Opioid Nonabusers: An Inconvenient Truth

It seems as though every state in the country is passing laws intended to address our opioid addiction and overdose problem.

Make no mistake about it: this is a big problem. The American Society of Addiction Medicine has reported that drug overdose is “the leading cause of accidental death in the United States, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers.”

Leaders in health care, government, and law enforcement are all scrambling to find ways to slow down the flow of opioids from both legal and illegal sources.

For instance:

• Recently passed federal legislation appropriated more funding to addiction treatment and education.
• New York moved to an all electronic prescribing system in part to make prescription diversion more difficult.
• Massachusetts passed laws limiting initial opioid prescriptions to 7 days and making addiction counseling in emergency rooms a requirement in certain circumstances.
• Ohio passed laws mandating the use of its state prescription monitoring program for opioid prescriptions involving doses that exceed 7 days.

To be clear, I support all efforts to prevent drug addiction, educate patients and prescribers, and offer more treatment options to those who wish to break the horrible cycle of addiction and abuse. But in the midst of all the discussion on how to reduce opioid prescribing and abuse, there seems to be awkward silence when it comes to the largest group of opioid users: nonabusers.

Nonabusers comprise the largest group of opioid users in our nation by far. These are the patients who are legally receiving opioids like oxycodone, hydrocodone, and morphine and are taking them as prescribed for pain.

The typical nonabuser saw a single prescriber for his or her opioid. They take their medication on schedule, or less frequently than allowed. When nonabusers use opioids for acute or postsurgical pain, they’re doing so to enable greater mobility and physical therapy, permitting a faster recovery and return to a better quality of life. When they stop taking these medications, they rarely ever need them again.

This describes the majority of opioid users.

For instance, around 207 million prescriptions were written for opioids in 2013, according to IMS Health data. That same year, there were about 14,000 deaths from opioid-related overdoses, according to the National Institutes of Health.

You could do all sorts of things with those statistics, but it’s simply a mathematical reality that for every 14,785 opioid prescriptions written, 1 individual died by abusing the medication. Of course, this sort of analysis isn’t very helpful, as it doesn’t take into consideration the number of opioids involved in deaths that came from nonprescription sources such as robberies or illegal importation.

Suffice it to say that more than 99% of prescriptions for opioids are written for nonabusers. Should all of those prescriptions have been written? Probably not, but that doesn’t change the fact that most of those patients aren’t abusing opioids.

It looks like we’re too afraid to speak up on behalf of the nonabusers. We’re too busy trying to assign blame to drug manufacturers, prescribers, and pharmacists. Meanwhile, very few individuals are speaking out about how opioids actually provide life-restoring pain relief to millions of patients.

If we said that most patients use opioids without becoming addicted, it would appear as though we’re blaming the addicted patient for the problem, which isn’t politically correct. I’m not blaming the addicted patient, either. What I’m saying is that statistically speaking, they comprise the vast minority of patients who use opioids. We’re writing laws and imposing rules to help manage the 1%, but in this case, I’m okay with that.

It almost seems as though opioid nonabusers are an inconvenient truth. The millions of patients who take their medications appropriately with stable dosing and have visited the same prescrber and pharmacy for years are almost supposed to be ignored. You can pretend that they don’t exist, but they’re the elephant in the room.

Still, the 14,000 deaths related to opioid overdose is 14,000 too many. I believe that our society should employ resources to help prevent addiction wherever possible and aid addicted patients in their recovery.

But I also believe that the vast majority of patients are taking opioids responsibly and that the majority of health care providers prescribe these drugs cautiously and carefully. Addicted patients need our help, but nonabusers need it, too, and health care professionals and politicians should stand up for them, as well.

Nonabusers often bear stigma and are sometimes made to feel like outcasts when they’ve done nothing wrong. I don’t think that’s fair, and I’m willing to speak up on their behalf.