A key part of the federal government’s narrative about the epidemic of addiction and overdose deaths in the U.S. has been that it is driven by doctors and other clinicians overprescribing opioid painkillers. That story line is false — and was never true.
The Centers for Disease Control and Prevention has traditionally relied on death certificate data compiled by the National Center for Health Statistics for its data on overdose deaths, organized as Underlying Cause of Death data using codes from the International Classification of Diseases.
In 2018, however, the CDC and the U.S. Bureau of Vital Statistics were forced to admit that they had been misattributing deaths involving illegal street fentanyl to deaths caused by “prescription” drugs. When this error was corrected, the number of deaths in which a prescription drug was reported dropped by half.
Incorrect attributions of illegal fentanyl as “prescription drugs” were only part of the problem. The entire system underlying cause of death statistics was poorly constructed to distinguish between deaths involving legal drugs versus those due to illegal drugs. Until recently, county coroners and medical examiners were trained to report causes of accidental deaths involving drug poisoning in 10 categories identified under Version 10 of the International Classification of Diseases (ICD-10):
- T40.0: Poisoning involving opium
- T40.1: Poisoning involving heroin
- T40.2: Poisoning involving other opioids
- T40.3: Poisoning involving methadone
- T40.4: Poisoning involving other synthetic narcotics
- T40.5: Poisoning involving cocaine
- T40.6: Poisoning involving other and unspecified narcotics
- T40.7: Poisoning involving cannabis (derivatives)
- T40.8: Poisoning involving lysergide [LSD]
- T40.9: Poisoning involving other and unspecified hallucinogens
These categories are not mutually exclusive. Any death certificate may contain up to 10 ICD codes, including multiple categories above, plus alcohol use or various diseases.
These days, U.S. deaths involving opium, cannabis, LSD, and/or other hallucinogens are vanishingly rare. About 20% of accidental deaths involving drugs in the list above are classified as occurring from “other and unspecified narcotics” — which simply means the coroner or medical examiner saw indications of a narcotic in the dead person’s bloodstream but couldn’t figure out which one it was. Likewise, drugs dispensed by prescription are included in multiple categories (T40.2, T40.3, and T40.4).
Enter the State Unintentional Drug Overdose Reporting System
In an effort to improve data collection and reporting, the CDC developed the State Unintentional Drug Overdose Reporting System (SUDORS), first rolled out in 2019. SUDORS data are not directly comparable to earlier reports from the CDC. Only 36 jurisdictions (census regions or states) covering about 48% of Americans have so far received CDC funding to retrain their coroners and medical examiners and put in place the necessary refined reporting systems. This compares to 57 jurisdictions under the U.S. National Vital Statistics system, which covers all U.S. states.
Recent SUDORS data are startling.
Between 2020 and 2022, more than 80% of all accidental drug overdose deaths tracked by the SUDORS dashboard involved opioids of some kind. About half also involved stimulants like cocaine or methamphetamine, that are almost never seen among clinicians’ patients. Prescription drugs were involved — among other factors — in about 12% to 18% of drug-related accidental deaths from 2020 to 2022.
The take-away from SUDORS is that prescription drugs are not now the primary driver in recent U.S. accidental drug overdose deaths. Data from elsewhere also show they never have been drivers.
Among many scientific papers that have explore this issue is a landmark 2018 report in the journal Science by Hawre Jalal and colleagues. They analyzed nearly 600,000 drug-related accidental death reports from 1978 to 2016 from the CDC’s Multiple Cause-of-Death files. Their findings strongly parallel those of SUDORS:
- Reports of accidental deaths involving heroin, synthetic opioids, cocaine, unspecified narcotics, methamphetamine, and unspecified drugs closely followed an exponential curve over 36 years. Contributions from individual drugs varied sharply from year to year, with several categories accelerating markedly after 2010.
- At no time during this period did reports involving what were then called “prescription drugs” occur in more than 22% of death reports.
The U.S. Drug Enforcement Agency (DEA) is entirely aware of the Jalal findings. The paper was reviewed in a 2019 DEA training session by the DEA Diversion Control Division for doctors renewing DEA licenses to prescribe controlled substances.
If opioid prescribing by clinicians is not the primary driver of bad outcomes for people who are prescribed opioids, then it is appropriate to ask what is. Another landmark paper, published in 2017 by Elizabeth M. Oliva and colleagues, offers definitive answers.
These researchers developed and applied the Veterans Health Administration’s Stratification Tool for Opioid Risk Mitigation (STORM) model to the medical records of more than 1.1 million people covered by the VA who were treated with opioid pain relievers for two years or more. The model accurately identifies those who are at highest near-term risk for overdose or suicide events while under medically managed opioid therapy for pain.
Between 2.1% and 2.5% of VA patients followed by the team experienced an overdose or suicide-related event within one year. However, the risk of such outcomes was three to 20 times higher in individuals who had a history of significant mental health issues than it was in others without such a history, who had simply been treated for pain by means of prescription opioids.
Why this matters
U.S. public health policy for treating severe pain is currently embroiled in major controversies, many of which are generated by opioid prescribing guidelines the CDC published in 2016 and 2022. These guidelines were generated in part because of the skewed narrative that the overdose crisis was supposedly being driven by doctors and other clinicians overprescribing opioid painkillers.
The 2022 version of the guidelines offers assurances that each patient should be treated as an individual. However, the CDC also repeatedly directs clinicians to evaluate the risks of opioid therapy versus the benefits, while providing no validated framework for doing so. The term “risk” appears over 400 times in the guidelines.
The CDC claimed — without supporting references from the medical literature — that a threshold of diminishing benefits exists for opioid doses above a 120-morphine-milligram-equivalent daily dose. They also recommend non-pharmacological, non-invasive therapies as “preferable” to opioids, despite the fact that no body of validated trials data demonstrates any such benefit. The message between the lines of the CDC guidelines is “doctors who prescribe opioids do so at their own risk — and the slightest error on your part in a hostile regulatory environment can put you in jail.”
As a health care writer and advocate for people in pain, I communicate with patients and clinicians every week. What I see is that pain medicine in the U.S. is failing both patients and clinicians, largely due to the CDC’s faulty narrative and the DEA’s harassment and prosecution of clinicians for legally and ethically prescribing opioid painkillers to their patients. The result? Millions of Americans living with severe chronic pain are being denied safe and effective pain management with prescription opioids, deserted by doctors afraid of being targeted and persecuted by DEA and state medical boards.
There is no rational prospect of solving the U.S. crisis of addiction and overdose deaths by continuing to suppress doctors and other clinicians from ethically prescribing safe and effective FDA-approved opioid analgesics.
Richard A. “Red” Lawhern, Ph.D. is a patient advocate and researcher focused on the intersection of public health policy and prescription of opioid analgesics for severe pain. He has moderated online patient support communities for nearly 30 years, and currently serves on the speakers bureau of the National Campaign to Protect People in Pain, an informal citizen lobbying group seeking major changes in public health policy for treatment of severe pain.