Balance, Pain, Palliative Care

“Fibs, lies, and statistics.” Do you understand the US Prescription Opioid Crisis?


“Sir,–It has been wittily remarked that there are three kinds of falsehood: the first is a ‘fib,’ the second is a downright lie, and the third and most aggravated is statistics……” The National Observer, London. 8 june, 1891.

In medicine, we often use statistics to paint a picture of science that fits our view of the world. Not fibs,not lies, statistics. One example I give in my oncology teaching relates to the following hypothetical headline:

“Chemotherapy results in a 50% drop in death from breast cancer after 10 years!”

I would have my family members take this therapy based on this headline. But if one looks at the data more closely, it may not be that simple. The death rate at 10 years dropped from 5% in those who did not have chemotherapy to 2.5% in those who had chemotherapy. I agree that is a 50% drop. But the reality is that the survival data at 10 years increased from 95% to 97.5%, a 2.5% improvement in overall survival at 10 years. Now I have to think about whether I would recommend this to patients and my own family members. Our practice is influenced greatly by statistics.

So lets look carefully at some of the statistics raised in a recent paper published in the BMJ by Canadian physicians.  There is no question that the US should be “Facing up to the prescription opioid crisis.”  PPSG as late as the 2008 State Report card (supported by the American Cancer Society and Livestong) restates the importance of balance.

In the United States, healthcare professionals, regulatory agencies, and policymakers currently are grappling with how to appropriately and effectively deal with two overlapping issues affecting public health: (1) untreated and undertreated pain, and (2) the abuse and diversion of prescription controlled substances, including opioid pain medications. Although controlled substances are recognized as indispensable medications for many painful conditions, especially when pain is severe, they also have a potential for abuse and these dual characteristics must always be considered concurrently. Importantly, a policy response to one of these issues should not have an unanticipated deleterious impact on the other.


The CDC has been monitoring deaths with which opioids have been “involved,” not caused.  In many cases alcohol, benzodiazepines or other drugs may have been the cause of death in people using or misusing opioids. In fact, if one looks at prescriptions drug deaths in Florida, there has been a similar increase in deaths involving alprazolam as there has been for oxycodone over a six year peroid.  But the use of the term “involved” has been a consistent so we are measurings apples and apples, not apples and oranges.

Deaths involving opioids in the USA have increased from 4041 in 1999 to 14459 in 2007.  Yes, a greater than 3 fold increase that we should aim to reduce, but in fact opioid-involved deaths increased from approximately 20% to 40% of all drug related poisonings, in reality a 2 fold increase (still too many!). And which opioids are we talking about. Methadone deaths increased nearly sevenfold (790 in 1999 to 5,420 in 2006). “Among opioid analgesic-related deaths, those involving methadone increased the most during the period from 1999-2006. Methadone’s use as a painkiller also increased more that twelvefold in the US from 1997 to 2006. “A lack of knowledge about the unique properties of methadone was identified as contributing to some deaths” as was the involvement of benzodiazepines in combination with methadone.

And the severity of this health problem varies greatly across the USA with an eightfold variation among the states. “In 2006, age-adjusted death rates for poisoning deaths involving opioid analgesics ranged from 1.8 to 15.6 deaths per 100,000 people.  In 2006, West Virginia, Utah, New Mexico, Oklahoma and Nevada had the five highest rates ranging from 10.5 to 15.6 per 100,000.”

This is not an attempt to minimize the issue of diversion or deaths related to prescriptions opioids in the USA and elsewhere in the world.  This is a call to use all of the resources we have at hand to address these major public health issues, a call supported by Gil Kerlikowske, the director of National Drug Control Policy at the Whitehouse. These are issues that greatly impact access to pain medicines globally.  So let me quote from the BMJ paper:

Maintaining access to opioid analgesics for appropriately selected patients while striving for major reductions in opioid related deaths is a challenging objective that must be a priority in the years ahead.

