Thursday, January 21, 2016

Is it Bad if Prescription Painkiller Deaths Increase?

It’s been widely reported that the number of deaths from prescription opioids has increased in recent years, and I’m willing to believe that the increase is real. My question of the day is: Is this really a bad thing?

While the total number of deaths has gone up, the rate of deaths as expressed “per legal prescription” or “per gram prescribed” has remained steady.  There were ~9,500 kg sold in 1999 and 4,707 “Other Opioid” deaths; there were ~24,300 kg sold in 2012 and 11,676 “other opioid” deaths. In other words, there were 0.50 deaths per kilogram in 1999 and 0.48 in 2012. Admittedly this quantity is slightly volatile and fluctuates between 0.4 and 0.5 over the period, but it doesn’t appear as though deaths per legally prescribed gram have increased significantly. (My figures for deaths are from the CDC’s Wonder database, and my figures for kg of opioids sold are awkwardly read off a graph that a former CDC employee kindly sent to me by e-mail. The original source for that information is the National Vital Statistics System, the DEA’s system for tracking potentially harmful medications. See my note at the bottom; be cautious about anyone’s tabulation of “prescription painkiller deaths.” They are always subject to many caveats. I am completely unsatisfied with how they are tabulated in this post or by the CDC.)

Any medicine entails some degree of risk. The risk of dying from any kind of medicine may be very small, and we may mitigate it as much as we feasibly can, but the risk never gets to zero. In this case, more people are making use painkillers, but the risk hasn’t changed. If the risk was acceptable in 1999, why isn’t it acceptable in 2014? Why the scare-mongering? A patient being treated for pain is at no greater risk today than 15 years ago. I’m picturing someone who has just made the sober decision to take a potentially dangerous medicine. He wakes up one day and realizes that there are four times as many people like him, taking similar medicine. Does he say, “Aaaaah! There’s more of me!”? Or does he say, “Great! The trade-off is worth it, and more people are getting the treatment they needed.” Scare-mongering about an increase in overdose deaths without looking at the risk *per user* is much like scare-mongering about an increase in murders without dividing by population.

Of course some people claim that most (or *all*) of the increase in painkiller use is attributable to irresponsible doctors handing the stuff out like candy. Or perhaps it’s due to an increase in “seeking” behavior by painkiller addicts (though this is a problematic story because the increase in illicit use doesn’t show up in SAMSHA or the Monitoring the Future surveys). On the other hand, some people insist that pain was under-treated in the past and we’ve just now caught up with the problem. These points are debatable, and indeed they are much debated. But the debate is silly without this piece of information: “For whatever reason you use prescription painkillers, the risk to a random user is no higher than it was 15 years ago.” Whatever threshold we have for “unacceptable risk” should apply in all time periods. Maybe a death rate of, say, 1 per every 2,000 prescriptions written is acceptable for intense pain, but not for mild pain or recreation use. Or maybe that level of risk is acceptable for all pain levels *and* recreational use. Maybe grown-ass adults should be able to decide their own thresholds for themselves. I’m not trying to settle this debate or answer the question I posed in the title of this post. I certainly have an opinion, but the point of my post is not to convince you to share it. I’m merely trying to clarify what the trade-off is in this debate.

All that said, I believe there is low-hanging fruit here to pluck. A constant death rate really *is* unacceptable if there are simple, unexplored solutions that would reduce it. Most of these deaths, as I have said before, are drug interactions, *not* single-drug overdoses. We’d go a long way toward bringing down the death rates with better education, perhaps starker warnings, for pain patients taking multiple drugs. Some genuine harm reduction is possible here. But I suspect it’s counterproductive to wag our collective fingers at painkiller users while saying, “Don’t do this!” or at doctors while saying, “Don’t let him use this!” or at policymakers while saying, “Don’t let him prescribe it *and* don’t let him do it!” Prohibition is a blunt and ineffective instrument for addressing this problem. 

Note: I’m just using the “other opioids” category to represent prescription painkiller deaths, which isn’t quite right, although it is the largest single drug poisoning category that the CDC has a code for. Some tabulations include methadone and “other synthetic narcotics,” which may or may not be valid. At any rate, any tabulation will show that “prescription painkiller deaths” are up by roughly the same factor as “Opioid sales” or “number of prescriptions.” So whether it’s really 0.5 deaths per kilogram or actually 0.75 or 2.0 or 10 deaths per kilogram, I don’t really care. My point is that it hasn’t changed much. (Try doing your own by reading the figures off of the chart at the bottom  of this page.)

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