The US Opioid Crisis – Misdiagnosed, Mistreated and Mismanaged Part One

By R Carter

In the year 2000 I attended the first state sponsored medical symposium on what at that time, didn’t have a name such as opioid crisis or epidemic. I lived in Oklahoma and like so many other things in that part of the country; trends arrive later there than they do on the east and west coast. So I assumed what they talked about had already progressed further in those locations. There were only two data points to show, the rise in opioid prescribing as well as the rise in opioid related deaths.

Yet even then, it was clear from presenters, all physicians, that these two data points were inexorably connected. As a skeptic, I don’t buy into such conclusions without more proof. Ever since that meeting I have watched as this phenomenon unfolded and until 2019, I wasn’t truly convinced to what extent, prescribed opioids contributed to overdose deaths. That said, I wouldn’t deny their involvement either, the question I wanted answers for, was to what degree.

Looking back the ironic thing that stands out were the sponsors of that two day meeting who were the pharmaceutical companies, which are now accused of causing the opioid crisis. More specifically, Jansen pharmaceuticals the makers of Fentanyl were one of the leading sponsors. Twenty years later they’re accused by Oklahoma of being a public nuisance with a half billion dollar fine hanging over their heads. This after being one of several companies who raised concerns in the beginning.

So let me put this in context. This wasn’t a meeting for anesthesia providers with corporate sponsors pitching their opioids for use in surgery. This was a meeting for all healthcare provider types about opioid addiction concerns and the pharmaceutical companies, were picking up the tab. I don’t know about you, but suing them now just doesn’t set right with me.

So I continue to believe the opioid crisis, like addiction, has no simple answers and a rush to judgement for a single cause, is both irresponsible and naive. That irresponsibility has proven itself with the creation of a new disenfranchised minority group known as chronic pain patients.  

Caught by surprise

After a nation was caught off guard and unprepared, there’s been a lot of finger pointing at who’s to blame for the opioid crisis. No one wants to own their part, despite the fact that millions of individuals in government, healthcare, insurance, pharmaceuticals and other industries, made billions on the backs of chronic pain patients over the last thirty years. Now it’s time to pay the piper and everyone is running for cover.

In this series of articles I will attempt to update the historical context of how the opioid crisis began, the forces which contributed to it and how it evolved. The growing body of evidence paints a picture which is anything but simply a prescribing problem. The other question I’ll ask is who profits from what got us here and who profits from the methods used to address it.

Misdiagnosed

The first victims in the rush to cover have been chronic pain patients (CPP). More specifically CPP’s who used their medications in a responsible manner. Evidence today screams it was never simply a prescribing problem, but CPP’s continue to bear the brunt of this initial judgement.

In the early stages of this trend it was completely impossible to connect the dots between prescribing and overdose deaths, but it was a reasonable assumption they were connected in some manner. Ultimately, connecting the dots required an overhaul of our vital records system, as well as new methods for collecting data and responding to those findings.

While reagent tests could be used to identify other types of opioids during an autopsy, there were no procedures available, or funds, for investigating on a large scale, every suspected opioid overdose death. As a nation we didn’t even have a definition for poisoning which included the various forms of medicinals attributed to overdose deaths. To classify these threats, changes were needed in many areas including the ICD-10 diagnostic codes used to classify poisonings from pharmaceuticals.

Updating our vital records system on a State by State basis would require billions of tax payer dollars and take up to ten years for how we collected and processed overdose data. But given the growing threat, the funds were allocated and the efforts began, including the adoption of State sponsored prescription drug monitoring systems, which cost each State on average, $1 billion a year to maintain.

Mistreated

Between 1999 and 2010 treating the problem focused on reducing prescribing and the nation’s supply of prescription opioids. The conventional wisdom at the time was, by simply reducing access to and supplies of opioids, overdose deaths would correct to lower levels. This concept is known as the Vector Model for Disease, identify the source, attack the source, stop the disease. But this premise doesn’t take into consideration anything smarter than a bacteria or a virus. So human diseases like addiction, which are more behavior based than anything else, don’t fit this model of stomping out the source and hoping for the best.

