America's War on Pain Pills Is Killing Addicts and Leaving Patients in Agony.

• Author: Sullum, Jacob

CRAIG, A MIDDLE-AGED banking consultant who was on his school's lacrosse team in college and played professionally for half a dozen years after graduating, began developing back problems in his early 30s. "Degenerative disc disease runs in my family, and the constant pounding on AstroTurf probably did not help," he says. One day, he recalls, "I was lifting a railroad tie out of the ground with a pick ax, straddled it, and felt the pop. That was my first herniation."

After struggling with herniated discs and neuropathy, Craig consulted with "about 10 different surgeons" and decided to have his bottom three vertebrae fused. He continued to suffer from severe lower back pain, which he successfully treated for years with OxyContin, a timed-release version of the opioid analgesic oxycodone. He would take a 30-milligram OxyContin tablet twice a day, supplemented by immediate-release oxycodone for breakthrough pain when he needed it.

Then one day last May, Craig's pain clinic called him in for a pill count, a precaution designed to detect abuse of narcotics or diversion to nonpatients. The count was off by a week's worth of pills because Craig had just returned from a business trip and forgot that he had packed some medication in his briefcase. He tried to explain the discrepancy and offered to bring in the missing pills, to no avail. Because the pill count came up short, Craig's doctor would no longer prescribe opioids for him, and neither would any other pain specialist in town.

"I have lived my life by the rules," says Craig (whose name I've changed at his request). "I made one mistake, and they condemned me for it. They were basically saying that I'm a druggie when I have been fine for four years. My first pill count ever, and they boot me." He says a nurse at the practice told him "the doctors were getting tired of all the scrutiny, so they were booting all the opioid patients."

Without the OxyContin, Craig says, "every morning is a challenge to get out of bed." Even with liberal use of ice packs and Biofreeze, he says, "It's horrible. I can't expect to live a life like this. I'm not a junkie. I'm not a threat to society. I'm not a threat to myself. I simply want to live my life without pain."

LIKE OTHER PATIENTS across the country, Craig is a victim of the recent crackdown on prescription opioids, which is based on a narrative that mistakenly blames pain treatment for a plague of addiction and death. Most Americans believe we are in the midst of an "opioid crisis" that began in the 1990s with the introduction of OxyContin. According to the generally accepted account, deceptive marketing encouraged reckless prescribing, which led to widespread addiction among patients and record numbers of opioid-related fatalities--a situation President Donald Trump has declared a public health emergency.

Former New Jersey Gov. Chris Christie, who chaired the President's Commission on Combating Drug Addiction and the Opioid Crisis, invokes that narrative when he talks about "the injured student-athlete who becomes addicted after [his] first prescription" or remembers the law school classmate who died of an overdose after getting hooked on the oxycodone he was taking for back pain. Such examples are misleading because they are rare, accounting for only a small percentage of opioid-related deaths.

Contrary to the impression left by most press coverage of the issue, opioid-related deaths do not usually involve drug-naive patients who accidentally get hooked while being treated for pain. Instead, they usually involve people with histories of substance abuse and psychological problems who use multiple drugs, not just opioids.

Conflating those two groups results in policies like the pill count that left Craig without the pain medication he needed to get out of bed in the morning, go to work, and lead a normal life. The rationale is that cutting people like him off will stop them from ending up dead of an overdose in a Walmart parking lot next to a baggie of fentanyl-laced heroin.

But the truth is that patients who take opioids for pain rarely become addicted. A 2018 study found that just 1 percent of people who took prescription pain medication following surgery showed signs of "opioid misuse," a broader category than addiction. Even when patients take opioids for chronic pain, only a small minority of them become addicted. The risk of fatal poisoning is even lower--on the order of two-hundredths of a percent annually, judging from a 2015 study.

Despite such reassuring numbers, the government is responding to the "opioid epidemic" as if opioid addiction were a disease caused merely by exposure to opioids, a simplistic view that ignores the personal, social, and economic factors that make these drugs attractive to some people. Treating pain medication as a disease vector, the government has restricted access to it by monitoring prescriptions, investigating doctors, and imposing new limits on how much can be prescribed, for how long, and under what circumstances. That approach hurts pain patients by depriving them of the analgesics they need to make their lives livable, and it hurts nonmedical users by driving them into a black market where the drugs are deadlier.

