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   From: a425couple@hotmail.com   
      
   THE BIG IDEA   
   The Myth of What’s Driving the Opioid Crisis   
   Doctor-prescribed painkillers are not the biggest threat.   
      
   By SALLY SATEL February 21, 2018   
      
   THE FRIDAY COVER   
   TFC-04-27-18-FINAL.jpg   
      
   As an addiction psychiatrist, I have watched with serious concern as the   
   opioid crisis has escalated in the United States over the past several   
   years, and overdose deaths have skyrocketed. The latest numbers from the   
   Centers for Disease Control and Prevention show fatalities spiraling up   
   to about 42,000 in 2016, almost double the casualties in 2010 and more   
   than five times the 1999 figures. The White House Council of Economic   
   Advisers recently estimated that the opioid crisis cost the nation half   
   a trillion dollars in 2015, based on deaths, criminal justice expenses   
   and productivity losses. Meanwhile, foster care systems are overflowing   
   with children whose parents can’t care for them, coroners’ offices are   
   overwhelmed with bodies and ambulance services are straining small-town   
   budgets. American carnage, indeed.   
      
   I have also watched a false narrative about this crisis blossom into   
   conventional wisdom: The myth that the epidemic is driven by patients   
   becoming addicted to doctor-prescribed opioids, or painkillers like   
   hydrocodone (e.g., Vicodin) and oxycodone (e.g., Percocet). One   
   oft-quoted physician refers to opioid medication as “heroin pills.” This   
   myth is now a media staple and a plank in nationwide litigation against   
   drugmakers. It has also prompted legislation, introduced last spring by   
   Senators John McCain and Kirsten Gillibrand—the Opioid Addiction   
   Prevention Act, which would impose prescriber limits because, as a news   
   release stated, “Opioid addiction and abuse is commonly happening to   
   those being treated for acute pain, such as a broken bone or wisdom   
   tooth extraction.”   
      
   But this narrative misconstrues the facts. The number of prescription   
   opioids in circulation in the United States did increase markedly from   
   the mid-1990s to 2011, and some people became addicted through those   
   prescriptions. But I have studied multiple surveys and reviews of the   
   data, which show that only a minority of people who are prescribed   
   opioids for pain become addicted to them, and those who do become   
   addicted and who die from painkiller overdoses tend to obtain these   
   medications from sources other than their own physicians. Within the   
   past several years, overdose deaths are overwhelmingly attributable not   
   to prescription opioids but to illicit fentanyl and heroin. These   
   “street opioids” have become the engine of the opioid crisis in its   
   current, most lethal form.   
      
   If we are to devise sound solutions to this overdose epidemic, we must   
   understand and acknowledge this truth about its nature.   
      
   For starters, among people who are prescribed opioids by doctors, the   
   rate of addiction is low. According to a 2016 national survey conducted   
   by the Substance Abuse and Mental Health Services Administration, 87.1   
   million U.S. adults used a prescription opioid—whether prescribed   
   directly by a physician or obtained illegally—sometime during the   
   previous year. Only 1.6 million of them, or about 2 percent, developed a   
   “pain reliever use disorder,” which includes behaviors ranging from   
   overuse to overt addiction. Among patients with intractable, noncancer   
   pain—for example, neurological disorders or musculoskeletal or   
   inflammatory conditions—a review of international medical research by   
   the Cochrane Library, a highly regarded database of systemic clinical   
   reviews, found that treatment with long-term, high-dose opioids produced   
   addiction rates of less than 1 percent. Another team found that abuse   
   and addiction rates within 18 months after the start of treatment ranged   
   from 0.12 percent to 6.1 percent in a database of half a million   
   patients. A 2016 report in the New England Journal of Medicine concluded   
   that in multiple published studies, rates of “carefully diagnosed”   
   addiction to opioid medication averaged less than 8 percent. In a study   
   several years ago, a research team purposely excluded chronic-pain   
   patients with prior drug abuse and addiction from their data, and found   
   that only 0.19 percent of the patients developed abuse and addiction to   
   opioids.   
      
   Indeed, when patients do become addicted during the course of pain   
   treatment with prescribed opioids, often they simultaneously face other   
   medical problems such as depression, anxiety, other mental health   
   conditions, or current or prior problems with drugs or alcohol.   
   According to SAMHSA’s 2014 National Survey on Drug Use and Health, more   
   than three-fourths of those who misuse pain medication already had used   
   other drugs, including benzodiazepines and inhalants, before they ever   
   misused painkillers. And according to CDC data, at least half of all   
   prescription opioid-related deaths are associated with other drugs, such   
   as benzodiazepines, alcohol and cocaine; combinations that are often   
   deadlier than the component drugs on their own. The physical and mental   
   health issues that drive people to become addicted to drugs in the first   
   place are very much part of America’s opioid crisis and should not be   
   discounted, but it is important to acknowledge the influence of other   
   medical problems and other drugs.   
      
   Just because opioids in the medical context don’t produce high rates of   
   addiction doesn’t mean doctors aren’t overprescribing and doing serious   
   harm. The amount of opioids prescribed per person in 2016, though a bit   
   lower than the previous year, was still considered high by the CDC—more   
   than three times the amount of opioids dispensed in 1999. Some doctors   
   routinely give a month’s supply of opioids for short-term discomfort   
   when only a few days’ worth or even none at all is needed. Research   
   suggests that patients given post-operation opioids don’t end up needing   
   to use most of their prescribed dose.   
      
   Among people who misused prescription pain relievers in 2013 and 2014,   
   only 22 percent said they received the drugs from their doctor.   
   In turn, millions of unused pills end up being scavenged from medicine   
   chests, sold or given away by patients themselves, accumulated by   
   dealers and then sold to new users for about $1 per milligram. As more   
   prescribed pills are diverted, opportunities arise for nonpatients to   
   obtain them, abuse them, get addicted to them and die. According to   
   SAMHSA, among people who misused prescription pain relievers in 2013 and   
   2014, about half said that they obtained those pain relievers from a   
   friend or relative, while only 22 percent said they received the drugs   
   from their doctor. The rest either stole or bought pills from someone   
      
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