Law enforcement stepped up efforts to identify outliers in healthcare and other industries who diverted opioids for non-medical purposes, as well as prescribers who abused the privileges of prescribing. These actions began driving healthcare providers out of the business of pain management, physician fears over being targeted by law enforcement left CPP’s abandoned, forced off of medication or with reduced levels that all but kept them alive but without an ability to provide for their own basic needs.

Without an admission of error, by 2013 this approach was widely believed to be an inaccurate assessment and efforts were started to identify why opioid prescribing was down but opioid overdose deaths were spiking to new highs.

With an average contribution to the gross national product of $69,000 per person, the 15 million CPP who take opioids daily should be contributing more than $1 trillion dollars to our economy. But only if their chronic pain conditions were treated as they were prior to implementing arbitrary fixed limits. This has yet to occur so about 70% of CPP’s were forced on to lower dosages or off completely and haven’t yet returned to the work force.

Mismanaged

We’re now twenty years into the opioid crisis and legitimate CPP’s remain a Cinderella story overshadowed by their ugly step-sisters, the drug abusers. Most States have had prescription drug monitoring programs (PDMP) in place for 10 years. Yet as of Dec. 2019 Massachusetts is the only State to publish overdose data which has been cross referenced with the State’s PDMP. Those records show prescribed opioids play far less of a role than what was previously assumed.  If other States did the same, then State AG’s suing Big Pharma, might not consider it the nearly certain, deep pockets they once thought.

After 2010 the 2nd wave of the opioid crisis began, in large part due to the results of cracking down on prescribing. While some regulation seems appropriate too many reliable stories have surfaced about law enforcement going too far and convicting physicians guilty of nothing more than having a different perspective from those with an anti-opioid view. Law enforcement has pitted doctor against doctor as they sought ways of reducing prescribing which as of late 2019, looks like a dead end for why opioid overdoses continue to climb.

As data continues to accumulate, it’s unclear to what extent prescribing has played a part in addiction and opioid overdoses, even though this remains the conventional beliefs of officials. The 2nd wave of the opioid crisis came in 2010 from a resurgence of heroin not prescribing, followed by a 3rd wave in 2014 of synthetic opioids such as fentanyl analogs. While many who come out of treatment centers claim they were first introduced to opioids through an opioid prescription, little evidence exist for identifying these events as causal agents which lead to opioid addiction. If such a conclusion were sound logic and a forgone conclusion, we would have seen evidence of this trend as far back as WW1 and WW2 when millions were treated with morphine for wounds received in combat.

The fallout from these missteps

A survey of 813 CPP, taken in 2019 showed that more than 66% had suffered from chronic pain for more than 10 years. 87% took opioids daily; nearly 60% take between 50 and 120 MME per day and were on larger doses prior to the 2016 CDC guidelines for chronic pain.

70% have been forced tapered or terminated from a previously stable dose, with 60% of those forced to stop medication abruptly without medical support. 64% suffered an adverse event which may have hospitalized them and 30% considered suicide during these forced actions.

Legitimate CPP have not only been victims of bad policy and mistakes but the consequence of that policy goes beyond pain management. The same survey showed that 74% were left unemployable and 11% were forced into lower paying jobs. 59.7% had financial losses in excess of $30K per year, 34.3% with a loss in excess of $50K, 20.2% with more than a $70K loss and 5.3% with more than a $90K loss per year. In total, 100% of CPP’s have suffered some level of financial loss due to an inability to work in positions they previously held before being forced down or off medication. When applied to a government estimate of 15 million Americans who use opioids for chronic pain, that comes out to $900 million a year in pre 2018 lost wages.

Click this link to follow this series to Part Two.