Tuesday, September 12, 2017

Medical Statistics III: Why So Many Opioid Deaths?

So today, we get to the last question: why is there such an epidemic of opioid deaths from prescription abuse?

Easy: there ISN'T any epidemic of opioid deaths from prescription abuse.

This nonsense was debunked a year ago:
According to the National Survey on Drug Use and Health (NSDUH), nonmedical use of opioid analgesics such as oxycodone and hydrocodone peaked in 2012 and has since dropped below the rate in 2002. Although the recent decline in prescription painkiller use was accompanied by an increase in heroin use, total opioid use was still lower in 2014 than in 2012. 
Despite the decline in use, opioid-related deaths reported by the U.S. Centers for Disease Control and Prevention continued to rise through 2014, when there were 29,467, a record number. An overwhelming majority of such deaths -- more than nine out of 10, according to data from New York City -- involve mixtures of opioids with other drugs rather than straightforward overdoses.
So what's skyrocketing?

Heroin use (with deaths from same up 300% in the last few years), and the recent tendency to cut street heroin with synthetic "designer" fentanyl (acetyl fentanyl), a non-pharmacopeia version of the drug, only produced by back-alley chemists. Ordinary fentanyl is 30-50 times stronger than the purest heroin. Heroin cut with acetyl fentanyl is hundreds of times more potent (because with drugs, 1+1=37, or 52, or eleventy-nine, because >shocker!< drug cartels don't submit their product for FDA testing regimens, and there's no label on the product).  So junkies who shoot it up, wanting a bigger high, get a dose so potent they're found cold and dead with the needles still stuck in their arms, and no amount of Narcan would ever save them. You see an uptick in heroin deaths, I see Darwinism in action.

Heroin deaths going up, morphine, oxycodone, etc. coming down.

And who's using that heroin?


Youngsters shooting up, just like you'd have thought, not old farts.
Note the fall off in heroin deaths: They tend to kill themselves off by 35 or so, and by 55 the survivors have generally kicked junk, or kicked their oxygen addiction. Opioid deaths go exactly the other way: the older you get, and the longer you take prescription pain meds, the greater the likelihood you'll screw up and off yourself, usually accidentally, whether straight overdose, combining pills with booze, and a non-zero number of chronic pain sufferers who get depressed, and decide to see what comes after this life.

Which latter is bad, but hardly epidemic.

The people we saw in yesterday's graph, the ones getting all those Rx opiates? They're the ones on the chart above where those deaths decrease from the peak caused by stupidity/abuse.

Almost like I knew what I was talking about.

Not least of which because it's hard (not impossible, but hard) to kill yourself on Rx painkillers.

In fact, going back to the TownHall column from 2016, prescription opioids are pretty tame stuff.
The CDC says "health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills." That year the CDC counted about 16,000 deaths involving opioid analgesics*, or one for every 16,000 or so prescriptions. 
Opioid-related deaths are rare even for patients who take narcotics every day for years. 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.  
The risk of addiction also has been exaggerated. According to NSDUH, those 259 million painkiller prescriptions in 2012 resulted in about 2 million cases of "dependence or abuse," or one for every 130 prescriptions. A recent study by Castlight Health estimated that 4.5 percent of people who have received opioid prescriptions qualify as "abusers," and its definition, based on the amount prescribed and the number of prescribers, probably captures some legitimate patients as well.  
According to NSDUH, only a quarter of people who take opioids for nonmedical reasons get them by obtaining a doctor's prescription. Hence the sequence that many people imagine -- a patient takes narcotics for pain, gets hooked, and eventually dies of an overdose -- is far from typical of opioid-related deaths.
The rarity of addiction to opioids should come as no surprise to the vast majority of Americans who have taken Vicodin or Percocet for pain. Maybe they enjoyed the buzz, but they did not continue taking opioids every day once their pain was gone. 
The truth is that using such drugs regularly for their psychoactive effects appeals to only a small minority of people, which is one reason heroin has never been very popular even among illegal drug users. "We lose sight of the fact that the prescription opioids are just as addictive as heroin," says CDC Director Thomas Frieden. In other words, not very.

