Dr. Jeffrey Singer of the Cato Institute returns to the show

Jeffrey Singer: The “Doctor for Liberty” on Opioid Abuse

20 min readJul 13, 2019

Dr. Jeffrey Singer, an Arizona surgeon and Senior Fellow at the Cato Institute, has a message that some Americans will consider a bitter pill to swallow: People will always use drugs, and many will harm themselves and others in the process.

The government’s response to this fact of life has been a multi-billion dollar failed War on Drugs.

The best evidence suggests that not only has this war failed to achieve its intended aim, it has actually made the problems of drug abuse and overdose worse.

The “Doctor for Liberty” returned to the show of ideas, not attitude — listen or read the transcript below:

TRANSCRIPT

Bob Zadek: Welcome to The Bob Zadek Show, the longest running live libertarian talk radio show on all of radio. Thank you so much for listening.

In the life of the average American, there are two institutions that exist to protect and look after our self interest and our well-being. These are the government, to whom we pay a fee to take care of us, and the entire medical health care community, who we pay through fees and premiums and the like. When we pay that medical community, we expect one thing in return. That they will look after our best interests and protect us from harm. That’s a fair summary of the structure of life in America and how we are protected.

What happens if those two major institutions, government on the one hand and the medical profession on the other start to work at cross-purposes, where rather than work together in their relative spheres, both to protect Americans, they work against one another so that the positive effects of one offset to some degree the good work of the other. Well, you don’t have to speculate about that because that’s what’s happening in America today, specifically in the area of addiction and opioid use.

We have drugs — opioids in particular — which are prescribed by doctors. When a doctor decides that this is the right prescription for us we trust them. But now we have government inviting itself into the privacy and sanctity of the doctor’s office, saying “No, doctor, we know better. We will prevent you under pain of fines, imprisonment, or loss of license, from doing what you determined to be in the best interests of the patient.”

I will leave you to decide who best to believe in this tension between what a doctor believes is best and what government believes is best.

This morning I am happy to welcome to the show Dr. Jeff Singer, to discuss this crucial tension. Jeff is a senior fellow at the Cato Institute. He works in the Department of Health Policy Studies. Jeff has a unique view because he has spent a great deal of his life studying both political effects and medical effects on the medical profession. Jeff is a practicing surgeon. He’s the founder of Valley Surgical Clinics, the largest and the oldest group of private surgical practices in Arizona. Jeff has been working as I said, as a senior fellow at Cato studying this issue. Jeff will share his knowledge with us on the often contrary pressures of government on the one hand and the medical profession on the other. Jeff, welcome to the show.

Jeffrey Singer: Thank you for having me. Good morning.

An Overview of “Opioids”: Misleading Terminology

Bob Zadek: The subject this morning is not healthcare, because that wouldn’t be the subject of a radio show but the subject of a four-year graduate level program, which we don’t have the time for.

We picked this specific issue because it is so much in the news and so profoundly misunderstood by journalists who write about it, by the audience of journalists who read it, by bloggers and by governmental officials. It is my hope that you can shed light where there regretfully is so much darkness.

First, there are words that get used all the time in the media but without explanation as to what they mean. So let’s define some terms for the minute. First of all, the subject this morning is opioids. Now, an opioid is a very specific drug. It is a prescription. You can say, “I would like to buy an opioid,” but that’s not the case at all. So Jeff, just to help the audience follow our discussion, tell us about what an opioid and how that meaning is misused in discussion in the media and in the press.

Jeffrey Singer: Opioids refer to a very broad category of drugs that have some relationship to the opium plant. There are opiates, which some people use interchangeably with opioids and opiates are actually direct natural derivatives from the opium plant. For example, morphine and codeine are opiates. They come directly from the plant and they are refined and then used medically. Opioids are opiates that have been modified chemically in the laboratory to enhance their effectiveness or change some of their qualities. They called “semi-synthetic” opioids, like oxycodone or hydrocodone. They are semi-synthetic. They have a portion of the original components of the opiate. Then there are completely synthetic opioids like fentanyl.

