In 2016 testimony before U. S. Senate Special Committee on Aging Opioid Use Among Seniors, Doctor Sean Mackey of the Stanford School of Medicine provided a broad overview of opioid use. While the annual 28,700 opioid-involved deaths in the US is alarming, we must keep in mind that “more than 100 million Americans have pain that persists for weeks to years. Notably, 99,971,300 of those with persistent pain do not die of opioid-involvement. The constructive role of opioid medications is often ignored in angry political rants that confuse the vast number of legitimate uses with the relatively small number of illicit use of opioids.
Doctor Mackey regards pain management as a moral imperative and reminds us that chronic pain can be a disease in itself. That perspective is lost in recent CDC regulations which say that “doctors should try pain relievers like ibuprofen before prescribing the highly addictive pills, and that they give most patients only a few days’ supply.” Trying ibuprofen first is fine, but limiting those who need stronger medications to a few days of supply is ridiculous. The CDC seems unconcerned that in most states, to obtain each opioid prescription the patient must attend a doctor’s appointment. Opioids cannot be prescribed by phone.
The CDC guidelines would force the patient into twice weekly pain appointments. Perhaps CDC employees enjoy medical benefits that pay for hundreds of doctor’s appointments each year along with a job that allows 50 sick days each year. Most who suffer chronic moderate to severe pain are not that lucky.
Many patients with moderate to severe pain have physicians who follow the rules and when needed, prescribe strong pain medications such as hydrocodone, oxycodone, oxymorphone, dilaudid, tramadol or even fentanyl. Their patients can be properly educated — taught to use medication suitable for the level of pain they are experiencing and taught to watch for any side effects that should lead them seek immediate medical help. Legitimate use of opioids can alleviate long term pain without inducing an overdose.
Among seniors with part D Medicare coverage, about 30% are prescribed opioids for legitimate reasons. That suggests about 30 million within the US population are prescribed opioid medications. The vast majority of that prescription opioid use is benign, effective and low in cost.
Prescription opioids are priced between $0.36 per 50mg tablet for tramadol to $6 per fentanyl transdermal patch releasing 50 micrograms per hour. It is easy to find higher prices, and use of coupons can result in even lower prices. The hydrocodone and oxycodone opioids are priced between $1 and $2 per 5 milligram tablet. The 300 milligrams of acetaminophen added to each tablet is thought to be an abuse deterrent that works by damaging the patient’s liver if more than 12 tablets are used in a day.
A small fraction of the opioid users who hold a legitimate prescription for opioid medications overuse the drug or supplement it with an illicit drug such as heroin. Heroin has been banned since 1925, yet it is involved in 25% of all drug overdoses. Heroin is not prescribed by physicians nor is it manufactured by legitimate pharmaceutical companies. Heroin, and not all opioids, is the proper target for aggressive regulation.
Fentanyl has legitimate uses for controlling severe pain, but it is cheap to manufacture and sometimes is illicitly blended on the street into heroin or another opioid. Since fentanyl is about 100 times more powerful than heroin, it can easily cause overdose death. Indeed, much of the so-called opioid epidemic is caused by an illicit heroin-fentanyl cocktail. There are also some designer drugs related to fentanyl that are even more lethal (e.g. carfentanil, which has already been banned for human use). These deadly potions kill very quickly.
Every year we hear another sermon on law and order and anti-opioid sabre rattling. It becomes bullying when it takes the form of CDC regulations that threaten all opioid users with the loss of access to effective pain control. To be sure the CDC’s message is heard, physicians’ livelihoods are threatened if they fail to fall in line with the latest political dogma on pain control.
Overdoses are a legitimate concern, but determination to stop drug abuse should not become an excuse to carpet bomb the vast majority of patients whose legitimate use of opioids allows them to function, earn a living, and remain a constructive member of society.