Opioid deaths are not mainly about prescription opioids

A recent study of opioid-related deaths in Massachusetts underlines this crucial point, finding that prescription analgesics were detected without heroin or fentanyl in less than 17 percent of the cases. Furthermore, decedents had prescriptions for the opioids that showed up in toxicology tests just 1.3 percent of the time.

Alexander Walley, an associate professor of medicine at Boston University, and five other researchers looked at nearly 3,000 opioid-related deaths with complete toxicology reports from 2013 through 2015. “In Massachusetts, prescribed opioids do not appear to be the major proximal cause of opioid-related overdose deaths,” Walley et al. write in the journal Public Health Reports. “Prescription opioids were detected in postmortem toxicology reports of fewer than half of the decedents; when opioids were prescribed at the time of death, they were commonly not detected in postmortem toxicology reports….The major proximal contributors to opioid-related overdose deaths in Massachusetts during the study period were illicitly made fentanyl and heroin.”

The study confirms that the link between opioid prescriptions and opioid-related deaths is far less straightforward than it is usually portrayed. “Commonly the medication that people are prescribed is not the one that’s present when they die,” Walley told Pain News Network. “And vice versa: The people who died with a prescription opioid like oxycodone in their toxicology screen often don’t have a prescription for it.”

That is by Jacob Sullum at Reason, via Arnold Kling.


The study seems to show that it's not the doctors' fault. As they are useless in these circumstances, we can legalize and regulate, regulate and legalize!

Right, as long as doctors keep feeding their patients' drug addiction, patients don't die, which means as long as drug addiction is purely a chronic health problem, drug addiction is not harmful, just as insulin and analogs prescribed constantly is not a problem for diabetics, hypertensive drugs prescribed constantly is not a problem for those with high blood pressure, etc.

The problem is treating drug addiction to opioids as a crime, but not drug addiction to nicotine, though selling to, or buying for, under age nicotine addicts is a crime.

Too bad those who claim to want to get government out their lives are extremely driven to get government into the lives of the other 60%+ of the rest of society by inventing thought crimes and criminalizing acting in accordance with beliefs about individual liberty. Requiring a measure of maturity before such individual liberty seems wise public policy, but hardly beyond that.

lets deconstruct what you said here!
"which means as long as drug addiction is purely a chronic health problem, drug addiction is not harmful,"
you conclude -a chronic health problem is not harmful.
that is some smith college level sophistry/sociology

Don't be silly. Mulp only got into Bryn Mawr.


It's going to be end of mine day, but before finish I am reading this enormous paragraph to
increase my knowledge.

I'm not sure this is saying anything that isn't recognized. Recreational chemicals laced with fentanyl or other unknowns. But how many people started with prescription pain killers prescribed for a valid reason, then moved to street drugs which eventually killed them?

Yes. I’m not sure who thinks that Docs are driving the volume. Anecdotally at least they seem to be the gateway for many people. They’ve commercialized the long-known street tactic of making the first hit high-quality and free.

My thought, too. Is there a response to this? Persons gets hooked on opioids via prescription drugs. At some point, prob at the time the prescription ends, it becomes cheaper to acquire illegal non prescription opioids than prescription opioids. I thought this was known?

You might want to change "cheaper" to "easier". Street drugs are much more expensive than that Rx, especially when you factor in that insurance isn't picking up part of the tab for former.

Yes, thanks! I guess I was using cheaper in a more general sense. But easier would have been more precise.

If you can find regulated drugs on the street they are much more expensive. Oxy is $30/pill vs $5 for heroin.

That's why they are making counterfeit Oxy with Fentanyl.

End prohibition to save lives.

This from scientific americanOpioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause
But the simple reality is this: According to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.

The standard story is that patients get addicted to prescription painkillers. No reputable doctor is going to continue to fill prescriptions for an addict who's using the drug to get high, so the addict turns to illicit sources and illicit drugs such as heroin or non-prescription fentanyl.

I don't know how truly valid or prevalent that standard story is, but this research doesn't even try to find empirical evidence for or against it. Instead it finds that dead addicts rarely had prescription drugs in their system. Well duh, that's what the standard story tells us to expect.