The category of opioids is a very broad category. Heroin, for example, which is diacetylmorphine is an opioid. Heroin is just a brand name that was given to it when it was developed in the 1890s by Bayer. When people hear in the news, opioid overdose deaths, they are thinking that this is doctor-prescribed oxycodone. But in fact, according to the government’s own data in the most recent year we have 2017, three quarters of overdose deaths related to opioids are deaths from fentanyl and heroin.

The fentanyl that is involved in the overdose deaths in this country, according to the Drug Enforcement Administration, is what is called “illicit fentanyl.” It is not fentanyl that is made by pharmaceutical companies for medical use, which in most is either an intravenous solution used in hospitals or a skin patch that you wear on your skin that slowly absorbs over a few days.

The fentanyl that’s involved in the overdose deaths is coming in from a powder form from laboratories from China and now from Mexico. And oftentimes it comes in through the mail. It is coming in through airports and other ports of entry. It’s very difficult to detect. People order it on the dark web and then receive it. Drug dealers are using things like pill presses to make it look like a prescription-type drug like Vicodin or Percocet and then they sell it for nonmedical users on the street. Or, they use it as an additive to heroin to make the heroin more potent. As we all know, when it comes to prohibition, it tends to incentivize the development of more potent forms.

It is easier to smuggle in smaller amounts. You can also get more by subdividing it into more pieces to get more bang for your buck if you’re going to take the risk of smuggling. So when we hear opioids in the news — there were 49,000 opioid related overdose deaths in 2017 — everybody is thinking that is from prescriptions. But actually, out of 49,000, if you take away people who were found to have a prescription type opioid in their system that was mixed with other things like cocaine, heroin, tranquilizers, alcohol, and eliminate that, the percentage of opioid-related overdose deaths in 2000, were less than 10%.

We have learned that the word “opioid” doesn’t tell you what the story is about, because an opioid is a label that could describe either a prescription drug manufactured under the regime of a licensed drug manufacturer with all of these quality controls prescribed by a doctor to a patient because a doctor has decided that patient needs this prescription. That’s one classification of the opioid. The very same word can be used to describe illegally manufactured fentanyl or similar substance with no controls whatsoever illegally brought into this country and sold on street corners or whatever the distribution channels. Both deaths from that opioid would be classified the same way in a newspaper article but they have nothing in common in actuality besides some chemical similarities.

Prescription Opioid Use: A Low Risk Drug

Bob Zadek: Now, Jeff, a lot of the attention that the media has given, and then the government has given is to the prescription drug opioid manufactured under the regime of a drug company with procedures that are regulated and controlled by the government and are sold pursuant to the prescription regime in this country and prescribed by a doctor. What is the illness the doctor is trying to cure with the prescription of an opioid?

Jeffrey Singer: Opioids are a very effective for managing pain. We’ve known this since antiquity. In the days of the ancient Roman and Greek doctors they knew that they relieved pain. It could be acute pain, like a postoperative surgical pain or chronic pain. So opioids are effective in treating pain. Another misconception out there is that these people who are dying from prescription opioid overdose deaths is due to doctors prescribing pain medications. However, the overwhelming majority are due to people who have multiple drugs in their system including alcohol, cocaine, and heroin.

They are actually not using it under a doctor’s prescription for medical purposes. They are called “non-medical users.” They are self-medicating for their own pain, either psychological or physical. So if you look at peer reviewed studies, prescription opioids given in the medical setting have an overdose rate of anywhere between 0.01% and 2.05%.

The mortality rate from taking opioids on a daily basis is roughly equivalent to the risk you’re taking by taking an aspirin a day for cardiovascular health or being put on a blood thinner because you have atrial fibrillation. It is relatively safe.

Now, other pain relievers actually can be more dangerous. We hear a lot about ibuprofen. These can kill kidneys and affect bone marrow negatively. Tylenol in high-doses can kill the liver. So in many respects the risks you are taking with nonsteroidal anti-inflammatories for long periods are greater than properly prescribed opioids in a medical setting.

