Writing in her blog at the National Institute On Drug Abuse, Dr. Nora Volkow and co-author Dr. Joshua Gordon of the National Institute of Mental Health offer the insight that “Suicide Deaths Are a Major Component of the Opioid Crisis that Must Be Addressed”. [1] The article is far-ranging and much more deeply nuanced than we commonly see in our daily news. It is also regrettably three years late and several steps short of useful.
Volkow and Gordon write “…the opioid overdose epidemic is not limited to people with opioid addiction who accidentally take too much of a pain reliever or unknowingly inject a tainted heroin product. Concealed in the alarming number of overdose deaths is a significant number of people who have decided to take their own life.” As far as they take their narrative, these highly authoritative authors are correct. They also state “With current initiatives to reduce opioid prescribing, many pain patients find themselves either unable to get treatment they need or stigmatized as “addicts” by the healthcare system, compounding their difficulties.”
And there, they stop. As a patient advocate in social media, I must go beyond such weak apologias to propose real action.
Every week, I witness the rising desperation and despair of people in agony who have been denied treatment by misdirected policies of Federal and State drug enforcement agencies and State Medical Boards. Restrictive “initiatives” are literally killing people by driving them into medical collapse.
In April 2019, the CDC published “clarifications” of their 2016 CDC Guidelines on opioid prescription in chronic pain, stating that guidelines were never meant to become legislated mandates – despite the fact that over 30 States had already done just that. In the same month, FDA announced safety warnings against rapid taper or unilateral discharge of legacy patients formerly managed on opioid pain relievers.
But Federal and State drug enforcement authorities and State Medical Boards continue what amounts to a witch hunt against any doctor who prescribes opioids for severe pain. Faced with potential sanction and loss of their livelihoods, doctors are deserting their patients in droves. A recent study found that 40% of primary care clinics in Michigan will no longer allow their doctors to prescribe opioids to new patients. [2] Patients in social media tell me that the desertion rate may be much higher elsewhere.
The continuing exodus of healthcare providers out of pain management is especially obnoxious in light of the fact that no less an authority than the American Medical Association has repudiated the central logic of the 2016 CDC Guidelines, used widely as an excuse for restricting patient access. In Resolution 235 of the AMA House of Delegates (November 2018) and AMA Board of Trustees Study 22 (June 2019), the AMA has thrown down the gauntlet. They declare that the central metric of the Guidelines -- Morphine Milligram Equivalent Daily Dose (MMEDD) -- is not useful beyond broad general guidance, and some patients benefit from doses exceeding the 90 MMED declared as a threshold for review of risks versus benefits. The AMA Board of Trustees declared that insurance companies and pharmacy chains issuance of “high prescriber letters” amounts to blacklisting doctors and their patients without legal due process.
A truly fundamental reality compounds the foolishness of the DEA and States. We now know beyond any contradiction from CDC data, that medical prescribing cannot possibly be the cause of our opioid crisis.
According to the CDC, US National prescribing rates for pain are six times higher in seniors over age 62 than among young people under age 19. But opioid overdose deaths from all sources (legal, diverted, or illegal) are six times higher in youth than in seniors. Moreover, opioid mortality in seniors has been largely stable at the lowest levels in any age group, while it has skyrocketed in youth during the past 20 years. [3]
As acknowledged by Dr. Volkow herself, addiction is not a predictable outcome of prescribing and addiction in medical patients is rare. [4] Prescribing by doctors is NOT the central problem in overdose mortality or addiction itself [5].
So what’s to be done about all this? I suggest to Dr. Volkow and Dr. Gordon, that it’s time to take off the blinders and get out in front of the issues with unequivocal leadership. US National policy on medical opioids and the doctors who prescribe them must change for both healthcare agencies and law enforcement. AMA Resolution 235 must become a National policy. The CDC Guidelines must be suspended immediately pending major rewrite by a different agency -- perhaps the NINDS Office of Pain Policy, supported by NIDA, NIMH, HHS/CMS and FDA, and including multiple patient advocates as voting members of the writing team.
We must also recognize that America’s opioid and suicide crises are much larger than just prescribing or even street drugs. The factors which cause people to be increasingly vulnerable to addiction and suicide are largely socio-economic. Forty years of wage stagnation compounded by automation of formerly manual labor jobs, structural unemployment and the hollowing-out of rural communities throughout the Rust Belt, deep South, and rural far West have rendered millions of people vulnerable to the distractions of street drugs. We face a crisis not of medical exposure, but of despair. Without major redevelopment of our labor force and infrastructure, nothing fundamental will change in either overdose or suicide statistics.
References:
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Pooja A. Lagisetty, MD, MSc; Nathaniel Healy, BS; Claire Garpestad, BS; Mary Jannausch, MS; Renuka Tipirneni, MD, MSc; Amy S. B. Bohnert, PhD, MHS “Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids” July 12, 2019, JAMA Network Open. 2019;2(7):e196928. doi:10.1001/jamanetworkopen.2019.6928
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Richard A. Lawhern, PhD, “Stop Persecuting Doctors for Legitimately Prescribing Opioid s For Chronic Pain”, STAT News, June 28, 2019. https://www.statnews.com/2019/06/28/stop-persecuting-doctors-legitimately-prescribing-opioids-chronic-pain/
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Nora D Volkow, MD, and Thomas A McLellan, Ph.D. “Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies” . NEMJ 2016; 374:1253-1263 March 31, 2016]. http://www.nejm.org/doi/full/10.1056/NEJMra1507771
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Jacob Sullum, “New Survey Data Confirm that Opioid Deaths Do Not Correlate with Pain Pill Abuse or Addiction Rates.” Reason Magazine, August 21, 2019. https://reason.com/2019/08/21/new-survey-data-confirm-that-opioid-deaths-do-not-correlate-with-pain-pill-abuse-or-addiction-rates/
