MORE EVIDENCE EXPOSING CONTINUING OPIOID OVERPRESCRIBING WHILE A LETHAL OPIOID CRISIS WORSENS

Opioid high-risk use and overdose continue to mount after pandemic stressors dissipate while medical overprescribing is shielded and empowered by distractions from compliant media

by Clark Miller

Published July 31, 2022

From the CBC July 4, 2022  piece describing research published in The Lancet, conspicuously missing in American media coverage. 

Dr. Julio Fiore, an assistant professor at McGill who researches post-operative recovery, said his team found that prescribed opioids had no more of an impact on the pain experienced after minor surgery than over-the-counter painkillers. 

. . .

Fiore said the findings suggest avoiding prescribing opioid painkillers could in many cases improve a patients’ recovery experience, while helping to mitigate the well-documented perils of opioid addiction.

“We really expect that these findings encourage changes in prescribing practices,” Fiore said in an interview.

“After all, like the prescription of opioids, like after discharge, our research showed that it does not seem to be as beneficial for patients as previously believed.

Of the studies examined, 30 involved minor procedures (most of which were dental) and 17 involved procedures of a more moderate nature on, for instance, a shoulder or foot.

Among the opioids most commonly prescribed by surgeons are oxycodone, hydromorphone, tramadol and codeine, according to the researchers. 

The prescription of opioid painkillers varies widely across countries, and studies suggest Canadian doctors still prescribe more opioids than their counterparts in Europe — but not as much as doctors in the United States.

One 2019 study examining post-operative prescriptions found that almost half of U.S. patients had received high-dose opioid prescriptions after certain surgeries, which was nearly double the rate of Canada and nine times the rate of Sweden.

 

Those are some remarkable understatements, compared to results reported in the original research. 

Background

Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.

Findings

47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI –0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes.

Interpretation

Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings.
 

That is, for most types of surgeries, opioids do not provide benefit for pain that could be provided by other types of prescribed substances that do not carry the same risks – abuse, diversion , development of dependence, and misuse in an increasingly lethal, iatrogenic opioid crisis. 

From the CBC piece, 

Dr. David Juurlink, head of clinical pharmacology at Sunnybrook Health Sciences Centre in Toronto, who was not involved with the study, said many doctors and dentists in Canada still put opioid painkillers on a “pedestal.”

He said the study builds on previous research and his own experience as a practising doctor. 

“The key message is these drugs are still valuable. They are certainly valuable in hospitals,” Juurlink said, but then added that doctors and dentists should be “mindful of the fact that these drugs don’t work as well as we were taught and they aren’t as safe as we were taught. And very often, patients can do just fine without it.”

But that’s a gross distortion, by omission. 

It leaves out an inconvenient truth – 

the fact that any attentive and intellectually competent medical student in any credible medical education program would have learned just the opposite, by exposure to facts established about opioids and their effects and use available for decades and longer.  

There has never existed, not at any time, a body of research evidence to provide even preliminary support for the safe practice of prescribing opioid medications for chronic painor with the expectation of durable benefit for chronic pain.

See, for example:

Chou, R et al.  2015. The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop.  Ann Intern Med. 162:276–286.

From the beginning, well prior to explosion of runaway, widespread use of prescription opioids for centralized chronic pain, all lines of evidence pointed against and contraindicated their use. There was never support for their safe, effective use due to longstanding:

I)  lack of research evidence for effectiveness long-term

 II) evidence for the potential for hyperalgesia

Hyperalgesia – increased sensitivity to pain – induced by use of opioids (OIH) is known and described extensively, beginning late 19th century.

See, for example:

Lee, Marion et al. 2011. A Comprehensive Review of Opioid-Induced Hyperalgesia Pain. Physician 14:145-161

III) established addictive potential of opioids

The high abuse and addictive potential of opioids including those prescribed for chronic pain is long-established (1), generating a history of statutory control (2) e.g. Harrison Act (1914); Boggs Act (1951) and others.