The healthcare professional will tell you, “don’t take this with alcohol, certainly don’t crush it and snort it or crush it and inject it into your veins.” This is non-medical use. What is happening now is that with all of these misconceptions, the government has gotten into the action. Politicians are always trying to “help us” and “fix our problems.” Ronald Reagan who said that the most frightening words are from the government saying, “I’m here to help you.”

Dependence versus Addiction

Bob Zadek: We have learned that opioids, when properly prescribed, have a statistically insignificant adverse effect. Although I’m not a doctor I dare say any prescription drug which a doctor prescribes, if you gulp it down and take it well beyond the dosage your doctor recommends, or you abuse it, it will harm you. So if you take an opioid prescription drugs in a way other than it is prescribed and it will harm you.The fact that the misuse of a drug will harm you is hardly the reason for governmental intervention. How did the government get involved to begin with? What was the politics? Why do we read so much about doctors prescribing opioids and back alleys.

Jeffrey Singer: In order to answer that I have to clear up one other misconception out there, and that is dependence versus addiction. Now, opioids are a class of drugs where if you take them for a prolonged period of time, your body physiologically adjusts. You can become what is called “physiologically dependent” on it. So if you try to suddenly or abruptly withdraw the drug, you’ll get, in the case of opioids, hellish withdrawal symptoms that could last several days. Many drugs, even beta blockers, which people take for high blood pressure, can cause withdrawals that can even be fatal.

Unfortunately, none of our politicians and journalists would say you are addicted to a beta blocker, but they would say you are addicted to an opioid. They equate dependence with addiction. In fact, the official description of addiction is, and it is the “compulsive use of a substance despite negative and self destructive consequences.” That’s not the same thing as dependence. When a person has been on an opioid for a long period of time, say for they were in the hospital for two months for a major trauma. If you take them off opioids abruptly they will get horribly sick. Sometimes the pain they experience will be even worse.

They need to be maintained on opioids and gradually tapered off. It could take some time, sometimes several weeks, but they are not addicted. In fact, as a surgeon, I have had patients tell me when I am discussing their proposed surgery, “what are you planning to prescribe me for pain after the surgery? The last time I was on an opioid I went into withdrawal and it was a horrible experience. I don’t want to go through that again.”

That’s not the kind of comment that will be made by a person who is addicted. That kind of person wants to go through that pain. They want the opioid because they are craving it. It is a compulsive behavior disorder. But unfortunately, our media and politicians equate the two. The actual addiction rate with opioid use is roughly 1 to 3% based on the research. It’s this misunderstanding that fueled a lot of the bad laws passed in this country.

The Story of Government Intervention: Historical Background

Bob Zadek: We start with a doctor practicing medicine and concluding that based upon his training or her training, the patient would benefit from a prescription for oxycontin or one of those other opioid based pain killers. That is done in the privacy of a doctor’s office. How did that start to draw the attention of government? Please explain, out of all of the interactions between doctor and patient in the privacy of a medical suite or a medical office, why did opioids draw the attention? Especially since there is nothing surprising about prescribing a pain killer to stop pain.

Jeffrey Singer: I am going to have to give a little brief historical background. Basically, back in the 1970s when the war on drugs was really kicked into full gear by President Nixon, doctors, patients, and the entire public had a tremendous fear of any of these drugs. We were given this tremendous myth that one dose of the drug can hook you for life. So throughout the 70s and into the 80s, doctors were extremely stingy with pain medicine. Oftentimes, when we offered pain medicine to patients, patients were afraid to take it. There were many studies coming out showing that people were not getting adequately treated with pain.

We were overreacting with fear. We should be much more generous in treating pain. We should take pain more seriously. So by the early nineties, the government agencies, the National Institute on Drug Abuse, and all the respected institutions were encouraging doctors to relax their restrictions on giving pain treatment. So we saw a lot more prescriptions of opioids taking place as the late nineties came about. Now, a recent study came out from the University of Pittsburgh, that found that the nonmedical use of both illicit and licit drugs have been on a steady and exponential increase since the 1970’s. There is no trend towards stopping it.

