Opioid overdose deaths are going up, but the result — a crackdown on physician prescribing — may be the wrong way to go, especially since so little is known about the people who are dying, according to an expert in pain and opioids. We asked Lynn R. Webster, M.D., director-at-large for the American Academy of Pain Medicine, to discuss the connection between opioids prescribed for pain, substance abuse and overdoses.
“We have very little data to know whether or not the people who have been taking the medications as directed have developed any substance abuse problems,” said Webster, who is also medical director of the Lifetree Clinical Research and Pain Clinic in Salt Lake City, Utah. “We don’t know with absolute certainty who is overdosing.”
There are two major populations at risk who have been harmed by prescription opioids: people in pain who have legitimate prescriptions and people who use the drugs after they have been diverted (whether bought from a drug dealer, obtained from a friend on the school bus, or “stolen” from the family medicine cabinet), said Webster.
“I don’t want to discount the tragedy of the overdose deaths, whether it’s a kid who was using recreationally or a patient who couldn’t stand the pain any more and took too much,” Webster told ADAW. But blaming the prescribers is unfair, he said. Also, unfortunately, it will hurt patients in pain.
Webster said that an increasing number of physicians are being investigated by the Drug Enforcement Administration, and this is having a chilling effect on legitimate prescribing of opioids for pain. “We often view public health problems in a dichotomous way — it’s all or nothing,” he said. “So there are often unintended consequences.”
Webster is particularly interested in knowing how many of the 15,000 deaths covered in the Vital Signs report from the Centers for Disease Control and Prevention (CDC) last month (see ADAW, August 20), were patients in pain, compared to patients not receiving medications for the treatment of pain. He asserts that simply having received a prescription for pain within the last year does not necessarily mean that prescription caused the overdose death.
The literature — including the Vital Signs report and the landmark West Virginia study published in the Journal of the American Medical Association in 2008 (see ADAW, Dec. 15, 2008) — typically use a time frame of one year to show whether someone’s prescription caused their death. More information is needed, he said. “I’d like to know if they used the medicine as directed,” said Webster. “I’d also like to know whether they obtained the medicine from some diversion.” Because the data isn’t on death certificates, there’s no way to know, he said.
The CDC Vital Signs report showed that one-third of the opioid overdose deaths were due to methadone — and not related to methadone prescribed for opioid addiction. Many Medicaid formularies now require methadone to be used for pain instead of other medications, because it is so inexpensive, Webster noted. “Methadone is the most commonly prescribed pain drug for the poor.”
However, it also requires training, because methadone is slow-acting and if a patient takes another pill too soon in order to get more rapid pain relief, overdose will follow. “Patients are not always compliant, so they’ll often use more than directed,” he said, adding that doesn’t necessarily mean they are addicted.
The majority of overdose deaths involve more than opioids — typically benzodiazepines, said Webster. In many cases, the medical examiner doesn’t even credit the poly-drug issue and says that the opioid alone caused the death, he said. “More importantly, epidemiologists including the CDC don’t acknowledge the combination enough,” Webster said.
Addiction is not the same as someone misusing or overusing their medication in order to get out of pain, said Webster, adding that 1 out of 2 patients on chronic opioid therapy may take too much. But they are not necessarily addicted — they are dependent.
Finally, Webster believes that many of the overdose deaths are technically suicides. “It’s not that they left a note,” he said. But he has had patients tell him, after he advises them to take only the prescribed amount of their medication, that they would rather die than live with the pain. “Not waking up in the morning is acceptable to them,” he said.
Most patients with chronic pain need to take medications on a long-term basis, said Webster. For those who do not do well on moderate- or high-dose opioids, he tapers them off the medications and then prescribes Suboxone, which treats the pain.
The CDC and the American Society of Addiction Medicine did not return emailed requests for comments.