I encountered an absolutely stunning piece the other day about how there really was no opioid epidemic. The author's various arguments all centered on the basic idea that law enforcement and other special interest groups spread the lie about opioid use being epidemic so that they could increase law enforcement measures and make it more difficult for chronic pain patients to get access to opioids. There are a lot of these conspiracy theories going around. There are active posters on Twitter who continue to beat the drum that this is a heroin or fentanyl problem and not a problem with prescription opioids. The same group will suggest that the problem is now benzodiazepine prescriptions - maybe even gabapentinoids! They make the false claim that "anti-opioid zealots" want to stop opioids for chronic non-cancer pain, even if it means that some of those pain patients will commit suicide. They continue to post debunked information about how a trivial number of pain patients become addicted to opioids if they are properly prescribed.
Time for a lesson about the opioid epidemic and how it evolved from the land of 10,000 lakes - my home state of Minnesota. The graphics I am posting here are all from the Minnesota Department of Health and the Minnesota Department of Human Services. In some cases the opioid involved overdose mortality is broken down into specific categories and in other cases it is just an aggregate number. The first graphics I am going to post is on the epidemiology of admissions for substance use treatment from two time intervals for comparison.
These maps are county by county density plots of the rate of admissions from a particular county comparing 2007 to 2017. There are certainly limitations using administrative data but on the other hand it is the only data available and I would not be surprised if there was not some reporting obligation by licensed treatment programs to the state. The most significant limitation on admissions data is that services in the US are rationed and there are never enough openings or finances to treat the people who need it. Treatment programs also open and close. There is the question about whether all admissions are captured.
Given those limitations it is clear that the rate of admissions form Minnesota counties of residents being being treated for heroin use, methamphetamine use and intravenous drug use (IVDU) have all increased significantly from 2007 to 2017. In fact, the total number of IVDU admitted in 2017 was about the same for both heroin (N=5148) and methamphetamine (4843) users. By comparison, in 2007 the number for IVDU were about 20% of the current numbers with heroin admissions at 1008 and methamphetamine admissions at 798. In a separate report speedballing or the injection of methamphetamine and heroin is discussed but there are no numbers given on people who are using both.
The first lesson from admissions data is that the total number of residents using this compounds per county and the rate of use per county are both increasing. The geography of the spread is also of interest. Minnesota has 54 counties and only 7 are considered metropolitan or urban counties. The rest are considered rural. Large blocks of these rural counties have increasing numbers of residents being treated for heroin, methamphetamine, and IVDU. To me that is an epidemic.
Additional data looking at the epidemic in Minnesota comes from reference 2. It is interesting because it is a direct comparison of deaths occurring in rural versus metro or urban counties. It also looks at the types of drugs involved in the overdoses.
As can be seen in the above graphs, opioid and heroin overdoses both increased over the 16 years of the study period. In the Metro sample, the baseline rate of opioid overdose deaths was 43 Metro and 11 Greater Minnesota in 2000 and by 2016 this had increase to 256 and 138 respectively. In the case of heroin overdose deaths the baseline rate was 1 Metro and 1 Greater Minnesota in 2000 and by 2016 the increases were to 110 and 40 respectively. The rate of increase in opioid and heroin deaths in Greater Minnesota may have been impacted by the greater rate of increase in stimulant use and associated deaths. This may imply greater availability of stimulants across a wider population area than opioids - but overdose deaths is an obvious problems for all of the compounds listed on these graphs. According to my arithmetic that is a 9 fold increase in the death rate due to opioid and heroin overdoses over 16 years.
The final consideration is how is it that so many people started using heroin and fentanyl? Many of the epidemic deniers seem to be suggesting that it just happened that way. It was totally unrelated to opioid prescriptions. If a clinician like me tells them that I have talked to hundreds of opioid users and I have heard initial use of heroin from exactly one person - they suggest that I don't know what I am talking about. That is where this compelling graphic about opioid prescriptions comes in showing about an 8-fold increase in opioid prescriptions in the USA over about the last two decades. It would place opioid overdose deaths as about the 13th leading causes of death in the state. Once an addiction starts, the economics of drug use is that most people can get heroin for considerably less than they can buy prescription opioids on the street. That and the general characteristics of addiction lead to higher risk use of intravenous heroin and a greater potential for overdose.
Even though every data set has it's limitations, the alternate hypotheses by the epidemic deniers need to be considered as alternate explanations. Conspiracy theories about people scheming to prevent the treatment of chronic pain and the "war on drugs" don't make any sense. If either explanation were true it would have to explain the explosion in opioid prescriptions in the 21st century and everything that unfolded since.
It does not.
The only reasonable public policy must stop these overdoses and explode the associated myth that excessive opioid prescribing is necessary for the treatment of chronic non-cancer pain.
George Dawson, MD, DFAPA
References:
1: DAANES SUD Detox and Admission Trends CY1995-CY2017. Minnesota Department of Human Services, 2018.
2: Drug Overdose Deaths among Minnesota Residents 2000-2016. Minnesota Department of Health Injury and Violence Prevention Section, 2018. Link
Graphics:
All graphics are from public documents from the Minnesota Department of Health and Minnesota Department of Human Services.
Hmm, what is the element of Personality Disorder in this seeking of opiates, and benzos, and even stimulants as some element to improve cognition and awareness from opiate sedation???
