The President's Opioid Commission

I was going to read the recent report by the President's Commission on Combating Drug Addiction and the Opioid Crisis and give a scathing review. It turns out that Jacob Sullum pretty much nailed it so I don't have to. Still, I read the first 50 pages and skimmed the rest (the report is very repetitive so I'd be surprised if I missed any major themes). The report starts with 56 bullet points, not a single one of which says, "Let's back  off of this failed program." Almost every bullet point is a call to expand existing government programs or add new ones. My response after reading their list was, "No thanks, you've done quite enough already." The whole thing stinks. The authors of the report and the policymakers they are writing for apparently lack any ability to be self-critical. It's like they can't see, or can't even imagine, that this whole sad episode is the fault of bad policy, namely drug prohibition. The report utterly fails to address or even acknowledge the argument put forth by legalization and harm-reduction advocates. That's why it's hard to take seriously any report that comes out of the official government drug policy bureaucracy. If this was at least a conversation, where critics make arguments against government policy and the relevant government agencies respond honestly to those arguments, I'd have more hope. Instead, what I see is a bureaucracy spews nonsense, then plugs its ears and shakes its head when you try to explain how insane it sounds. On the few occasions when I've gotten drug prohibition advocates to actually engage in argument with me, they offer ridiculously flippant and obviously ad hoc arguments, promptly leave the conversation when challenged, and occasionally reappear to make the same silly arguments with no apparent memory of the previous discussion. I'd like to be more charitable than that, but I've seen this pattern a number of times. I think the drug enforcement and drug policy-making apparatus is so entrenched and conservative that it isn't allowed to question its existence. It seems that certain policies are not even allowed for consideration. The report confirms all of these impressions for me.

The report pretty much rehashes the standard narrative of the opioid crisis, which goes something like:

Lax prescribing standards and a dramatic increase in the amount prescribed lead to opioid abuse and increasing overdoses. With their appetites for opioids now stoked, normal patients graduated to opioid abuse, and prescription opioid abusers graduated to heroin.

As I've argued, this story makes no sense. You would have expected to see a rise in opioid abuse over the period when opioid prescriptions were trippling, but this trend of rising abuse utterly failed to appear. A few irresponsible journalists are writing silly articles about how drug libertarianism is a failure, when in reality we haven't tried anything vaguely resembling drug legalization. The rise in heroin overdoses doesn't necessarily have anything to do with the earlier increase in opioid prescriptions. More likely, it's just an effect of fentanyl and other super-powerful opioids making street "heroin" cheaper, with the lower price attracting new users. Heroin definitely got deadlier. It's not simply that the number of users increased; the deaths per user also increased by a factor of two or so. This supports the notion that heroin today is more likely to be adulterated than it was six or seven years ago, before heroin deaths started rising. This issue of heroin adulterated with fentanyl is 100% a product of drug prohibition. When asked, heroin users say they are scared of fentanyl. They know about the overdose risk and try to avoid it. From a testimonial that I can't find now, they tend to say that heroin gives them a more "mellow" high, whereas fentanyl just knocks them out. It's not pleasant and it's downright frightening. If these addicts could get their hands on legal, pharmaceutical-grade heroin of known purity, we wouldn't be seeing any of these fentanyl or heroin overdoses. Once again, you can read the entire report by the president's commission without learning any of these important details.