The 1970 Controlled Substances Act (3) lists opioid drugs commonly prescribed for chronic pain as Schedule II Substances (4), highly controlled as “drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence”

IV) understanding of the psychogenic nature of centralized chronic pain

Chronic pain (5) – long-lasting pain that is non-cancer, not caused by acute tissue damage or inflammation – is established by decades and multiple lines of evidence and research as psychogenic (generated by mental/emotional states) in nature and with indicated treatments that are psychological (behavioral health therapies), not biomedical.

See, for example:

Dersh, Jeffery et al. 2002. Chronic Pain and Psychopathology: Research Findings and Theoretical Considerations. Psychosomatic Medicine:  64: 773-786

[Numbers 1 – 6 in parentheses in boxes link to online sources listed at bottom of post.] 

V) evidence for cognitive behavioral therapies (CBT) as the indicated treatment for chronic pain

Extensive and longstanding research (6) establishes that effective and durable CBT treatments for centralized chronic pain (long-lasting pain that is non-cancer, not due to acute tissue damage or inflammation) are psychological (behavioral health therapies), not biomedical, fundamentally targeting underlying beliefs and mood states associated with pain. 

See, for example:

Cherkin, DC et al. 2017. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA. 317(6):642–644. doi:10.1001/jama.2016.17814

For a critical review of the current evidence: Doxa Deconstructed:  Chronic Pain is Not What You Think

All relevant lines of evidence existed decades prior to emergence of runaway misuse of opioids and the current crisis.

One point that Dr. Juurlink neglected to explain in his noting  “the fact that these drugs don’t work as well as we were taught and they aren’t as safe as we were taught” is that over the past decades of doctor overprescribing generating the opioid crisis,  what he and his fellow medical prescribers “were taught” didn’t come from the research established and available for decades, instead from pill salesmen. 

That’s right, pill salesmen. 

Protests against the Sacklers

The Sacklers did not, could not, open a chain of retail outlets Americans could walk into and buy the opioids off the counter. No. Not a single opioid pill provided to living or dead Americans came to them from the Sackler family, from Purdue Pharmaceuticals, from any employee of a pharmaceutical or opioid manufacturing company. The only originating suppliers were licensed medical professionals meeting with patients in exam rooms, providing medical services to them, then writing prescriptions that supplied them with the opioids. Without their signatures, no opioids were dispensed.

Instead, what the evil Sackler family did was pay pharmaceutical reps – pill salesmen – to visit doctors (medical prescribers) in their offices during and between visits with patients and hold guns to the prescribers heads to force them to prescribe the opioids. And the reps forged their signatures on prescriptions, and they threatened harm or death to the families of licensed medical professionals if they refused to prescribe the opioids.

Ha! Funny. Of course they didn’t.

They didn’t need to. Instead, the pill salesmen – with exactly the level of qualification to understand and evaluate medical need and the research bearing on safety of the opioids as you would guess, that is, none – explained to the doctors that, against all longstanding evidence, these opioids are effective and safe for all forms of pain. And? Those helpful pill salesmen, conveying clinical understanding of opioid safety and use to America’s medical professionals, took them out to nice dinners, and lined their pockets with speaking junkets, where the newly educated doctors would explain to their colleagues the safety and need for the opioids, based on what they had learned, from salesmen.

Those physicians relied, with the health and safety of their patients at stake as with any medication and certainly for controlled substances, on the information provided them by those pill salesmen. Salesmen, not healthcare professionals or researchers.

The overprescription and misprescribing of opioids

has continued over the years and decades of an increasingly lethal epidemic, described here, here, here, here, here, and here

While continuing to misprescribe, decades into an increasingly lethal opioid crisis, America’s medical professionals only began protecting patient rights and health after forced to at risk of legal violation for failure to meet longstanding, established ethical requirements for any medical intervention – by providing informed consent.