I can imagine, as this article seems to be trying to argue, that the gateway for most dead addicts was not prescription drugs but rather abuse of other drugs be they meth or alcohol or whatever. But this article doesn't even begin to help us distinguish between those stories.

"No reputable doctor is going to continue to fill prescriptions for an addict who's using the drug to get high, so the addict turns to illicit sources and illicit drugs such as heroin or non-prescription fentanyl."

Are you saying reputable doctors are going to stop prescribing drugs because the patient might get high sometimes, because reputable doctors want their patients to risk death from street drugs?

Nah. We will swap them to methadone, buprenorphine, and drugs that are harder to use to get high and less likely to result in death. Unfortunately, the powers that be do not trust us to manage such prescriptions without specific training so we instead dutifully make the referrals to the docs who can manage these things and then get to watch our patients get turned away the trained docs hit their patient caps.

Once addicted, they don't take the drug to get high, but rather to avoid withdrawal symptoms.

You do know that, don't you?

I'm pretty sure most experts in addiction don't find the negative reinforcement model persuasive anymore.

If people only take opioids to avoid withdrawal then after they go through withdrawal they should be fine with no interest in the pills or risk of relapse. Yet tons of people go weeks or months, sometimes years, without using and then relapse. Did they spontaneous go into withdrawal after not using for a year? Probably not.

What can explain that? This standard theory I've heard, grossly oversimplified, is that people get cravings to use that are trigged by cues. These cues are hard to "unlearn" and persist for years and even decades.

>I don't know how truly valid or prevalent that standard story is

Well, thank you! It appears we have a rare, sane poster here at MR.

>but this research doesn't even try to find empirical evidence for or against it.

Well, of course not. Evidence is for chumps; publishing emotional stories that fit the narrative is all the rage (here and elsewhere).

The preferred narrative here is well-established: lazy/greedy/evil doctors are the real problem here. Do not pay any heed to the drug lords crossing the border at will and selling death to our most vulnerable and desperate people. Indeed it would very hateful of you to even try to imprison those "non-violent drug offenders."

Focus on the doctors. It's their fault. So hey, shouldn't the government step in and radically overhaul the medical system?

What? I am comfortable blaming reckless doctors and drug dealers. Who isn't? Where is this leniency you imagine towards drug lords that smuggle tons of heroin across the border?

And despite what you may believe even fewer addicts die from opioids they have synthesized themselves. ... what? no one ever claimed that? well, I'm sure that it merits as much space as the above. As in "none". It would be interesting to learn if TC harbored such an obviously erroneous meme. (Because if not, why would he waste his and our time?)

"we analyzed individually linked postmortem opioid toxicology reports and prescription drug monitoring program records to determine instances of overdose in which a decedent had a prescription *active on the date of death* for the opioid(s) detected in the toxicology report"

Emphasis mine. This is a misleading metric relative to the claims being made because an inappropriate expired prescription from, say, a year ago could have lead to the addiction that killed a person today using non-prescribed opiods.

To paraphrase your quote, individual taking opioids prescribed by doctors seldom die, no matter how addicted to opiates they are.

Which does not rule out the possibility that they died afterwards due to an addiction caused by taking opiates in the past as prescribed. A study that wants to conclude that "opiod deaths are not mainly about prescription opioids" needs to rule out prescription as the *ultimate* cause of death; this study only look at the *proximate* cause, and that makes it misleading apropos the claims being made. It is enough of a leap that I suspect it is motivated by an ideological pre-commitment of some sort.

A proper study would look at whether the deceased had a prescription at some point in the past. If there's no history of prescription, then the conclusion would be a strong one.

You are WAY overthinking this.

Here is the point, whether or not it is true:

However they may have started, the vast majority of deaths by opioid overdose are not from a prescription. Thus, the study contradicts the widely shared meme that evil doctors are killing people with opioid prescriptions just for the money.


Now, let's play a little chess (I hate chess) and think ahead a move or two.

Where are the drugs coming from? China via the border with Mexico? ????

It has always seemed blazingly obvious that people OD because they become addicts and are then cut off from the safe pharmaceutical supply. You will get some ODs from people doing Oxy and Xanax and half a bottle of whisky but I bet the majority are not from popping pills.

if it is so blazingly obvious that people od because they are cut off from
a "safe" pharmaceutical supply show us your proof/evidence/work!