First it was heroin, then it was cocaine in the 80s and into the 90s. Then it was prescription painkillers like vicodin, and then it was oxycontin, which is concentrated oxycodone. This was popular with nonmedical users because they could obtain it, crush it, and either snort or inject it to get a much bigger dose, either injected it or snorted it, they get a much bigger dose than if they did that with an oxycodone pill. Of course now the problem is with fentanyl and other heroin-like drugs. So by the late nineties the most popular drug of abuse was prescription painkillers.

Bob Zadek: I want to remind the audience that this was not through prescription. The drug itself was a prescription drug, but it was not through a prescription. It was gotten outside of the normal prescription channels. And that’s very important to the telling of this story.

Jeffrey Singer: It was what they call “diverted prescription opioids.” So, we saw less attention given to the crack cocaine crisis or other drugs back in the 1970s and 80’s, maybe because the victims were not white, middle class middle-American kids. By the early two thousands, diverted prescription painkillers were starting to be used non-medically throughout the country in middle class suburban communities. This was gotten through the black market. Prohibition incentivizes certain doctors to operate pill-mills. They were just giving you prescriptions to use non-medically. They often had deals with drug-deals.

“Prohibition incentivizes certain doctors to operate pill-mills.”

Doctors were arrested. One in Orange County who was arrested for writing prescriptions for $600 to people who want to abuse it. This was all outside of the realm of medical practice. Of course when it started affecting middle class suburban America, it started getting the attention of politicians. So now we have a crisis. It didn’t seem to matter when intravenous drug users would die from heroin overdoses in the inner city because that was a different population.

False Science: Laying the Blame on Prescription Drugs

Jeffrey Singer: They came to the conclusion that it was the doctor’s prescribing opioids that was causing the overdose crisis. There were some unethical doctors who were basically profiteering in the black market. These were not mainstream doctors. They were a tiny minority. I would argue that the cause was the lure of money provided by drug prohibition. Setting that aside, this made the government began clamping down on doctor’s ability to make prescriptions. Altering the dose came later. They first they wanted to stop these prescriptions because the number of prescriptions had gone up tremendously between 2000 and 2010.

The politicians made this mistake of equating the cause of the overdose crisis with those prescriptions. I published a study in a peer reviewed journal of pain research in February along two other authors. We looked at government data going back as far as was available from the National Survey on Drug Use and Health. We found that there is absolutely no correlation between the number of prescriptions written and past month nonmedical use of a prescription pain reliever as well as past year diagnosed with prescription pain reliever use disorder, throughout the entire 2000's.

As the number of prescriptions actually doubled, the past month nonmedical use of a prescription pain reliever and the past year diagnosed with prescription pain relief use disorder had no relationship. But nevertheless, the policymakers and the press and their new bubble decided that it was the doctors that caused this.

They started clamping down by having these monitoring boards which monitor how much we prescribed, and they decide we prescribe too many opioids, we get a visit from the government. Many of us lose our licenses, and some of us are even going to jail. So the doctors cut back dramatically.

Counterintuitive Effect Government Intervention

Jeffrey Singer: Since 2010, the number of high dose opioid prescriptions has dropped more than 60% and overall all opioid prescriptions dropped about 30%, and in consequence, the overdose rate has skyrocketed. As the availability of diverted prescription opioids dried up, the population of nonmedical users of opioids migrated to the next available thing, heroin and fentanyl.

“Since 2010, the number of high dose opioid prescriptions has dropped more than 60% and overall all opioid prescriptions dropped about 30%”

The data suggests that most of the people who are dying of heroin and fentanyl overdoses are not preferring to use fentanyl. Fentanyl is being mixed in with the heroin to increase its potency and to facilitate its smuggling in smaller amounts. So, the patients who need the pain medication are suddenly finding they can’t get it. They are told after an operation that they should take Tylenol or Advil. Or the length of prescription of opioids has been shortened to a few days instead of two weeks. Doctors are so frightened by some of the horror stories that they are not prescribing opioids at all.

