Who Is Telling The Truth About Prescription Opioid Deaths? DEA? CDC? Neither?

"Controlled Prescription Drugs (CPDs) ... are still responsible for the most drug-involved overdose deaths and are the second most commonly abused substance in the United States."

2018 National Drug Threat Assessment. Drug Enforcement Administration, October 2018.

I just don't get it. A newly-released 164-page report just issued by the DEA maintains that controlled prescription drugs are killing more Americans than any other type of drug (1); even more than heroin and fentanyl. But if you've been keeping up in this area this sounds very strange. Can it really be true that drugs like Vicodin and Percocet are killing more Americans, especially when one report after another lays the blame on illicit fentanyl and its scary analogs? What is going on? Are we seeing more of lying by omission or the use of intentionally misleading statistics, such as we've seen from the CDC and its advisors (See: The Opioid Epidemic In 6 Charts Designed To Deceive You)? Is this claim legitimate? 

While the quote at the beginning seems clear enough, it is either intentionally deceiving, or unintentionally confusing. Here's why.

First, given the non-stop barrage of opioid crisis stories, most of which have been dead wrong, many people will automatically assume that "controlled prescription drugs" refers to prescription opioids. It does not. Other classes of drugs are also controlled and they are lumped together with opioids:

"Controlled prescription drugs (CPDs) includes, but is not limited to narcotics (e.g. Vicodin, OxyContin), depressants (e.g. Valium, Xanax), stimulants (e.g. Adderall, Ritalin), and anabolic steroids (e.g. Anadrol, Oxandrin)."

Indeed, if you look carefully enough there is a separate definition for opioid analgesic drugs:

"Opioid analgesic overdose deaths include deaths from natural and semi-synthetics: codeine, morphine, oxycodone, hydrocodone, and methadone."

This means that:

• Controlled prescription drugs may be responsible for most drug-related overdose deaths, but since other classes are included in the CPD group we cannot know whether this conclusion applies to opioid analgesics without knowing the contribution of depressants, stimulants, and anabolic steroids.
• If you believe that this language is reminiscent of what we heard from PROP (2) and the CDC you are not alone.
• If you believe that this language may be intentionally constructed to convey another message you are not alone.

So, let's rewrite the quote at the top to make it more accurate:

"Controlled Prescription Drugs (CPDs) ... are still responsible for the most drug-involved overdose deaths and are the second most commonly abused substance in the United States, but opioid analgesics may or may not be."

There are plenty of reasons to suspect that they are not. Let's start with another statement two paragraphs below the one at the top.

"Illicit fentanyl and other synthetic opioids — primarily sourced from China and Mexico—are now the most lethal category of opioids used in the United States."

This claim seems to better represent reality. Here are some other reality checks.

Figure 2 clearly shows that medications are responsible for far more deaths than heroin, fentanyl and the other classes listed. Given the tone and content of what appeared before this chart, it is not unreasonable to expect that the public and media will simply assume that opioid analgesics are represented by the purple line.

This is puzzling for a number of reasons. First, what is meant by medications? Opioids? All prescription drugs? It's neither. But you have to look pretty hard to see why.

Rather than have you strain your eyes I pieced together the bits of relevant information into something that you can actually see. And guess what?

Ain't that something? The medications, which sure are killing a lot of people as shown in Figure 2, are not opioids, or restricted prescription drugs or even unrestricted drugs. They are ALL drugs. Including OTC (Advil, Aleve) and prescription (indomethacin, diclofenac) non-steroidal anti-inflammatory drugs (NSAIDs). Although estimates of annual deaths from NSAIDs vary widely they are significant: 3,000-16,000 deaths per year. 

Were OTC medications included in order to skew the results? The CDC and PROP have used this trick over and over again; it works. I don't know about the DEA, but feel free to ask Uttam Dhillon, Acting Administrator Drug Enforcement Administration. He signed the report. 

Uttam Dhillon, Acting Administrator Drug Enforcement Administration

The language of the report is one thing, but its conclusion seems to fly in the face of everything we have been seeing about overdose deaths. How is it possible that fentanyl is not the drug most responsible for overdose deaths? Especially when we see other data, like this:

Are pills really killing more people than heroin and fentanyl? Source: National Institute on Drug Abuse (NIH)

And this:

Since 2014 heroin and fentanyl combined are responsible for far more overdose deaths than pills.Source: CDC/The Wall Street Journal

Or these, which are only a few, of countless headlines?

Or the fact that the number of opioid analgesic prescriptions has dropped since 2012...

Source: Herald-Dispatch

...While total opioid overdose deaths have soared during that same time:

Source: CDC

I don't know exactly how the DEA came up with its conclusions but this whole thing just doesn't smell right. Does anyone really believe that Vicodin is killing more Americans than fentanyl and carfentanil? I sure don't.

If we are being tricked again, ask yourself who stands to benefit from the DEA claiming that prescription opioids are still the main problem. The DEA is part of the Department of Justice, which is run by Attorney General Jeff Sessions. 

"Preliminary data from the CDC shows that drug overdose deaths actually began to decline in late 2017 and opioid prescriptions fell significantly."

Attorney General Jeff Sessions, October 2018

It would seem that Sessions is trying to take credit for "turning around" the opioid crisis by maintaining that policies which have made opioid prescribing much more difficult have actually saved lives. Here's the "turning around." Not especially impressive.

Turning around? Please. Source: CDC

No, that's a bunch of nonsense. The harder it becomes to get pills, the more people flock to heroin and fentanyl. No matter how the DEA plays funny statistics games, combines drugs into groups that make no sense, or buries inconvenient captions in tiny print under graphs, we are left with 164 pages of sleight-of-hand and spin.   

If you don't believe me, Dr. Jeffrey Singer, writing for the Cato Institute, says pretty much the same thing:

What jumps out of these numbers is the fact that efforts to get doctors to curtail their treatment of pain have not meaningfully reduced the overdose rate. They have just caused non-medical users of opioids to migrate over to more dangerous heroin and fentanyl. Fentanyl and heroin—not prescription opioids—are now the principal drugs behind the gruesome mortality statistics. 

Jeffrey Singer, M.D., November 2, 2018

So, is the DEA report little more than a carefully constructed attempt to score cheap political points on the backs of pain patients - the group that is suffering the most from the anti-opioid movement? 

Don't ask me. I don't do politics. Too painful.

NOTE:

(1) But far fewer than alcohol.

(2) PROP is an acronym for Physicians for Responsible Opioid Prescribing. The group, which consists of a bunch of self-anointed opioid experts played a significant part in putting together the execrable "CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016," which is the basis for new laws and policies which are so bad that they have managed to kill more addicts while at the same time legitimate denying pain the medications they need to exist.