Other comments:

  • Methadone is identified in the BMJ paper as needed special registration for patients and physicians because “methadone toxicity can be fatal, the drug is often sold illegally and some patients seek prescriptions from multiple physicians and pharmacies.”  Registration was established as Methadone Maintenance Treatment Programs were using opioids for the treatment of opioid addiction, a questionable medical use in the earlier 60s and 70s. US law was amended in 1974 to allow for MMT programs.
  • Oxycodone was developed in 1916, as part of an ongoing drug development projects in Europe, quite separate from the Harrison Act.

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide

Discussion

12 thoughts on ““Fibs, lies, and statistics.” Do you understand the US Prescription Opioid Crisis?

  1. Regarding the statistical “lie”: In the 60s, Bayer aspirin was touted as “goes to work twice as fast”. The cliam was true – the drug started to dissolve in gastric juices in 0.25 seconds rather than 0.50 seconds. Amazingly, I just saw the same claim made by the same company in a commercial recently. The general public has not been told what questions to ask about statistical claims that relate to the real-world relevancy of the claim. Unfortunately, many physicians seem all too eager to accept these spurious claims and use them to guide patent care – an abhorent practice.

    Posted by Stugee1 | September 1, 2011, 2:33 PM
  2. Any idiot know’s that aspirin will not kill real pain

    Posted by Tim | September 1, 2011, 8:39 PM
  3. Why do we continue to punish pain patient’s?? Does anyone know what it’s like to feel nothing but pain??? Why do they torture pain patient’s??? It’s not unusual for a pain patient to be acused of selling their medication, not taking it, when the pharmacy loses prescriptions etc. the patient is blamed. This kind of treatment for people who suffer every day is worse than the pain. Once you are wiped out financially by medical bills and end up on medicaid you are now considered lazy, no good, suspicious, this is the real crime of the medical industry. They eat sick people up and spit them out like garbage when they have exhausted the patient and their funds. What kind of a sick society treats sick people like criminals. What goes around comes around and I don’t want to be alive when it all comes around.

    Posted by Tim | September 1, 2011, 8:47 PM
  4. According to the CDC, increased prescribing of opioids has led to the worst drug epidemic in 40 years. OD deaths are not the only factor that has increased at an alarming rate. So have rates of addiction. Millions of people have been seriously harmed by the aggressive use of opioids to treat chronic pain. Among the groups that have suffered most, are pain patients. According to a recent study by Bocarino, 35% of pain patients on opioids met criteria for addiction. These individuals will struggle for their entire lives from an illness that harms families and communities. It’s also an illness that and can lead to increases in infectious diseases, children in foster care, crime and other problems.

    You say “This is not an attempt to minimize the issue of diversion or deaths related to prescriptions opioids in the USA and elsewhere in the world” but it sure seems like that’s what you’re doing.

    When it comes to statistics about one of the most urgent public health problems facing our nation, I believe we can trust the CDC. For more information from the CDC about this epidemic, please see the following slides:
    http://www.cdc.gov/about/grand-rounds/archives/2011/pdfs/PHGRRx17Feb2011.pdf

