Monday, May 16, 2016

"Opioid Epidemic" - The NYT Editorial Board Joins the Herd

The New York Times gets it wrong on the opioid “epidemic:”

Every major media coverage of this story gets a lot of important details wrong. Every single one omits vital facts that undermine the story. Frankly I’m getting frustrated with this nonsense. Here’s how it opens:

The opioid epidemic is now a leading cause of death in the United States, ravaging communities across the country.

Huh. “A” leading cause? Note the indefinite article “a” rather than “the.” It is most certainly not “the” leading cause, unless you fixate on some tiny sub-demographic of age/race/geography where it does happen to be the leading cause. There were 2.6 million deaths from all causes in the United States last year. The leading causes of death are heart disease and cancer, and these beat drug poisonings by a very wide margin. You have to do some serious cherry picking in the “young adult” demographic to find a subcategory where drug poisonings top the list.

Opioids, a category of drugs that includes heroin and prescription painkillers like oxycodone, killed more than 28,000 people in 2014, and the rate of overdoses has tripled since 2000, according to the Centers for Disease Control and Prevention.

The 28,000 number is combining heroin and prescription opioids (which to the NYT’s credit is clearly stated). This combination of different substances reeks of bad faith. It's adding together different things to get an inflated (thus more shocking) number. These are very different problems with very different causes. Heroin use is a fairly clear indicator of a drug problem or some kind of risky behavior, but many (I would claim *most*) of the prescription opioid poisonings are due to drug mixings by patients with legal prescriptions who *don’t* have an addiction or drug-abuse problem. A very large proportion of these drug poisonings are mixtures of opioids and benzodiazepines or alcohol. A simple stern warning not to mix these drugs would likely prevent a large number of these deaths, but the NYT has failed to meaningfully inform its readers on this point. That’s a real shame, because unlike policy recommendations, “never mix X and Y” is advice that a reader can  actually use. The very next sentence is:

Almost two million Americans abused or were dependent on these drugs in 2014.

A number which hasn’t risen significantly since 1999, when opioid prescriptions and opioid deaths began to rise. The NYT editorial board might have shared this information with its readers, because it completely undermines the rest of the piece. If you can quadruple the number of prescriptions (and the sheer tonnage of opioids consumed) and *not* get any more addicts, then apparently these drugs are a lot safer than these scare stories imply. By the way, the SAMHSA survey that the 2 million number comes from also shows a breakdown of the source of prescription painkillers. 53% of respondents said they got them “free from a friend,” which is not a reliable supply for a hard-core addict. Two million sounds like a lot, but it’s 0.7% of the population. And (also from the SAMHSA survey) there are about three times as many people who use these drugs every year without ever experiencing an abuse disorder. Maybe two million painkiller addicts is a big deal, and perhaps the treatment programs this piece is advocating for would be worthwhile. But it’s not a growing problem and it can’t be attributed to the increasing volume of prescriptions.

The country is facing a health emergency, and it would be tragic if a self-imposed budget rule got in the way of a robust federal response.

More pointless hyperbole.

The federal government can make the biggest difference by expanding high-quality treatment programs.

Fair enough. I don’t particularly object to this. However:

States, which have more sway over doctors and hospitals, need to do more on the prevention side by placing limits on opioid prescriptions.

This will likely lead to *more* overdoses. Limiting the legal supply will drive many addicts to the black market. Limiting the legal supply is what makes heroin and cocaine so deadly. Let doctors decide which cases are appropriately treated with painkillers and which ones are appropriately addressed by some other treatment. Let’s not allow police, bureaucrats, or the NYT editorial board to interfere in decisions where they lack the relevant expertise. A bland executive directive to "decrease the volume of opioids prescribed" is likely to backfire and cause more deaths.

“Many people become addicted because of being prescribed an inappropriate amount of opioids or for too long,” said Gov. Maggie Hassan of New Hampshire.

A politician joins the chorus of scare-mongers. Not surprising. Once again, the increase in opioid prescriptions hasn’t appreciably increased the number of illicit users *or* the number of addicts.

This editorial is like so many others I see on the opioid “epidemic.” It’s filled with some true facts and accurate numbers, but also some glaring, inexcusable omissions. The facts are held together with a mistaken narrative. It’s incredibly lazy reporting.

My take is very different from the dominant narrative: We have a useful treatment for pain management in the form of prescription opioids. As with almost any medical treatment, there is some probability of death given the treatment. That risk has not changed at all: a quadrupling use of the treatment has quadrupled the number of deaths, roughly speaking.  It is bad public health policy to simply count up total deaths and worry when the number gets big. A total number of deaths (which, trivially, would quadruple if the population quadrupled and nothing else changed) is an irrelevant public health consideration. The relevant question is: What is the acceptable risk for a given treatment? If opioid use for pain management was an acceptable treatment in 1999, it’s an acceptable treatment today, because the risk per prescription hasn’t changed appreciably.

What bothers me most is that media outlets fail to inform their readers in a way that might *actually* reduce the number of drug poisonings. Only ~20% of prescription opioid deaths involve just one substance; most of these are multi-drug interactions, with benzodiazepines and alcohol being the biggest offenders. Warning the reader against potentially dangerous drug interactions would go a long way. Heroin poisonings, by the way, also usually involve multiple substances. Of all heroin poisonings, heroin *by itself* is the culprit only about 30% of the time (a true “overdose,” as opposed to a multi-drug poisoning). It might help to stop calling these "overdoses" and clarify that there are dangerous combinations of drugs, even each individually is ingested in a safe dosage. 

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