Lefties never need evidence. Everything is just obvious to them. Whatever feels true is very certainly true. If you take issue with this, it's because you hate people.

"People overdosing? Seems obvious we should blame the healthcare industry. Which is just more evidence that the government should take it all over."

See? It's easy and fun!

Of the death certificates I have signed for opioid overdoses, the vast majority never had a safe pharmaceutical supply, ever. They did street drugs from start to finish and were killed because they took even more risks than normal while taking their drugs.

It is rare that I have a dead patient from their first shot of heroin. Typically we have saved the dead ones with naloxone several times prior to the fatal OD. They die because they are injecting poison directly into the veins and are dosing off non-primary endpoints. It is little more than Russian roulette even if you give them pharmaceutical grade heroin; tolerance makes stable dosing impossible and they will eventually miss the mark. Fentanyl and all the stuff in the cut just speeds of the process and increases the risk. Difference of quantity, not quality when it comes to risk.

"Furthermore, decedents had prescriptions for the opioids that showed up in toxicology tests just 1.3 percent of the time...Prescription opioids were detected in postmortem toxicology reports of fewer than half of the decedents..."

Piecing this together, it appears that almost half ("fewer than half" minus 1.3 percent) of the decedents had prescription opioids in their system that were not prescribed to them (the decedents). There appears to be a serious problem in the illegal traffic of prescription opioids. Doctors writing prescriptions to people who traffic them in such large quantities on the street is a serious problem in my view.

And, I would be curious to know what is going on from someone with experience. A few possibilities:

1. Dealers are mixing prescription opioids with their heroin or heroin/fenantyl "product" (if so, why?);

2. Users themselves are doing the mixing (why--a better high?);

3. Opioids are taken separate from heroin/fenanyl when the latter is not available;

4. Heroin/fentanyl is taken separately when opioids are not available.

In 3 and 4 the drugs show up in combination in the system but not because they were taken as one dose.

Which is cheaper?

Pills masquerading as prescription opiods obtained on the street are found with fentanyl in them a non-trivial percent of the time. It's anyone from the proximate dealers to the manufacturers (often in China) doing the mixing.

Does anyone else remember the town in the Same Quinones book that actually lost its Walmart because stolen goods from the store were being traded for opioid pills from pill mill doctors (although not from doctors in the town, people had to drive much farther than that). Or rather, oxy pills had become the local currency with which people paid for TVs and stuff the users would steal, quite brazenly. Maybe the employees themselves had little interest in stopping it. The prescriptions themselves were mostly covered by Medicaid. It explained how people with little income were able to finance a drug habit that, in theory, should have been a sign of affluence. Or decadence, if you like.

It takes a lot of theft for Walmart to exit a town.

I don't care about people, obviously, but it's a shame to ruin a town.

Obviously, too, pace mulp, government was very much "in the lives" of these people.

I'm not addicted to opioids, so I don't need the government's help securing them, but I am addicted to lunch. It's the loner's favorite meal. I have no trouble preparing it for myself, as I had no trouble preparing it for my child during his school years. School-bought lunch was actually an occasional treat for him. I thought of that when I read recently that the city's school district had sent out a memo, covered in the press, pleading with parents to please not send their kids with sack lunches from home to school anymore. Basically, they said, they needed everyone to get on board with the institutional school lunch, to further increase their funding from the feds, which would give them greater purchasing power to improve the quality of their ingredients. They get reimbursed the same, whether the kids pay for lunch (rare) or not.

I hope this isn't contributing to a general falling-away of the supremely basic task of making one's own lunch, but the fact that the district continues offering both free breakfast and lunch all summer long when schools are not in session, doesn't bode well - though I do realize others may view that as utopia made real.

"Get out of our lives" - from whichever direction, right or left, how would you even define that at this point? All I know is, it's only a thing in the distant abstract.

Hydrocodone and oxycodone (generics for Vicodin and Percoset respectively) are dirt cheap and you don't need Medicaid or other insurance to afford them.

