More Evidence That Opioid Policymakers Keep Aiming at the Wrong Target

Jeffrey A. Singer

A new study released earlier this year adds more evidence to the mountains of evidence that policymakers trying to solve the overdose crisis have been aiming at the wrong target.

Researchers from the Dartmouth University School of Medicine recently published in the Annals of Surgery the results of a prospective clinical trial of 221 opioid naïve surgical patients prescribed opioids at discharge and followed for one year after surgery. Eighty‐​eight percent of the patients had cancer‐​related operations. Their surgeons prescribed opioids for pain control when they discharged them home from the hospital. The researchers accessed the Prescription Drug Monitoring Program (PDMP) to monitor the patients’ long‐​term opioid use.

Their findings: 15.3 percent filled opioid prescriptions 3–12 months after their initial surgery. Six percent of the time, it was because of pain related to the initial (“index”) operation, but 51 percent of the time, it was due to a new painful condition, and 40 percent from undergoing another surgery. The remaining 2.3 percent (five patients) filled opioid prescriptions one year later because of chronic pain due to recurrent cancer (two), a new medical condition (two), and a chronic abscess (one). Only one patient filled an opioid prescription 12 months post‐​hospital discharge for no specific reason. The researchers noted that patients disposed of their leftover opioids at a high rate. They concluded:

In a group of prospectively studied opioid‐​naïve surgical patients discharged with guideline‐​directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long‐​term opioid use did occur for other, well‐​defined, medical or surgical reasons.

This latest study adds to a January 2018 study in BMJ by researchers at Harvard and Johns Hopkins that examined 568,000 opioid naïve patients prescribed opioids for acute and postoperative pain from 2008 to 2016. The researchers found a total “misuse” rate (all “misuse” diagnostic codes) of just 0.6 percent.

It also supports the result of a prospective study of emergency room patients sent home with prescription opioids for pain and followed for six months, published in the Annals of Emergency Medicine in May 2020. That study found that one percent (five patients) met the criteria for persistent opioid use by the end of the follow‐​up period. Four of the five patients still had moderate or severe pain in the affected body part six months after release from the emergency department.

As I and my co‐​authors reported in the Journal of Pain Research in January 2019, there is no correlation between opioid prescription volume and the non‐​medical use of or addiction to prescription opioids. And data from the National Survey on Drug Use and Health shows that the addiction rate among persons aged 18 and above has remained essentially unchanged throughout the 21st century, with the percentage addicted to prescription painkillers hovering at around 0.7 percent from 2002 through 2014, despite prescription rates surging to record highs in the early 2000s and then, after 2012, dropping more than 60 percent.

It seems that no amount of evidence will convince policymakers to abandon the false narrative that doctors treating their patients’ pain caused the overdose crisis. This refusal causes many patients to needlessly suffer while driving non‐​medical users of diverted black‐​market prescription pain pills to illicit fentanyl.

Lawmakers and policymakers, blind to the evidence that drug prohibition is the primary cause of the overdose crisis, have given us the worst of both worlds: patients inadequately treated for pain while overdose deaths soar.

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