We’ve all heard about America’s so-called “opioid epidemic.” Nearly 100,000 people died in 2021 of causes that included overdose by one or more narcotic drugs and often alcohol. We also hear assertions from anti-opioid advocates that this epidemic was caused by doctors “over-prescribing” opioid pain relievers to their patients. These assertions are fundamentally wrong on fact. U.S. national health care policy and law redirections are needed to correct such distortions.
Doctors prescribing to their patients did not create the U.S. opioid crisis.
Undeniably, America is undergoing a public health crisis in rising rates of drug addiction and tens of thousands of yearly drug-overdose-involved deaths. However, it is equally undeniable that doctors did not cause this crisis by over-prescribing opioid pain relievers to their patients. Illegal street drugs instead drive our “crisis,” primarily fentanyl imported from Mexico and China.
As Dr. Nora Volkow (director of the National Institute on Drug Abuse) and Thomas A McMillan noted as early as 2016,” addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons exposed to opioids — even among those with pre-existing vulnerabilities.”
Our real crisis is instead driven by the socio-economic determinants of health; it is one of hopelessness rooted in 50 years of wage stagnation, ever-increasing wealth inequality, under-investment in national economic infrastructure, and the hollowing-out of the rust belt, rural and inner-city communities by structural poverty, leading to the collapse of family support systems. Vulnerability to addiction is created by the circumstances in which people live, not by medical exposure.
These realities are vastly misunderstood by the Centers for Disease Control and Prevention, the Veterans Administration, and law enforcement agencies, particularly the Drug Enforcement Agency. Despite repeated false claims of an “association” between prescribing and opioid deaths, data published by the CDC itself directly contradict such conclusions.
For millions of Americans, long-term opioid therapies are the only treatments that make severe pain manageable and preserve limited quality of life. However, U.S. public health policy is killing patients in wholesale lots by forcing doctors out of pain medicine and patients into street markets or suicide.
When it is understood that doctors are not now — and likely never were — the primary source of America’s opioid crisis, much of current public policy on addiction, overdose deaths, and harm reduction is revealed to be either profoundly misdirected or outright fraudulent nonsense.
What must be done today?
America’s opioid crisis is multi-dimensional. So also must be needed redirections of health care policy. Some of these redirections will likely require new laws.
Corrections at the federal level
1. Immediate public withdrawal and repudiation of the fatally flawed and actively dangerous 2016 and 2022 revised CDC guidelines on the prescription of opioids, with notification of State Medical Boards and Departments of Health that these guidelines should no longer be used as references in State health care regulatory documents.
2. Immediate public repudiation of the Department of Veterans Affairs and Department of Defense May 2022 “Clinical Practice Guideline for the Use of Opioids in the Management of Chronic Pain” and the related “Opioid Safety Initiative.” Both documents suffer from the same cherry-picking and misrepresentation of research that is deeply evident in the CDC guidelines.
3. Amendment of the Controlled Substances Act of 1970 to halt pre-trial asset confiscations directed against clinicians; coercing clinician staff with threats of prosecution if they do not testify against clinicians must also cease.
4. An immediate stand-down order to the Drug Enforcement Agency is needed, halting prosecutions of clinicians until the publication of definitive standards for judge and jury instruction under the 2022 Supreme Court decision in Ruan v. the United States. Such standards must be accompanied by a related standard for qualification of “expert witness” testimony submitted against clinician defendants.
5. Given the current artificial shortage of critical anesthetic and analgesic medications caused by the DEA, the authority of that Agency to set production quotas on scheduled medications must be rescinded.
At the state level
6. All states should replace laws that limit patient access to opioid medications under medical supervision or create sanctions against clinicians who prescribe opioid analgesics within their own best understanding of patient needs. Models for policy redirection are offered in recent legislation passed in New Hampshire, Rhode Island, Oklahoma, Arizona, and Minnesota.
Replacement of CDC and VA practice guidelines
7. The FDA or National Academies of Medicine should convene a one-year consensus conference on clinical practice standards for treating acute and chronic pain, supported by clinical specialty academies and Boards. Conference participants should have hands-on professional experience in hospital and community medical practice for pain management. Voting participants should also include chronic pain patients or their advocates. An interim draft should be published via the Federal Register for public comment. Actions in response to every comment must be tracked and reported.
The 2018-2019 Department of Health and Human Services Inter-Agency Task Force on Best Practices in Pain Management offers a model for processes to ensure public transparency and scientific accuracy.
A plea for help and a demand for change
Millions of U.S. citizens now live every day in a nation in pain. Much of their pain is now caused by misdirected public health policy and outright fraudulent misrepresentation of the risks and benefits of prescription opioid medications. Even officials who have “inherited” this debacle must surely acknowledge that if they aren’t part of the solutions, they are part of the problem.
The message to government decision-makers is clear: We will no longer be silent. We demand your immediate actions on our behalf.
Richard A. Lawhern is a patient advocate.