    Posted by Andrew Kolodny | September 2, 2011, 4:13 PM
    • Your argument here is based on the idea “I believe we can trust the CDC”. Most in your position will tout MM as a alternative that will lift the pressure to prescribe opioids… but the fact is that the DEA made the same moves against it decades ago , and would have had you believe the same horror stories which have proved absurd. To a person in the desert without water, drinking ones own urine sounds like a wonderful idea that might have them live another day…to those with plenty on tap, it seems like a dangerous and foolish idea. The problem here lies with our idea of addiction and the idea that it can be the WORST thing that could ever happen to a person…a person who would have their life destroyed by chronic pain has nothing more to lose, and the risks involved with taking opioids are well worth it. This idea is alien to the general public , who can get through their minor aches and pains with acet or ibu (which quite frankly might mean that their pain subsided without pharmacology at all, given that most recent studies prove that acetaminophen for instance in no better than placebo). For those that wake with pain daily, or never get to sleep period because of it, spend their day revolved around managing their symptoms, isolated from their friends and families…what you are saying is absolutely mute. Large portions of their life has already been stolen , and they want to appreciate what is left. Even given the rate of addiction , it is by no means vindication, of the act of leaving up to nine times the persons incapacitated due to pain that could be easily managed. These are (as they say) “first world problems” and the worries of a nation who has their priorities completely out of wack. A majority of this hogwash comes from YOUR KIND , those who make a living off of addiction. The same individuals who for decades have told them that if they were once an addict they will always be an addict. You are LOOKING to make this as big of a problem as you possibly can, because your lively hood depends on it. And while I realize that is quite blunt, no one else seems to want to cross that line. You saying its inappropriate to leave a patient to their own devices for 5 months is a half truth. While a follow up visit in a month would be appropriate , one of the largest burdens to chronic pain patients, is the constant supervision and interruptions. This is a problem that a patient MUST learn to deal with/manage ON THEIR OWN, because doctors do not have the time or resources to accurately measure a QUARTER of the information necessary (and they never will). The ideas and policy you are so in love with ARE the problem. You expect that the patients new purpose in life is to ensure YOUR comfort, when it is about THEIRS. The idea that a patient is supposed to regain their life, with you knocking on their door each and every month is absurd, and an idea that is rotting this country and its citizens brains from the inside out. A true chronic pain patient learns very quickly that overuse/abuse ultimately hurts them in the long run, and the statistics DO support that. It is the generalization and lumping of statistics/ideas, which you do quite a good job of, that is causing this gridlock (and ultimately suffering). One may gather from all of these numbers (if OTHER societal issues are taken into account) that we have a GENERAL problem in America that is far greater than addiction. That resources and opportunity in general, are becoming harder and harder to obtain , and that the American people are resorting to less sophisticated lifestyles as a result. At the end of ALL articles such as this, we often come to the point where the only answer is live and let live. Humans are far more capable of managing their own lives than you give them credit for, and a large portion of the education you feel is necessary is already obtained by those who care enough about themselves to obtain it. A major factor here which i don’t think is EVER being taken into account, is the LIVE FAST AND DIE YOUNG mantra that has swept the nation like never before (DURING THESE SAME TIMES). You have many people in this nation who feel there is nothing here for them to stick around for, and whether you agree with them or not, they DO affect the numbers. While you may provide insight , its not you (or the governments job) to tell people how to live their life, and both have carved out way to much leverage regarding. You want this fixed…listen…listen to the most valuable piece of information you have available to you, THE PEOPLE WHO ACTUALLY EXPERIENCE THIS AFFLICTION. Painting the most valuable asset as only liars was the biggest mistake made. You can read ANY opioid related article and find the answer you are looking for in the comments section. The guidelines you are living by are crap , and the farthest thing from the truth. A majority of it is outdated and heavily biased. The differences in results from person to person are FAR greater than you give them credit for , and so are the repercussions of tht misstep.

      Posted by Derk Prizzl | November 1, 2016, 10:04 PM
  5. Andrew,
    Allow me the liberty to put the quoted sentence back into the context of which it was written.

    “This is not an attempt to minimize the issue of diversion or deaths related to prescriptions opioids in the USA and elsewhere in the world. This is a call to use all of the resources we have at hand to address these major public health issues, a call supported by Gil Kerlikowske, the director of National Drug Control Policy at the Whitehouse. These are issues that greatly impact access to pain medicines globally. So let me quote from the BMJ paper:

    “Maintaining access to opioid analgesics for appropriately selected patients while striving for major reductions in opioid related deaths is a challenging objective that must be a priority in the years ahead.”

    There are many questions (and I was taught to ask questions of life by both the Jesuits and my medical teachers):
    What is the quantity of tablets entering the illicit market from pharmacy theft?
    What is the impact of these thefts on our opioid consumption data (it is all reported to the INCB)?
    Why are HMOs allowed to push Methadone for pain control (to save money) without ensuring the education of the prescriber? This is not be what you or I would call responsible prescribing.

    Kerlikowske has indicated the lack for data is a significant problem in efforts to address this major priority of maintaining access while decreasing opioid related deaths (From the BMJ paper to which you had brought my attention). There is increasing awareness that the challenges of the “haves” are severely impacting the majority of the world’s population who are the “have-nots” when it comes to pain relief.