It ought to have been cheap selling in such volume! I don't have the book, but this excerpt from the author's talk with Russ Roberts gets at what I was recalling. Perhaps he was mistaken:

Sam Quinones: And to also understand that we need to be--one of the great things about this story that I learned was, this story, doctors get a lot of blame for it. But, you know, a big part of why this happened was because we Americans didn't want to be accountable. We didn't want to be accountable for our own consumer choices, for our own behavior. Doctors would say--talk to any doctor, any primary care doctor will give you some amazing stories on this. People come in: 'Well, I have pain, Doc.' The doc says, 'Well, you need to eat better. You need to exercise more. You need to start swimming. You need to stop smoking.' Etc. It's a bunch of things like that. 'Do yoga.' Whatever. And people do not want to do that. That's why pills were so appealing ...

Russ Roberts: So, I want to talk about another part of the problem. And yeah, I certainly agree that we have a certain cultural problem here with suffering, delayed gratification, here--you name it. We want to avoid it. Which is human. We all understand that. It's one of the curses of being wealthy. But there's a piece of the story that was just extraordinary to me. I'm going to try to spin it out, and you can then fill it in. So, there were these doctors ... in what are called pill mills, particularly in areas--Ohio, and Kentucky, West Virginia--depressed areas economically, people having trouble finding work. And the doctors set up shop; they are going to dispense a prescription every 3 minutes, because they want to make money. They are not reliable, honest doctors; they are just going to write prescriptions. They are going to say, 'Are you in pain? Yes. Good; here's a prescription.' It takes 3 minutes. So, you are going about 20 patients an hour. People are lined up. Addicts and others are lined up to get at these drugs. To see the doctor--I just want to talk about the financial side--to see the doctor, it's a $250 cash payment.

Sam Quinones: Right. No insurance accepted.

Russ Roberts: Correct. So, you show up. You give the doctor $250 that maybe you've stolen or fenced, whatever, from whatever. And then, that gives you the piece of paper. The doctor gives you the opportunity to buy oxycontin, a supply. It's going to cost about $1000--I forget how long a supply. Is this a month or 3 months? I can't remember. But a long supply.

Sam Quinones: Could be a month.

Russ Roberts: A month. Let's say $1000. But you don't have $1000. You do have a Medicaid card. And the co-pay for Medicaid is $3. Which seems like a very nice, thoughtful thing. But what it means is that the taxpayer is going to cover $997 of this. The addict is going to cover $3. And then the punchline--that's interesting by itself and as an economist who has often talked about the value of cash, I can't help but note the irony that we give people Medicaid because we don't want them to have cash as a way to use it on drugs and alcohol. So there's an incredible tragedy here. So, they take the $3 co-pay; they $1000 worth of drugs; and it's worth $10,000 on the street.

The numbers are way, way out of whack in that quote. I've never been to a "pill mill", though there were plenty of them in S. Florida (note: not a poor area overall) when I lived there, but ok maybe they charge $250 a visit. Though that seems awfully high for a depressed area. The (legit) med practice I go to now in Baltimore bills about half that for an office visit. But there is no way a 90 day supply of oxycodone (generic for Percoset) costs $1000. Three years ago I had a script for 60 such pills after foot surgery and it cost c. $10.
Oh, and for reasons I won't detail, I happen to know that as a street drug those things go for up to $20 per single pill.

We need more opioid deaths to make room for people who actually have their act together.

A doctor prescribes opioids, the patient becomes addicted, the doctor then refuses to renew the prescription, the patient resorts to the black market or stealing, and the patient dies, but not from "prescription opioids".

The only sane person in your hallucination is the doctor who refused to prescribe more drugs. So sure, let's blame him!

I always find it helpful to recall that the US was the not the first country to be hit by fentanyl. Estonia, for instance, had a massive wave of fentanyl deaths that started before the US, without all the US prescription opioid consumption, and peaked sooner. Currently, their opioid supply has moved beyond fentanyl to derivatives that are even less safe.

It seems to me that the problem was not overprescription per se. Rather, as in Estonia, there seems to be spiral where opioids are seen as acceptable drugs of abuse (entering into the space of marijuana, alcohol, tobacco, and ecstasy), illicit suppliers elect to increase the addictiveness and potency of their drugs, and we end up with much more deadly drugs.