*{For the record, there were 33,561 automobile deaths that year, and 33,563 firearms deaths (suicide/homicide combined), so for a country "awash in opioid prescription drugs", Rx meds are about three times safer than cars or firearms, so anyone wanting to ban any one of them is pretty conclusively a raging jackass, and mathematically retarded}

So what's really going on with all the hype?
I suspect blogger Silicon Greybeard has likely tumbled to the primary critical impetus:
bought-off politicians being greased by the folks who manufacture Narcan:
"Cui bono?  Who benefits?  As always, start by asking that.

Thankfully, while I was playing guitar, Mrs. Graybeard (who can be a much better search engine weenie than me) started asking some questions.  It starts with a simple observation: have you noticed the push for every cop, every paramedic and every rescue group in the country to carry naloxone?  There was even a story about librarians administering it to addicts to save their lives.  Have you heard that the price of naloxone has gone up at least 17 fold in the last few years?  And isn't it interesting how everyone has heard the complaints that the makers of (epinephrine) epi pens, Mylan, hiked their prices 4x but no one seems to complain that naloxone has gone up 17x?

Going down that rabbit hole leads directly to Hillary Clinton and the Obama administration.  This is according to the Wikileaks emails found here.  You should read the whole thing.  Someone sleuthing around in the Wikileaks archive posted this (there are grammatical and other errors in here, but I've left the author's words as found):
There seems to be money flowing into the Clinton Foundation from big pharma. The CEOs are donating to Hillary's campaign. On the campaign trail I've seen Bill Clinton name drop the drug naloxone. The recent emails on wikileaks confirms that the one of the goals of the Clinton Foundation is to make this drug be everywhere. One of the manufactures of this drug is Hospira, a company recently bought by Pfizer. 
There seems to be serious conflicts on interest. been the campaign and the companies. For example Clinton wants to give these campaigns 7.5 billion dollars through federal programs. This is an OP-Ed from Hillary from last year:

Today I’m releasing a strategy to confront the drug and alcohol addiction crisis. My plan sets five goals: empower communities to prevent drug use among teenagers; ensure every person suffering from addiction can obtain comprehensive treatment; ensure that all first responders carry naloxone, which can stop overdoses from becoming fatal; require health care providers to receive training in recognizing substance use disorders and to consult a prescription drug monitoring program before prescribing controlled substances; and prioritize treatment over prison for low-level and nonviolent drug offenders, so we can end the era of mass incarceration.
The call for Naloxone by name was echoed by Tim Kaine - before he became her running mate in the last election - and by John Podesta.  Call it crony capitalism or crony socialism, either way it's corrupt to the core.

The drug isn't under patent, so there can be generics.  Hospira/Pfizer is one of only a few manufacturers and they've all jacked their prices up.  The defense seems to be "but we don't charge as much as the other guys".  Are the prices a function of supply and demand or "get it while the gettin's good"?

The states are jumping on the bandwagon, too - along with first aid instructors and even gun bloggers.  Everybody is trying to get first responders to carry naloxone or the narcan nasal spray.

Conspicuous in its absence is that none of the governments seem to be pushing anti-addiction treatments and therapies, just the drugs.  Admittedly when someone is comatose and ready to die from their OD, they don't benefit from counseling, but without breaking the addiction cycle they're probably going to need more of the drug someday.

It could be that the cartels are supplying heroin more cheaply than before and usage patterns are shifting to the cheaper heroin.  When the cartels cut their heroin with cheaper fentanyl, it's easier for addicts to overdose and die.  But the heroin overdose problem is not the myth that it's prescription drugs and it's entirely possible that a bump in heroin deaths is being exploited all the way around."
And that self-greasing axle is how you get nitwits at the Sacramento Bee furiously pointing fingers at not-the-problem, and politicians hog-troughing full-snoutedly for pimping an opiate agonist in every pot and pocket, for a problem that won't respond to either of those solutions.

This is why everything government touches, it fucks up:
They can't read their own data, the press can't follow the obvious facts, or find their own asses with both hands and a map, and then politicians see an opportunity to ladle in some pork barreling and do some log-rolling to keep the contributions coming, and the "solutions" make a host of other things worse, while making nothing they were supposedly aimed at better.

