The Opioid Overdose Crisis

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Page last updated June 10, 2020 by Doug McVay, Editor/Senior Policy Analyst.

46. Barriers to Adequate Pain Care

"Adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and the societal stigma that is applied, consciously or unconsciously, to people reporting pain, particularly if they do not respond readily to treatment. Questions and reservations may cloud perceptions of clinicians, family, employers, and others: Is he really in pain? Is she drug seeking? Is he just malingering? Is she just trying to get disability payments? Certainly, there is some number of patients who attempt to 'game the system' to obtain drugs or disability payments, but data and studies to back up these suspicions are few. The committee members are not naïve about this possibility, but believe it is far smaller than the likelihood that someone with pain will receive inadequate care. Religious or moral judgments may come into play: Mankind is destined to suffer; giving in to pain is a sign of weakness. Popular culture, too, is full of dismissive memes regarding pain: Suck it up; No pain, no gain."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 46-47.

47. Significance and Growing Prevalence of Lower Back Pain

"The potential impact of the growing prevalence of pain on the health care system is substantial. Although not all people with chronic low back pain are treated within the health care system, many are, and 'back problems' are one of the nation’s 15 most expensive medical conditions. In 1987, some 3,400 Americans with back problems were treated for every 100,000 people; by 2000, that number had grown to 5,092 per 100,000. At the same time, health care spending for these treatments had grown from $7.9 billion to $17.5 billion. Thorpe and colleagues (2004) estimate that low back pain alone contributed almost 3 percent to the total national increase in health care spending from 1987 to 2000. While about a quarter of the $9.5 billion increase could be attributable to increased population size, and close to a quarter was attributable to increased costs of treatment, more than half of the total (53 percent) was attributable to a rise in the prevalence of back problems."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 64.

48. Community Epidemiology Working Group Assessment of Non-Prescription Use of Prescription Analgestic in the US, 2012

"Mixed results were noted for prescription opioids, with increases in indicators for prescription opioids as a key finding reported by representatives in two areas—New York City and San Francisco—based on treatment admissions data (primary treatment admissions for opioids/opiates other than heroin increased in 2012 from 2011 in New York City), numbers of prescriptions (the Prescription Drug Monitoring Programs in both New York City and San Francisco showed increases in numbers of prescriptions in 2012), death data (unintentional opioid analgesic poisoning deaths increased in New York City by 65 percent from 2005 to 2011), and ED visit data (visits involving prescription opioids/other opiates increased in New York City from 2010 to 2011 and in San Francisco from 2004 to 2011). A decline in indicators for prescription opioids/opiates other than heroin was reported as a key finding in three other CEWG areas—Maine, Seattle, and South Florida/Miami-Dade and Broward Counties. Deaths related to prescription opioids/opiates other than heroin declined from 2011 to 2012 in Seattle and both Miami-Dade and Broward Counties in South Florida. Treatment admissions and drug reports among drug items seized and analyzed in NFLIS laboratories declined in 2012 from 2011 in the two South Florida counties. Arrests showed decreases in Maine from 2011 to 2012, and reported use of prescription-type opiates in the last month to 'get high' among high school students decreased significantly from 2010 to 2012 in the Seattle area."

"Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, Advance Report, June 2013" (Bethesda, MD: National Institute on Drug Abuse, December 2013), p. 4.

49. Opioid Involvement in Deaths in the US Attributed to Drug Overdose, 2016

According to the US Centers for Disease Control, in 2016, there were 63,632 drug overdose deaths in the United States. The CDC further estimates that of those, 42,249 deaths involved any opioid.

The CDC reports that in 2016, 15,469 deaths involved heroin; 14,487 deaths involved natural and semi-synthetic opioids; 3,373 deaths involved methadone; and 19,413 deaths involved synthetic opioids other than methadone, a category which includes fentanyl. The sum of those numbers is greater than the total opioid involved deaths because, as noted by the CDC, "Deaths involving more than one opioid category (e.g., a death involving both methadone and a natural or semisynthetic opioid such as oxycodone) are counted in both categories."

Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017.

50. Tightened Restrictions on Legal Prescription Hydrocodone Led to Increase in Illegal Sales

"Objective: To examine the effect on the trade in opioids through online illicit markets (“cryptomarkets”) of the US Drug Enforcement Administration’s ruling in 2014 to reschedule hydrocodone combination products.

"Design: Interrupted time series analysis.

"Setting: 31 of the world’s largest cryptomarkets operating from October 2013 to July 2016.

"Main outcome measures: The proportion of total transactions, advertised and active listings for prescription opioids, prescription sedatives, prescription steroids, prescription stimulants, and illicit opioids, and the composition of the prescription opioid market between the US and elsewhere.

"Results: The sale of prescription opioids through US cryptomarkets increased after the schedule change, with no statistically significant changes in sales of prescription sedatives, prescription steroids, prescription stimulants, or illicit opioids. In July 2016 sales of opioids through US cryptomarkets represented 13.7% of all drug sales (95% confidence interval 11.5% to 16.0%) compared with a modelled estimate of 6.7% of all sales (3.7% to 9.6%) had the new schedule not been introduced. This corresponds to a 4 percentage point yearly increase in the amount of trade that prescription opioids represent in the US market, set against no corresponding changes for comparable products or for prescription opioids sold outside the US. This change was first observed for sales, and later observed for product availability. There was also a change in the composition of the prescription opioid market: fentanyl was the least purchased product during July to September 2014, then the second most frequently purchased by July 2016.

"Conclusions: The scheduling change in hydrocodone combination products coincided with a statistically significant, sustained increase in illicit trading of opioids through online US cryptomarkets. These changes were not observed for other drug groups or in other countries. A subsequent move was observed towards the purchase of more potent forms of prescription opioids, particularly oxycodone and fentanyl."

Martin James, Cunliffe Jack, Décary-Hétu David, Aldridge Judith. Effect of restricting the legal supply of prescription opioids on buying through online illicit marketplaces: interrupted time series analysis. British Medical Journal. 2018; 361:k2270.