The truth about the opioid use disorder

Anyone who reads health news today must know that American medicine – especially pain medicine – is in trouble. Physicians have high levels of burnout due to administrative burdens, prior authorization requirements, and a health care system that tends to prioritize efficiency over patient care. This burnout leads to mental health problems and, in some cases, physician suicide.

Medicare payments to doctors have decreased by 26 percent since 2001 when adjusted for inflation, putting financial pressure on medical practices. However the high cost of health care in the US compared to other countries is a continuing concern. The US system of coordinating workplace health care has left millions of people uninsured or underinsured, especially during the recession.

Just as doctors are under a lot of pressure, so are patients who die from falls and commit suicide due to rejection by doctors. The condition is particularly acute among the 50 million or more US residents who suffer annually from chronic pain that is so debilitating that they bring them to the doctor for help. Further, there is no possible help. The practice of medicine in America has been criminalized due to massive government fraud. Doctors are alarmed by the ongoing National Witch Hunt by the US Drug Enforcement Agency. Some doctors leave the practice. Some post prominent notices in their offices, stating that they do not dispense opioids.

Compare this image with the 2016 announcements by one of America’s leading experts on drug addiction, Dr. Nora Volkow, Director of the US National Center on Drug Abuse:

Unlike tolerance and physical dependence, addiction is not a predictable consequence of opioid prescription. Addiction occurs in only a small proportion of people exposed to opioids – even among those with pre-existing weakness (Table 3). Older medical texts and several versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) may overemphasize the role of tolerance and physical dependence in the definition of addiction or measure these processes (DSM- III and DSM-IV). However, recent studies have shown that the molecular mechanisms that cause addiction are different from those responsible for tolerance and physical dependence, in that they evolve more slowly, last longer, ‘ and disrupts many brain processes.

Dr. Volkow and her co-author, A. Thomas McLellan, may have been too kind to the American Psychiatric Association (APA). “Opioid use disorder” is, in fact, a gross misnomer. Its origin is the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5), issued by the APA in 2013.

Prior to DSM-5, substance use disorders were classified as either “substance abuse” or “substance dependence.” DSM-5 combined these categories into a single disorder called “substance use disorder,” with opioid use disorder as a subtype within this broader category.

However, it is now widely understood among practicing physicians that drug addiction is not a mental disorder at all. As Dr. Volkow and others believe, drug addiction is a physiologic (not mental health) problem characterized by physical withdrawal symptoms when a person is quickly withdrawn after a long period of use. Some doctors also point to the severe pain that patients experience during forced withdrawal from opioid medications as a different type of “substance dependence.”

“Drug abuse” is a very different beast: it is characterized by continued cravings and use of opioids even when the user knows that such use is harmful to their relationships and quality of life. The DSM-5 identifies a number of symptoms that indicate the severity of substance abuse. However, nowhere in that deeply flawed document is a clinical framework provided within which nurses can choose the most appropriate treatment for the patient’s needs if they are suffering from chronic pain. and substance abuse. Similarly, the side effects of patient exposure to prescription opioids are often improvements in quality of life.

It goes without saying that the field research behind the DSM-5 was very poor. Two weeks before the announcement, the National Institute of Mental Health publicly rejected the DSM-5 as a framework for organizing research on mental health problems. That didn’t stop the US CDC from using the term extensively in its updated and greatly expanded 2022 opioid guidelines.

Now we know for sure that – despite repeated mistakes from the US CDC and DEA – there is no connection between prescribing and opioid addiction or overdose-related death. Many so-called “diagnoses” of opioid use disorder by doctors actually indicate a disease called “pseudo-addiction,” which is not painful for patients but for nurses who fear the risk of possible penalties. a crime. Such physicians may provide a substance use disorder diagnosis or enter “drug seeking” information for any patient who complains of insufficient pain relief or who notifies them of a report of successful initial treatment with prescription opioids. Such data are the “kiss of death” for continued effective pain management using safe and effective opioids. Sometimes that kiss of death directly results in suicide.

We also know that the best predictors of adverse outcomes in treating patients with prescription opioids have little to do with previous interpretations. As established by the predictive model for the one-year risk of opioid overdose or suicidal events, the risks are four to 20 times higher in patients with with a history of serious mental health problems or previous hospitalization due to overdose than patients with diabetes. there is no such history. For the population at greatest risk, only one factor among the eleven in the patient’s history is related to prescribing: the use of multiple sedating medications. The probability of overdose or near-suicide events from all causes was on the order of 2 percent or less in the Veterans Administration’s population of more than a million patients. Such an event falls within diagnostic error, exacerbated by noise generated by high patient loads and inadequate education of physicians in pain management.

Now is the time to remove the term “opioid use disorder” from medicine and public health policy. It’s also time to publicly reject and withdraw the CDC’s 2022 guidelines on prescription opioids — without a replacement. Through their incorrect use of the term and their emphasis on the dangers of drug abuse that is not supported by science, the CDC has shown itself to be operating from sloppy research and lack of knowledge or bad faith.

Richard A. Lawhern is an advocate of tolerance.