A large majority of opioid-related deaths now involve illicitly produced substances, primarily heroin and fentanyl. As usual, the government's efforts to get between people and the drugs they want have not prevented drug use, but they have made it more dangerous.

'HIGHLY ADDICTIVE DRUGS'

"WE'VE KNOWN FOR millennia that opioids are highly addictive drugs," says Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing. "We have an epidemic of people with the disease of opioid addiction in the United States. The reason it's become an epidemic is because opioids have been overprescribed by my colleagues, who were led to believe that we didn't have to worry about addiction."

Kolodny, who is also co-director of opioid policy research at Brandeis University's Heller School for Social Policy and Management, says the American Pain Society and the American Academy of Pain Medicine (AAPM) started to "advocate for opioids" in the late 1990s, taking the position that "the risk of addiction has been overblown, even that the risk of overdose death has been overblown, and that we should be prescribing much more for people with chronic pain." As a result, he says, "we got our patients addicted, and we stocked people's medicine chests with addiction, so their kids wound up getting addicted."

This gloss is superficially plausible. According to the U.S. Centers for Disease Control and Prevention (CDC), the amount of opioids prescribed in the United States more than quadrupled between 1999 and 2010, rising from 180 to 782 morphine milligram equivalents (MME) per capita. During the same period, according to CDC data, the annual number of deaths involving the kinds of opioids prescribed for pain also roughly quadrupled, from about 4,300 to about 18,500.

The relationship is not quite as straightforward as it might seem. Opioid prescriptions, measured by MME per capita, fell by nearly a fifth from 2010 to 2015, while deaths involving these drugs continued to rise. The CDC's numbers also indicate that deaths involving opioid pharmaceuticals are not always more common in states with higher prescription rates. In 2015, for instance, West Virginia's death rate was more than twice as high as Tennessee's, although it had fewer opioid prescriptions per capita. Rhode Island, New Mexico, and Utah had higher death rates than Oklahoma, where opioids were prescribed substantially more often.

Still, the expansion of the legal market for opioids obviously had something to do with the increase in illegal use of these drugs. Many of the pills were diverted to nonmedical users, either after they were prescribed or through theft from points higher in the distribution chain.

But greater availability of prescription opioids cannot by itself explain the rise in addiction and drug-related deaths. "The question is why so many communities were so vulnerable to developing problems with opioids in the first place," says Daniel Raymond, policy director at the Harm Reduction Coalition. Part of the answer, he thinks, can be found in the same factors that helped elect Donald Trump. "These pockets of the Rust Belt and Appalachia, with the loss of manufacturing jobs or traditional industry jobs, were extremely primed for developing a drug problem," he says. "It happened to be opioids, but it could have just as easily been--and arguably it has also been--alcohol or methamphetamine."

When Kolodny says "we got our patients addicted," he discounts the way unhappy circumstances, such as unemployment and dim economic prospects, make drug use more appealing. He also implies that pain treatment has been the main route to opioid addiction during the last two decades. But that is not what the evidence indicates.

According to a 2014 analysis of data from the National Survey on Drug Use and Health (NSDUH), 54 percent of nonmedical users got prescription opioids for free from friends or relatives. Another 16 percent bought or stole pills from friends or relatives, while 4 percent bought them from strangers. About 6 percent mentioned other sources, including online purchases, forged prescriptions, and theft from doctors' offices or pharmacies. Just 20 percent of nonmedical users said they obtained opioids through prescriptions written for them.

Although some people who now obtain opioids indirectly may have had prescriptions at some point, these results undercut the notion that nonmedical users typically start as bona fide patients. Even among the heaviest users, just 27 percent had prescriptions at the time of the survey, and it is not clear how many of those were legitimate at the outset. In most cases, says Sidney Schnoll, a physician specializing in addiction and pain treatment who works for the...