The physicians of the Charleston County Medical Society welcome the attention brought to the rising death rate from opioid overdoses. Concern over the loss of life and impact on our communities has reached the tipping point where action is needed and being demanded. Legislators have answered in kind — over 60 bills have been introduced at the federal level, including some sponsored by our own Sen. Tim Scott. In South Carolina, the governor recently signed nine bills into law with one of the stated goals of the Opioid Emergency Response Team being to “bring down the opioid prescription rate,” as reported in this newspaper.
The liberalized medical prescription of painkillers as mandated in the late 1990s by the independent Joint Commission and federal Centers for Medicare and Medicaid Services put many opioids into circulation, which increased the opportunities for misuse and abuse. Around 2010, law enforcement’s focus on unscrupulous “pill mills” and the bad doctors who ran them marked the peak in number of prescriptions written. Since then, legislation imposing limits on prescriptions and prescriber monitoring programs and sanctions have contributed to a decrease in number of prescriptions written for medical use by nearly 30 percent, with a decrease in 2017 alone of over 12 percent. Legal medical opioid production quotas have been cut by 45 percent by the federal government. Yet, the death toll from all opioids — over 600 last year in South Carolina — continues to climb.
Contrary to the narrative that the current death-by-overdose crisis is the result of doctors overprescribing opioids to our patients in pain are the facts. There is no correlation between the number of prescriptions written and a state’s death rate by opioid overdose. Although the District of Columbia had the lowest prescription rate in the nation in 2016 it had the fourth-highest death rate by overdose; Alabama, with the highest prescription rate had an average death rate. In 2016, just fewer than 5 million opioid prescriptions were filled in South Carolina — about 89 opioid prescriptions per 100 persons compared to the national rate of 70 opioid prescriptions per 100 persons — and the death rate due to opioid overdose was under the national average. Why, then, are so many people dying?
As pharmaceutical grade medical opioids became harder to obtain due to regulatory efforts, sales on the “street” and “dark web” spiked. Predictably, as with any prohibited substance, an alternative market materialized to meet the demand. In this black market, however, the drugs are far more dangerous and of dubious composition. Fentanyl and other synthetic opioids tainting fake prescription tablets, with potencies hundreds to tens of thousands of times more powerful than morphine, along with heroin, are being taken by unsuspecting people who then accidentally die. Importantly, the vast majority of those dying are not those for whom the medicine was legitimately prescribed — it is not our original pain patient who typically goes on to use and then die from illicit drugs. They are her friends and relatives who steal the pills or to whom they are being diverted and who statistically are already more likely to be misusing alcohol, cocaine and other drugs. In fact, most “opioid deaths” involve a combination of several drugs and alcohol.
The overdose rate for medically prescribed opioids for acute pain (such as kidney stones or surgery) is less than 1 percent and around 8 percent for long-term, chronic non-cancer pain management in recent very large studies. The vast majority of chronic pain patients use opioid therapy successfully to be able to function in life. It is evident from many sources that restricting prescriptions does not lower overdose death rates but merely pushes non-medical users to more dangerous drugs. Notwithstanding the evidence, our patients, who are being arbitrarily cut off or having doses limited to insufficient levels for their acute and chronic pain in response to these policies will, literally, suffer.
To be crystal clear, one overdose is a tragedy. However, pinning the blame on legitimate prescriptions for opioids is not evidence based. As doctors, we wholeheartedly support and will participate in professional and public educational efforts, medical alternative therapies for pain, harm reduction efforts and treatment of addiction without stigma or prejudice. However, we believe that the blunt, broad tool of restrictive legislation will not cure the death rate by opioid overdose and is fraught with unintended consequences for our patients. The right medication, in the right dose, for the right duration, for a given condition in an individual patient can only be resolved by the finesse of the doctor-patient relationship.
Marcelo Hochman, M.D., is chairman of the Legislative Committee and president-elect of the Charleston County Medical Society. William Simpson, M.D., is chairman of the Public Health Committee/Opioid Task Force.