figure 5 represents the same groups of opiates as Figure 3 plus Cocaine.
Figure 6 represents the same groups of opiates as Figure 3 plus Fentanyl or an analog. Fentanyl in this context, particularly between 2014 – 2019, comes from illegal sources
Figure 7 represents the same groups of opiates as Figure 3 plus Heroin..
Figure 8 represents the same groups of opiates as Figure 3 plus Heroin, plus Fentanyl. The data in Figures 8 and 9 strongly correlates with previous charts between 2014 and 2019, providing evidence which supports illegal drug use as opposed to prescription drug use. Further evidence for this is found in Figures 2 and 2.5.
Figure 9 represents Heroin and Fentanyl only. The spike in overdose deaths between 2014 – 2019 strongly correlates to other charts where prescription opiates are include, such as Figure 8. Together charts 2, 8 and 9 raise these questions.
- Do the higher overdose death rates for prescription opiates in Chart 2 between 2007 – 2014 as compared to Charts 8 and 9, reflect polydrug users scamming the system for prescription opiates
- Using false IDs, stolen prescription pads, paying cash for medical services, insurance fraud and other tricks.
- Once controls went into place, specifically penalties for prescribers, PCP’s refusing to treat chronic pain and such, were polydrug users who scammed the system, turning to the black market despite the safety issues in doing so? Leading to a spike in overdose deaths between 2014 to the present?
- Were legitimate pain patients who were force tapered or terminated also turning to the black market?
Chronic pain patients compliant with medical directions, monitored by a physician and confirmed through urine drug screens are likely not in these numbers, although there is no way to confirm this. Yet due to their numbers which is greater than 2 million, they make up the majority of chronic pain patients treated with opiates.
Figure 10 represents the same groups of opiates as Figure 3 plus Hallucinogens.
Figure 11 represents the same groups of opiates as Figure 3 plus Benzodiazepines. The data in Figure 11 strongly correlates to data in Figure 12, suggesting the use of Benzodiazepines with opiates is of no greater risk than the use of Benzodiazepines by themselves. This too is contrary to CDC’s standing position on the use of opiates and benzodiazepines.
Figure 12 represents overdose death from benzodiazepine only.
Figure 13 represents Heroin + Alcohol.
Figure 14 represents Heroin + Cocaine.
Figure 15 represents Fentanyl + Cocaine.
Figure 16 represents Alcohol only.
Ohio’s website while more flexible than the CDC’s on reporting polydrug use, does not have a selectable filter option to include polydrug use data cross referenced with PDMP data. The section which does cross reference PDMP data is limited to prescription opiates and or Fentanyl and analogs.
The ability to cross reference polydrug use overdose deaths with PDMP data is of great concern to the chronic pain community, the majority of which continue suffer under the stigma that chronic pain patients are no different than street addicts who have been scamming the system. As most chronic pain patients are or have been productive tax paying members of society, until forced tapered or terminated from care, having access to this information would be a positive step at restoring the confidence prescribers once held in this group of patients. It would also prove useful for prescribers in identifying at risk groups, by age, sex, county and other demographic segments.
For example, regardless of gender, individuals age 65 and older have the lowest incidence of overdose with opiates, second only to those under the age of 12, yet this group has a higher incidence of chronic pain conditions per capita than younger age groups. Yet under our current system, individuals in this age group suffer the same stigma as those in younger age groups.
In an age of evidenced based medical care, having access to such evidence is critical to ensuring fair and equitable treatment in the face of a health crisis such as addiction and overdose.