“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.
- 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.