    @jfclearywisc

    Posted by Pain policy & palliative care | September 2, 2011, 11:01 PM
  6. As you may know, for many years PPSG has argued against the CDC’s claim that the epidemic of ODs and addiction was caused by more aggressive prescribing of opioids. The argument from PPSG that pharmacy theft, not physician prescribing practices, is causing the epidemic, is absurd. The notion that we have opioids spilling out of medicine chests and in every high school and college dorm room because of pharmacy theft doesn’t make any sense. And it’s been very well demonstrated by the national drug use survey that 96% of non-medical users obtained the opioid from someone it was prescribed for or from their own prescription. See slide 15 http://www.cdc.gov/about/grand-rounds/archives/2011/pdfs/PHGRRx17Feb2011.pdf

    I’m afraid that PPSG’s notion of balance is all wrong. The trick isn’t to balance access for any potential medical use against efforts to control misuse. Instead, the goal must be to ensure appropriate access. FSMB’s model policy, drafted with the help of individuals on Purdue Pharma’s payroll, does not do this. And it’s the reason that state’s who have adopted the policy are now having a hard time reigning in inappropriate prescribers.

    Here’s an example of inappropriate access- Hydrocodone combo products are schedule III. This means that doctors can write a prescription for a drug that is as addictive as oxycodone and heroin with 5 refills. They are permitted to go 5 months without seeing the patient. That’s not appropriate. And that’s one of the reasons we have an epidemic on our hands.

    In PPSG’s history, have they every advocated against inappropriate access? If there was a true desire to achieve balance, then you would target inappropriate access in the same manner you target restrictions on prescribing.

    I agree that the epidemic in the U.S. may make it harder for the “have-not” nations to gain access. If palliative care advocates want to prevent this from happening, then they should stop advocating for practices that are fueling the epidemic, like treatment of chronic non-cancer pain with opioids and should start calling for appropriate access and appropriate restrictions.

    Please note a typo in my last post. The author of the study I cited is Boscarino- here’s a link to his abstract: http://www.ncbi.nlm.nih.gov/pubmed/21745041

    Posted by Andrew Kolodny | September 3, 2011, 9:06 AM
  7. Andrew,
    People who sell their medications are most likely not a person suffering from chronic pain in the first place, their doctor shoppers and get these medications to sell and abuse. These people are who make it hard on the people that actually really suffer.

    This is how a person becomes addicted to pain meds. For example-They get a sports injury and a doctor prescribes something like hydrocodone for short term use. That person all of a sudden finds this medication relieved their pain and was very surprised the way it worked. Then the injury gets better and that person refuses to stop the medication prescribed for a injury that last 2 weeks at the most,they get a taste of what pain medication can really do, then they continue to ask for more, start to doctor shop and their life spins out of control.
    People who actually suffer from chronic pain every day do not sell their medication, that’s the whole point to have these medications to control ones pain.

    Posted by Mark S. Barletta | September 4, 2011, 10:16 AM
    • Mark & Jim,

      I appreciate your comments. My clinical specialty is the treatment of opioid analgesic addiction, so this is a topic I’m very familiar with. My opioid-addicted patients can be placed into three rough categories:

      1) Became addicted through recreational use
      2) Became addicted through medical treatment
      3) First exposed medically, liked the effect, began to use recreationally

      Doctor shoppers (people who visit multiple doctors to obtain opioids” can also be put in three categories:

      1) Person is addicted and obtaining opioids for self.
      2) Person obtaining opioids to sell
      3) Person is addicted & obtaining opioids for self & to sell.

      It’s easy for people to think of “addicts” as having poor character- that these are bad people, making it hard for legitimate pain patients to obtain opioids because of their bad behavior. This is not true. Addition is a brain disease and it can happen to good people. It can also happen to people who take their medication exactly the way the doctor told them to. People with untreated addiction will often do bad things to obtain drugs but when provided with effective treatment, they regret these things.

      I very much disagree with Jim that some pain patients who “doctor shop” for pain medicine may not be getting the “right medication.” I agree that people will seek out additional doctors if they are unhappy with their treatment. But if they are getting opioids from multiple doctors without telling the doctors they’re doing this, I think the likelihood that they are have under-treated pain is very slim.

