Science Matters
Opioid Myths
Myth 1 : “Opioid deaths are from ‘prescription opioids’”
• Opioid deaths are mainly from non-prescribed illicit fentanyl found in heroin.
• “Prescription opioids” is a misnomer for illicit fentanyl and is not the same as a prescrip-tion for fentanyl. (1)
Myth 2 : “1 in 5 patients prescribed an opioid become long-term users.”
• This often-quoted statement is from patients prescribed long-acting opioids (who are characteristically chronic pain patients)
• From the exact same study, the risk of long-term use from short-acting opioids is < 2.5%. (2)
• In the ED literature, physicians who limit opioid prescriptions results in 1.4% chronic users. Physicians who are generous with opioid prescriptions results in only 1.7% chronic users. (3) Limiting opioid prescriptions from the ED makes very little difference in chronic use (0.3%). All of the hullabaloo surrounding limiting opioids in the ED will have NO functional impact on the “opioid crisis”.
Myth 3: “We should limit opioid prescriptions to ED patients so we decrease addic-tion and opioid deaths.”
• The tacit message of “iatrogenic addiction” of seemingly normal patients who receive an opioid script is the undercurrent of almost all articles about the “opioid crisis”.
• 50% of opioid prescriptions are written to patients with mental illness. (4)
• long-term use of a short-term opioid in opioid naive patients with acute pain is < 0.4%. (5)
• Even chronic use of opioids rarely results in opioid misuse.
• Persons who intentionally use opioids for non-medical reasons rarely results in heroin addiction and death.
• These distinct groups (short-term use, chronic use, misuse, heroin use) have rare cross-over. (6)
Myth #4: “Do not prescribe an opioid for more than 3-7 days for acute pain.”
• This strategy comes from a CDC guideline, but specifically the guideline states that this does not include pain that is traumatic or surgical. (7)
• This recommendation is based upon the weakest level of scientific data (type 4).
• We have states making laws and hospitals embracing policies for the ED based upon a CDC guideline without knowing the data, the important exceptions and distinctions. We currently have no good scientific data that these restrictions in the ED will do anything to ameliorate opioid overuse, misuse or death.
We must use good science to make rational and balanced decisions concerning the com-plex issues surrounding opioids. We must avoid hasty reactions with possibly bad unin-tended consequences in response to political, financial, or emotional pressure.
references
1. O’Donnell, JK et al. “Deaths involving fentanyl, fentanyl analogs, and u-47700 — 10 states July-Dec. 2016 MMWR Nov. 3, 2017:66(43):1197-1202.
2. Shah, A et al. “Characteristics of initial prescriptions and likelihood of long-term opioid use— United States 2006-2015 MMWR 2017;66(10):265-269.
3. Barnett ml et al. “Opioid prescribing patterns of emergency physicians and risk of long-term use.” New Engl J Med 2017;376: 663-673. (N=372)
4. Davis, M et al “Prescription opioid use among adults with mental health disease in the United States” J Am Board of Fam Med July 6, 2017:30: 407-417.
5. Sun EC et al. “Incidence and risk factors for chronic use among opioid naive patients in post-operative period.” JAMA Intern Med 2016;176(9): 1283-1293.