A couple of useful links from Sullum's Reason piece. Here is an absolutely heartbreaking list of suicides that happened after chronic pain sufferers were cut off from their opioids. These poor people were treated with suspicion by their doctors and eventually cut off from the only thing that worked for them. Expect more of this if we continue with current policy, that is if people like Robert VerBruggen and German Lopez actually succeed in influencing policy with their misleading and incomplete reporting on opioids. When people are choosing death over an existence without opioids, that probably means those people have very real and very serious problems with chronic pain. They weren't just "faking it" in order to score. Even admitting the caveat that these are merely plural anecdotes and not true data, for every one of these stories there are surely dozens or hundreds of chronic pain patients suffering in silence. For each suicide on this list, surely there were several that didn't generate a media presence or didn't pass the author's vetting criterion for inclusion. There is little doubt that patients are being denied necessary medicine, medicine that they are deadly serious about needing. (I can't find the link, but Radley Balko has said he's received hundreds of e-mails from chronic pain sufferers who couldn't get the opioids they needed. They started writing to him after he published some blog posts and articles on this topic.) Keep in mind the journalists who are critical of "loose" opioid prescriptions don't actually have a better mechanism for sorting true pain sufferers from fakers. They are just saying "tighter prescribing guidelines." It's not "We have a better predictive model," it's more like "change the threshold." They are in effect saying, give us fewer false positives but more false negatives negatives, fewer abusers but more untreated pain.

Sullum also links to a suggestive study from Massachusetts. It seems that only about 8% of decedents had a prescription in the months prior to their overdose. If this is reflective of nationwide patterns, it seems that most overdoses aren't normal pain patients who just accidentally mix substances, but are more typically people abusing opioids that they weren't legally prescribed. I could believe either way. If these stats were more definitive and nationally representative it would render a verdict in favor of the "illicit use" theory (over the "sloppy/inappropriate legal use" theory).

Finally, there are some useful statistics about the fraction of painkiller users who become addicts.

According to the National Survey on Drug Use and Health (NSDUH), 98 million Americans used prescription analgesics in 2015, including both legal and illegal use. About 2 million of them qualified for a diagnosis of "substance use disorder" (SUD) at some point during the previous year. SUD is a catchall category that subsumes what used to be known as "substance abuse" and the more severe "substance dependence." The Substance Abuse and Mental Health Services Administration, which oversees the survey, does not report the breakdown between mild, moderate, and severe SUD. But based on this survey, it looks like somewhere between 1 and 2 percent of prescription opioid users experience addiction in a given year. By comparison, NSDUH data indicate that about 5 percent of past-year drinkers had an alcohol use disorder in 2015. That group was about evenly divided between "abuse" and "dependence."

The NSDUH numbers provide a one-year snapshot. Some studies of patients who take opioids for extended periods of time find higher addiction rates, but they are still generally modest. A 2010 review found that less than 1 percent of patients taking opioids for chronic pain experienced addiction. A 2012 review likewise concluded that "opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence." A 2015 review noted addiction rates in various studies ranging from 3 percent to 26 percent in primary care settings and from 2 percent to 14 percent in pain clinic settings.

The risk of fatal overdose among patients is very low. The CDC cites "a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain" who were followed for up to 13 years. The researchers found that "one in 550 patients died from opioid-related overdose," which is a risk of less than 0.2 percent. A 2015 study of opioid-related deaths in North Carolina found 478 fatalities among 2.2 million residents who were prescribed opioids in 2010. That's an annual rate of 0.022 percent.

If you're suffering from chronic pain, or even acute pain that's only expected to last a few days or weeks, this might not seem like a bad deal. Yes, there is some non-zero risk of addiction, diversion, and overdose, but it's overwhelmingly worth the risk. Especially considering that anyone can simply decide to be cautious, take their medicine as prescribed, and not become an addict. (Call me crazy, but I'm one of those weird people who believes in free will and freedom of choice.)  It's clear from the report that the commission places almost no value on pain relief. They recommend removing it from patient satisfaction surveys. They want doctors to cease considering it "the fifth vital sign." That's truly sad. Sure, they might succeed in stopping doctors from juking the stats by over-prescribing pain medicine, but they're also going to leave a lot of people suffering in a living hell. Keeping pain medicine away from chronic pain sufferers is possibly the very worst thing our government does. Even separating it from the drug war generally and giving it its own heading, I'd put it at the very top, right up there with "draconian immigration restrictions."