      I believe Jim is referring to the concept of “pseudo-addiction”. This is a term that was coined by David Haddox, medical director for Purdue Pharma. It’s also a term that has been promoted by FSMB through their “Model Policy.” In general, the term means that patients who appear to be addicted because of aberrant behavior (taking too many pills, asking for high doses, doctor shopping, etc.) really have under-treated pain and the doctor should increase the amount of medication.

      Although this concept may be useful when applied in a hospital setting, it is very dangerous to teach this in regard to outpatient management of pain. It suggests to doctors that when a patient looks like they have addiction, they should escalate the dose. This is exactly the opposite of what they should do. If a patient looks like they may have the disease of addiction (which can be life-threatening), the doctor should carefully assess the patient for the disease of addiction.

      “Pseudo-addiction” is a dangerous and misleading concept. Yet it is frequently taught to doctors at pharmaceutical-industry sponsored lectures and it is included in state medical board policies across the country. The pervasiveness of the term is an excellent example of how the pharmaceutical industry has been able to negatively influence the practice of medicine.

      Posted by Andrew Kolodny | September 5, 2011, 10:10 AM
  8. Thanks for you input, and will await Andrew’s comment.

    A few points:
    “Doctor shopping” in itself may not be a good criteria with which to identify abusers. Some people with chronic pain “Doctor shop” to find someone who will take their pain seriously.

    However, opioids may not be the right medication for all chronic pain patients.
    I always ensure chronic headaches patients have seen specialists in migraine, as it is important that they have the maximal trial of anti-migraine therapy before considering opioids.
    This is a point brought out in the APS/AAPM Chronic Pain Guidelines by Chou et al, and which I wrote about last week (https://painpolicy.wordpress.com/2011/09/02/opioids-in-chronic-non-cancer-pain-lifeb4-death-film-16/). A link to the guidelines is provided there.

    I also have concerns about how we can minimize the sports injury situation you have described. Discussed this in an April posting “Reducing Opioid Diversion, Thinking outside of the box” https://painpolicy.wordpress.com/2011/04/28/reducing-opioid-diversion-thinking-outside-the-box/

    Again thanks for your comment..
    @jfclearywisc

    Posted by Pain policy & palliative care | September 4, 2011, 3:13 PM
  9. Totally agree that patients who are on opioids should only get their prescriptions from one doctor. Same applies with one pharmacy. I encourage learners and I personally speak to retail pharmacists, as they are an essential member of the team.

    I have seen multiple patients both on and off opioids who have seen multiple doctors and have been classified as “doctor shoppers” in multiple medical records when all they want is proper assessment and management of their pain. Hence with use of “doctor shoppers” in inverted commas. Some have left me with the diagnosis of a cancer recurrence that was missed because of the label of “doctor shoppers.”

    Point of Information: Dr Haddox was a doctor at the Medical College of Wisconsin from where the article on pseudoaddiction arose in collaboration with Dr David Weissman of the Palliative Care program. Dr Haddox went to work for Purdue Pharma years after that article was written. Term was coined in original paper to describe those with inadequately treated pain displaying behavior similar to those with “opioid dependency syndrome.” (WHO is preferring this to addiction). In particular “doctor shopping” was one of those behaviors.

    I think a blog on “psuedoaddiction” may be in order in the near future.

    Posted by Pain policy & palliative care | September 5, 2011, 10:48 AM
  10. Oncology has “doctor shoppers.” Talking about this with colleague the other day. Patients who will move from Oncologist to oncologist looking for someone to give them chemotherapy. Some regional centers will give chemotherapy to anyone who comes through the door (chemo mills).

    We try to stick very hard to the evidence and say no chemo when that is the appropriate thing based on a proper assessment and the characteristics of the patient. Same with opioids.

    I used to argue with my mentor who stated that “patient insistence” was a reason to give chemotherapy. Never bought that with chemo and don’t buy it with opioids. Sometime “tough love” is needed.

    Posted by Pain policy & palliative care | September 5, 2011, 11:11 AM

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