In progressive Oregon, a state with the highest rate of seniors hospitalized for opioid overdoses, abuse and dependence and the sixth-highest percentage of teenage drug users in a 2018 audit, medical prescribers aren’t changing much about their opioid prescribing. 

As a deadly drug epidemic continues to rage in Oregon, state officials have only made a few changes recommended by the Secretary of State’s Office nearly four years ago to curb opioid misuse.

That was the overarching finding of an audit released Wednesday of the state’s Prescription Drug Monitoring Program, which tracks prescriptions of controlled substances, including painkillers, stimulants and tranquilizers. 

. .

In the 2000s, amid an opioid epidemic fueled by overprescriptions, various states created databases to track them as a way of limiting excessive prescribing of opioids. Fifty states now have a monitoring program but many have tighter rules than Oregon and they don’t have a drug problem as severe as Oregon, said Kip Mennott, the Secretary of State’s audit director. Tightening the program’s requirements will help stem the problem but it’s not the only answer, he said.

. . . 

The program requires pharmacies to file information about prescriptions of controlled substances. Prescribers are supposed to register so state officials can identify excessive prescribers. Prescribers also search the database to identify patients who “doctor shopped” to obtain more prescriptions than they need.

But Oregon providers are not required to check the database when they prescribe controlled substances, the latest audit said. This is something auditors recommended in 2018 and is common in other states.

The audit identified patients with opioid prescriptions from “excessive numbers of prescribers” and “dangerous prescription drug combinations,” which includes mixing opioids such as OxyContin with sedatives, like Xanax.

It also said that state laws prevent the database from being shared with health licensing boards and law enforcement to monitor and address questionable prescription activity, another area of concern. 

“Questionable prescribing habits seen within the data, even those that are egregious, cannot be elevated to any regulatory or enforcement entities to directly look into those situations,” the 2018 audit said.

The Oregon Health Authority, overseeing Oregon’s use of Measure 110 decriminalization funds for substance use treatment improvements, responded to the concerns without indications of commitment to action –

“The agency is pleased with the performance of the (program) in ensuring appropriate use of prescription drugs, and helping people work with their health care providers and pharmacists to determine what medications are best for them,” the statement said.

But the agency will not play a major role in pursuing legislative changes.

With or without legislative and statutory compulsion to access data bases and more closely protect patients safety in their prescribing practices, Oregon medical prescribers have had access to those tools for protecting patients and the public for nearly a decade. They have chosen to not use them. 

New York Times Building

The role of America’s watchdog media

in the continuing misprescribing and lethal epidemic has been driven by compelled compliance, groupthink, diminished capacity, and cowardice

The desperately needed pat on the head, job security, and inclusion in a peer group of similarly impaired colleagues drive groupthink and lethal fabrications – 

That pharmaceutical companies performing as expected under American capitalism and unable to sell a single pill without America’s medical professionals writing the prescriptions, are responsible for the crisis.

That It’s The Fentanyl, against all  available evidence invalidating fentanyl as causal or explanatory of a worsening epidemic 

That the folklore of COVID pandemic stressors and isolation functioning as necessary distractions   – never supported by evidence and established as invalidated – account for a continuously lethal and worsening opioid crisis, even after those stressors have dissipated with no moderation of the crisis

These days, anything will do. Any absurdly constructed, distracting fabrication or villainous scapegoat. Anything to avoid the horror of threat of disapproval, loss of status, and being shunned for writing things that are true. 

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

Numbered links to sources

1 – The high abuse and addictive potential of opioids including those prescribed for chronic pain is long-established

2 – generating a history of statutory control

3 – The 1970 Controlled Substances Act lists opioid drugs commonly prescribed

4 – Schedule II Substances  are highly controlled as “drugs with a high potential for abuse”

5 – Common chronic pain is established by the evidence as psychogenic, not physical

6 – Extensive research establishes cognitive behavioral therapy (CBT) as the indicated treatment for chronic pain

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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