The biggest problem US docs created was removing the social stigma against opioid use and abuse. We created a perception that being addicted to opioids was no big deal, mostly safe, and something that people could do without losing all their social standing.

Does decriminalization work? Nowhere near as well as cultural barriers. Portugal, for instance, has safe injection and all the rest, yet it is experiencing a new wave of heroin use as old addicts return to heroin thanks a weakened economy. And lest we forget the difference in price for legitimate opioids and heroin/fentanyl is not all that high. Legitimate heroin supplies are going to cost at least as much as black market opioids so I suspect we will still have a lot of users who end up on fentanyl derivatives (for which there are no safe prescribing guidelines, nor even data for simple things like LD-50).

As with most major problems, the cause and solution are likely to be social. Historically, these sorts of epidemics die down as people die and the younger users decide to not try the things that killed all their older peers. Quite possibly all our "harm reduction" strategies and treatments will delay this process and leave more people dead; a first pass analysis of mass naloxone treatment suggested that it was associated with difference in difference increase in the opioid death rate due to increased use.

Unfortunately, I see no way out of the current situation that does not risk leaving many, possibly more than current rates, people dying.

It’s an interesting case of social stigma as Chesterton’s fence.

I suspect the enthusiasm for mainstreaming cannabis usage is another one.

Thanks as always for your professionally-informed insight, Sure.

There is a valid medical use for fentanyl, but only under the direction of an anesthesiologist in cases of severe trauma. It's certainly not something that could be prescribed for home use.

Not my area, but I would be comfortable prescribing it for palliation in terminal cancer patients.

It also works well in patients who cannot tolerate other opioids (e.g. unable to swallow with some difficulty for injections).

I have also been told that its lipophilicity is helpful for OB with intrathecal administration.

That said, fentanyl packs a lot of MMEs and I would prefer not bust something that strong out for just anything. Even with reversal agents, far too often it can end with a tube down your throat and you need to be in sorry shape for that risk to be the lesser of evils.

Is the standard for terminal patients a morphine drip? Two my relatives, one dying from multiple myeloma, the other from ALS, had those at home toward the end.

the obvious solution here is to entirely prohibit opiods and all dangerous/addictive drugs) , enforced by draconian criminal penalties !

...oh wait, our massive draconian War-on-Drugs has been a spectacular failure for past half century+.

The political mechanism of "Prescription Drugs" does not work and has huge unintended consequences.

A minor percentage of humans has been killing themselves with alcohol & drugs for centuries -- this is reality and the human condition -- it cannot be solved by politicians, police, and lawyers... nor strictly 'licensed' medical caregivers.

Opiods are the current deadly fad, but will be replaced by some other boogeyman drug in the future. Chemistry evolves for many purposes.

Interesting. Colorado began legalization around 2000 for "medical" marijuana and of course tried full legalization in 2014. Since that time their overdose death rate has ... marched upward like everywhere else in the country.

The actual data to date is that during periods of more harshly enforced prohibition, drug overdoses were less. The major waves of overdose deaths in this country have ... no overlap with changes with drug policy or enforcement.

What we do know is that deaths from alcohol, both for overdose and from all other causes, decreased dramatically during prohibition and only rebounded after decades.

In reality, for almost all of human existence, the ability to overdose on pleasant drugs was nonexistant. The cost of making high potency drugs limited their market reach and the vast majority of humans through history had trouble even getting properly drunk as they could not afford concentrated alcohol. We have increased the potency of drugs while decreasing their price that truly, for the first time in history, the average human can afford to be an addict and can easily afford pleasant things which can kill in single doses.

Will this epidemic pass? Why yes. People will die and things will adapt. Of course more people are dying from this than died from AIDS during the peak of that crisis. And that certainly was natural, what with STIs being part of the human condition for millennia.

We have a very nice example of what happens with free for all trade in drugs. It is called late Qing China and contributed to more death and destruction than anything else in human history until World War I.

But we get it. Better that those who "bring it on themselves" die than you be inconvenienced for realizing your full potential or have limitations on your recreation. After all they are poor, weak willed, and ignornant. F'em.

Overdose deaths from marijuana are all but nonexistent, so that has no place in the discussion.
The problem with drug wars is they tend not to work, at least not in societies with protections for civil liberties and privacy. And anyone with any economic education at all knows that increasing the price of a good creates an incentive to increase the supply.

