10th August, 2019
By Lynn Webster, M.D.
This article, in a slightly edited form, first appeared on Pain News Network on August 10, 2019.
The Washington Post has recently published a series of stories about the volume of opioids distributed over the past several years. Over 76 billion pills have been distributed throughout the U.S. from 2002 through 2012. That sounds like a huge amount, but it is difficult to know what the number means. It is clear that the stories are meant to suggest the number of pills is excessive and responsible for the rise in opioid overdose deaths.
This presumed correlation is one reason for the recent lawsuits that have been filed against opioid manufacturers and distributors. It has also spawned policies that appear to have worsened, not prevented, overdoses.
Though the situation has been framed largely as a prescribing problem, the reasons for the drug crisis are many. While overprescribing has certainly been a factor, it is probably less important than other factors, such as joblessness, homelessness, and despair, that may be more challenging to address.
The Correlation Between Prescriptions and Overdose Deaths
Let’s examine the data about the relationship between opioid prescriptions and overdose death rates.
The number of opioid prescriptions in the United States peaked in 2012 and reached a near 15-year low in 2017. Despite the steep decline by 2017 in the number of opioids prescribed, overdoses from all opioids continued to increase throughout that year. Overdoses from prescription opioids represented only 25% of the total number of drug overdoses. Therefore, something more than the supply of prescription opioids contributed to the number of overdoses.
After winning a year-long court battle with the Department of Justice, the Washington Post and HD Media, publisher of the Charleston Gazette-Mail in West Virginia, were able to access data from the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS). The information in the database shows that, between 2006 and 2012, West Virginia received the largest per capita amount of prescription opioids. The state also experienced the highest opioid-related death rate during that period.
However, Jacob Sullum recently reported in Reason that, in 2017, Kentucky had a higher death rate than Maryland and Utah, but its prescription rates were substantially lower than Maryland’s and Utah’s. He also pointed out, although Oregon’s prescription rate was among the highest in the country, its death rate from prescription opioids was about one-third of that.
Sullum further showed Kentucky, Nevada, Oklahoma, Oregon, South Carolina, and Tennessee were also among the 10 states with the highest per capita prescribed pills during the 2006-2012 period, but they were not the states with the highest overdose rates.
In a separate analysis, data from the Center for Diseases Control and Prevention and the U.S. Agency for Healthcare Research Quality showed no correlation — not even a weak one — between opioid prescribing rates and overdoses when comparing data from each state.
In addition, the rate of opioid prescribing is highest nationally for people 55 years and older, but this age group has the lowest overdose rate.
Around the World
The lack of correlation between the number of prescription opioid overdoses and the volume of prescribed opioids is consistent internationally.
In 2016, England prescribed the most opioids and saw the most overdose deaths in its history. However, the drug responsible for the deaths was heroin, not prescription opioids.
There is a raging opioid crisis in West Africa where, despite a low prescription rate, the number of addictions and overdoses has surged.
Most startlingly, in 2018, Scotland’s drug overdose rate exceeded that of the United States — ostensibly, largely because of heroin. There is no evidence of an overall increase in opioid prescribing.
No Simple Answers to the Opioid Crisis
It is clear that the data does not support a simple answer to the opioid crisis. Focusing all of our effort on decreasing the number of prescriptions will not solve the problem and is already creating unintended consequences.
In fact, in 2018, cocaine and methamphetamineeach caused more overdose deaths than prescription opioids did in the U.S. As the supply of prescription opioids has decreased due to the policies of the last few years, people have moved from prescription opioids to other illicit drugs.
The solution to the opioid crisis must be multi-pronged. Overprescribing played a role in causing the crisis, but sociological factors appear to have driven the demand.
We must consider what prompts people to turn to drugs in despair. A recent study published in SSM-Population shows job loss bears a significant correlation to opioid-caused deaths.
In addition, in the Proceedings of the National Academy of Sciences, Princeton University economists Anne Case and Angus Deaton(recipient of the 2015 Nobel prize in economics) showed mortality from substance use was linked to declining economic opportunity and financial insecurity.
Solving the drug crisis will not be easy. However, the disenfranchised members of our most impoverished communities deserve viable solutions to their problems. It is crucial to understand the degree to which job loss and hopelessness contribute to the drug problem. Reputable data proves that the volume of opioids prescribed is not solely, or even primarily, responsible for the opioid crisis. Let’s be sure we are not using prescription opioids as the scapegoat.
Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth” and co-producer of the documentary, “It Hurts Until You Die.”
You can find him on Twitter: @LynnRWebsterMD.