ReplyDeleteI know it is not the only variable, but, it is a contributing one of quantifiable measure...
Reminds me of a seminar that I presented as a resident on my Addiction Psychiatry rotation at the U of MN. My question was does a personality disorder predispose to addiction or does addiction lead to a personality disorder.
DeleteNow that I know something the majority I people I see develop what appears to be a personality disorder associated with the addiction. The impulsive Cluster B folks still have their problems but many people appear to be Cluster B in the throes of addiction. A surprising number of people start to use as a way to modulate anxiety/social anxiety.
Many of the people using stimulants and opioids notice that they seem brighter, smarter, more energetic, physically stronger, and "the person I always thought I could be". That is highly reinforcing but it deteriorates to a chronic anhedonic state with what appears to be significant personality changes.
Nice observation, but until the person develops long-standing recovery, even if it's organic factor to personality disorder that is transient because of the substance, it's still a personality disorder that needs to be approached with firm limit setting and strong boundaries and zero tolerance for being abused...
ReplyDeleteAnd yet too many providers not only want to excuse the rampant chaos and discord the addict brings into the office, but then they want you to treat them even more sympathetically than the typical patient...
Sorry, having dealt with addiction personally with family and friends as well as through my entire medical career starting in medical school, irregardless of it being countertransference, it's still what it is, people who need to accept recovery and stop terrorizing the Healthcare Community
I don't know what you mean by terrorizing. It reminds me of a person asking me how to handle manipulative people and I just said: "Refuse to be manipulated."
DeleteSome can certainly up the ante. I and several psychiatric and medical colleagues have been threatened physically for refusing to provide an Rx for the addictive drug of choice. Fairly obvious what is going on but I am sure that some will be given a prescription to get them out of the office.
I think that substance use self help and counseling helps to establish limits by non-psychiatric concepts like codependency, tough love, and others. They work in a practical way to prevent the pattern of addiction from being fueled by people who are unable to set limits and keep providing resources to the addict. After you have had you televisions and computers stolen and sold a few times it also comes naturally.
Possible the best intervention I have seen for physicians happened at the Mayo Clinic addiction conference form several years ago. They had an addict in recovery come in a detail how he manipulated physicians for prescriptions. That was a real eye opener for some of the docs in the crowd. The bottom line was that he could easily identify the doctors who he could manipulate into an Rx. He could also easily identify who would not give him and Rx and automatically move on to the next clinic.
I respect your bafflement to my using the term terrorizing, but, the way some providers react to addicts, there is an element of being terrorized in the way they respond to how addicts come into the clinics and private practices and manipulate and at times very much threaten to get what they want.
ReplyDeleteFor people to come to me and tell me I need to be more sympathetic because the patient has an addiction, it's just pathetic. Having an addiction doesn't give one carte blanche to get whatever is possibly offered in treatment.
Frankly, I think this is an element of politics to some degree. I think politicians are using the opioid crisis to further terrorize Physicians to toe the line, Obamacare certainly has essentially wiped out any independent autonomous ability to practice medicine the way we were trained.
Again, sorry I bring politics into it, but that's exactly what addiction wants, to divide and conquer, and use anyone who's even an unsuspecting ally to be used mercilessly to do their bidding.
To bring it back, it's the personality disorder in the addict that uses the pathological defenses to get what they want, not what they need...
Dr Dawson, let's not lose a nuance here, please.
ReplyDeleteI don't think anyone who studies public health would assert that we don't have a major public health problem with opioids. But where you and I perhaps differ is that I've looked deeply into the data published by CDC on State by State rates of physician prescription, rates of overdose mortality from all sources, and age demographics. What we find quite conclusively from this data is that there is no cause and effect relationship between prescribing and mortality. Moreover, the demographics powerfully contradict any such imagined relationship.
Rates of prescribing for pain are about three times higher to people over age 55 then they are to people under age 25. However rates of overdose mortality in seniors are the lowest of any age cohort and have largely been stable for 25 years. By contrast, mortality among young people has skyrocketed in the same period and is now six times higher than in seniors.
We do indeed have a significant opioid-related addiction and mortality problem -- with street drugs (heroin, fentanyl, Methadone, and Cocaine). But prescription opioids -- including even the significant volume of diverted prescription opioids dispensed from pill mills -- didn't cause this "epidemic" and aren't substantially sustaining it. Meanwhile patients are being denied opioid therapy all across America and doctors are being driven out of practice for "over-prescribing".
National drug control policy is profoundly misdirected, in a sort of "drunk under the lamp post" pattern. Having utterly failed to control importation or manufacture of illegal addictive drugs, Federal and State authorities instead go after lower-hanging fruit in regulated supplies of opioids and the medical providers who prescribe them to people otherwise living daily in agony. This is reality quite apart from any conspiracy theories on the part of aggrieved patients whose lives have been destroyed by such mis-directions.
You and I differ on the basis that I interview thousands of people with opioid use disorder of all ages and ask them how they started.
ReplyDeleteAs you probably know the incidence of opioid use in young people was low and stable for decades and that represented people who began using opioids from a non-medical source. Practically every young person I talk with did not start using heroin or fentanyl. They started with exposure to prescription opioids they obtained from a legitimate prescription.
And all it typically takes is one or two of those prescriptions.