Marijuana, however, is not a competing drug. In Colorado tax data has shown no drop off in ethanol consumption post-legalization. Drug combinations, pretty much universally, are more likely to result in lethal overdoses than single drug useage alone. Certainly I see far more poly-drug overdoses than singletons and anything that diminishes cognitive function (e.g. alcohol or marijuana) results in more overdoses of other drugs.

Drug wars tend to work. Prohibition decreased all cause mortality from alcohol everywhere it was tried. Both Qing China and Mao managed to dramatically reduce opium consumption and whatever one wishes to say about Singapore, overdose deaths are less common there than in say Kaula Lumpur.

And the drug libertines always overlook the impact of culture. Laws are part of the framing of the Overton window for personal behavior. Speed limits do not stop people from speeding, not force them to drive at that rate or below ... but lowering them will effect how much some people speed and will lower the speeds of some (small) fraction of drivers to match the limit. Likewise, banning doping does not stop Olympic Athletes from using performance enhancing substances ... but it does make it socially unacceptable to get caught. People are social animals far more than econometricians. Laws, and related habits, function far more for reducing demand than increasing cost.

At the end of the day. Pot is legal and overdoses are up. As a tool to reduce overdose deaths, legalization has been an absolute prima facie failure.

You're using a very narrow definition of "worked" there- basically just a single stat, and ignoring everything else, most notably the costs. Prohibition may have lowered the mortality rate a bit, but it greatly increased crime and corruption, ultimately birthing the Mafia. Moreover it turned millions of citizens into scofflaws. I had relatives old enough to remember Prohibition when I was growing up. Whether they were drinkers or not they were unanimous that it was a public policy disaster and should not ever be repeated.
Qing China was a radically different culture (and economy) from the US and parallels should be viewed with extreme skepticism.

Apart from not having also earned Ph.D. degrees in neurochemistry, most practicing MDs also have not been sufficiently trained in addiction management, in which case.

Begins to make me wonder whether licensed and credentialed medical doctors in this century are able to be well-enough informed about the myriad details of human physiology and human psychology ("human" psychology, not the academic versions) to practice medicine in the first place.

Of course we are not, but then who is? We have systematically destroyed all the old social structures that held society together and expect the healthcare system to pick up the pieces.

For the addicts, they have no contact with a pastor or priest. They are typically isolated from non-using family. They are removed from hobbies, organizations, and most non-pathological contact.

Doctors today need to be experts on anatomy and physiology. They need to be counselors. And help patients find meaning. And social workers who connect them to services. And friends who demonstrate care. Sure some of this labor gets outsourced to less credentialed individuals, but society expects MDs to manage all of these things and it is no surprise that we are drastically inferior to the rich social tapestry that used to help people resocialize after addiction.

While there are addicts who are down and out and living on the street, there are many who are not. Some are covert addicts. They live with family and have plenty of contact with non-addicted people. See also: alcoholics.

Alcoholism has a terrible cost on family contact. It is, in my personal experience, the single largest factor leading to familial estrangement in society today.

Far more alcoholics are people losing touch with their family (e.g. divorce, abandonment, estrangement) than are keeping it all together.

And lest we forget, substance abuse is bi-directional with isolation. People who are socially isolated are far more likely to become addicts.

Are there exceptions? Absolutely. But the norm is that addiction, by definition, tends to result in disruptions of social life.

I suspect that there are other negative consequences to the over-prescription of opioids, short of death.

I've written rather extensively on the subject, it's not the drug it is so much more. The link follows. In brief, exposure to opioids over some time, whether through prescriptions or illicit use has for practical purposes the same risk for an opioid use disorder developing. (Approx. 20-25%) https://docs.google.com/document/d/1itWF9xupGQhaBSwGw2jTQsXzqaYynI3AeNA7DLPt0Wo/edit?usp=sharing

This is so much common knowledge that one should wonder why this seems novel.

The risk of opioids is NOT the narcotic but the acetaminophen it is wrapped in. Reducing that amount from 500mg to 325mg saved a lot of lives.

I get little benefit from tylenol. I prefer ibuprofen wrapped drugs when I can get them.

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