Which is why people who don't know what the fuck they're talking about should STFU; and government, by definition, doesn't know what it's doing in 163% of all studied cases or situations.


One in ten kids 12-18 will take opioid pain relievers for non-medical use.
Pot is available in droves, and possession and use is becoming widely decriminalized.
We won't even talk about alcohol use/abuse.
All those opiate deaths?

Those are the exact consequences the "legalize everything" folks keep telling you won't happen.

The same people who'll decry Califrutopia for being batshit crazy, suddenly lose their minds when the topic of drug legalization comes up, because Libertaritardation, or something.
Keep asking for drugs to be available everywhere, and you're going to get what you wish for, good and hard. And you'll deserve it.

Part I
Part II


George True said...

Thank you for crystalizing what I have suspected for years. There is no opioid prescription drug epidemic. TPTP keep lumping heroin and Percocet into the same category and calling it an 'opioid epidemic'. As a result, they have made pain meds for people who have a legitimate need harder and harder to obtain, with lots of hoops to.jump through. And as a result of that, I think at least some of those people have turned to heroin, as it is widely available and it is cheap (sometimes cheaper than the street price for Percocets). So the gummint is actually creating heroin users. Color me not shocked.

Anonymous said...

I have no doubt I could go buy street heroin cheaper than I could get traditional pain meds. The problem being of course who knows the purity or potency or dosage etc.

Much to my surprise I learned that way back in the day one could walk into a pharmacy and buy pharmaceutical grade morphine or cocaine from Bayer or whoever without so much as a doctor's note. You could buy any pharmaceutical without a prescription either from your local pharmacy or through the mail. I'm not convinced that it wasn't a better system. Yeah I'd prefer the guidance of a physician but if you want to go buy your own bp or boner pills at walgreens on your own I see no reason why you should be prevented by the state from doing so. One could probably make a better case for restricting antibiotics than opiates.

Anonymous said...

Reason number 13,987 why the Clintons (all of them) should be beaten with barbed-wire covered baseball bats, dunked into lemon juice, folded, spindled, mutilated, set afire, hanged, drawn-and-quartered, and beheaded.

Mark D

SiGraybeard said...

Thanks for this series. Just read it all on the link to Part III from the Feral Irishman.

Really well done series, that communicates the story clearly. And I'm glad to have contributed what little I did.


Borepatch said...

Some of us libertarian(it) folks support decriminalization because the War On Drugs isn't doing bupkis to reduce supply. Prices are falling, which means that supply is increasing - despite a trillion dollars down the WoD rat hole and a bunch of civil liberties in the local PoPo impoundment year due to Civil Asset Forfeiture.

But sure - we all want legalized drugs and OD deaths, because reasons.

Other than that bit, this was a great post. ;-)

Aesop said...

Actions have consequences, and the road to hell is paved with good intentions.

I'm no fan of government getting the camel's nose under the tent, nor the endless civil liberties violations palmed off under The War On Some Drugs.

But decriminalization is fraught with more and bigger landmines than what we've got, as sure as gravity works, and they'll be endless. We do not have the same sort of Americans as we had here in 1880, so we can't simply revert to the 1880 status quo ante.
And the "War On Some Drugs" is designed not to do bupkis, and is doing exactly what your overlords intend, at every level.

I observe purely for informational purposes that countries which execute smugglers and dealers, and incarcerate junkies for their treatment, have a near zero recidivism rate on either count, and nothing like the level of the problem we enjoy under the half-libertardian and half-jackboots model currently employed, which combines the worst of all approaches, and delivers them to us at the speed of stupid, all on our tax nickel. Dysfunctional government ineptitude for the win!

And I daresay their budget for enforcement, court procedure, and incarceration is commensurately lower across the board as well.

Their ammunition budget may be higher, but that's a feature, not a bug.

You did more than a little, sir. What your wife found in her internet meanderings is probably just the tip of the government-trough and Clinton Crime Syndicate iceberg, and your essays have been germinating things in my head since you authored them. Sincere thanks.