We are going back to a pre-1970s treatment of pain. It is primitive. In the meantime, while we are hurting those patients, the overdose rate has risen. So when we started making these interventions, roughly half of the overdoses involved a prescription pain pill mixed with these other drugs. In 2017, less than 10% involved a prescription pain pill without any drugs, and about 25 to 30% had it mixed with things. So we created the next crisis of fentanyl and heroin. The University of Pittsburgh found this trend to be continuing.

And by the way, this is not just happening in the United States. We see this in Canada and Western Europe. Fentanyl is the number one problem in Europe, as well as heroin. The same holds true for Canada and Australia. A growing number of people are non-medically using licit and illicit drugs. Maybe there are more people who are troubled.

There is reason to believe that a lot of people are self-medicating. And not necessarily self-medicating for physical pain, but it could be for emotional pain or psychic pain. When you talk to people with a substance abuse disorder, they will often tell you that heroin takes them to a place where all of the things that make me not want to be alive not matter anymore. It numbs them. This is complicated and there’s no simple explanation and there’s no simple answer, but I think it was Mencken who said that for every single problem there is a simple explanation with a simple solution and they are both wrong.

Type Four Evidence: How Guidelines Can Spell Legislative Disaster

What is happening on the state level is that not only are the states monitoring and limiting how many numbers of pills you can prescribed, but they are also restricting the dosage. The CDC issued guidelines meant to be suggestive, not prescriptive.

This is because they were based on “type-4 evidence” — the weakest kind of evidence — much of which is observational or anecdotal. They also say that in many cases when treating a person with acute pain, five days worth of prescription opioids is sufficient. In many other cases seven days is sufficient. Well, as a doctor hearing that, this is type four evidence. Number two, this is suggestive. And number three, in most cases this is sufficient. I’m saying, “Well, tell me something I didn’t already know. In the meantime, I’ll continue to prescribe my pain medicine for my patient based upon what I know about that patient and the situation.”

In their conclusion they said that they write that the doctor knows best and should obviously weigh the risks and benefits for each patient. But the politicians don’t understand nuance. Policy is hard to make nuanced. You can’t really nuance with short tweets on twitter. So they started passing laws. In my state they said “no more than five days.”

[P]oliticians don’t understand nuance.

If I have a patient who’s in pain I can’t give them more than five days worth. There are some other studies noted that suggest that more people are overdosing on opioids when they have more than the equivalent of 90 milligrams of morphine a day of whatever their opioid is than less that.

Nevertheless, they point out in their studies that there are people who are on the equivalent of 200 milligrams of morphine a day. who do not overdose. This is because people get tolerant and because there is relatively low risk. So, nevertheless, there is no nuance.

Most states have passed laws limiting the dosage. Now pharmacies and even medicare are deciding that if a doctors prescribe a dosage exceeding more than 90 morphine milligram equivalents in a day, they have to get special permission in order to do that. So in other words, we have all these non-doctors, using ham-handed one size fits all interpretations of what they were told originally was not meant to be taken as conclusive, and which was based on weak data. They made this into a statute.

Bob Zadek: We have a patient, let’s say a schoolteacher who has severe back pain. The doctor says, “I can alleviate your pain so that the quality of your life will be materially better. I have the perfect solution, but I am not allowed to give it to you, even though the fact that if I prescribed this painkiller for a longer period of time than the government thinks is necessary, it has no adverse effect on you or on society.”

There is no effect to anybody. But the doctor lives in fear of losing their license or worse, by prescribing what is best for the patient. And that is because the government has decided to invite itself into a doctor’s office and to second guess them.

There is no societal benefit to this. This is just cruelty. It is not based on any science, but upon witchcraft.

75% of overdoses are heroin and fentanyl and less than 10% are prescription painkillers without anything else.

Jeffrey Singer: It is based upon this false notion that it is our prescribing opioids to our patients that is creating this overdose crisis, ignoring the fact that 75% of overdoses are heroin and fentanyl and less than 10% are prescription painkillers without anything else. They are ignoring that. So they are making my patient who needs relief from pain stay in pain, and this is not going to stop one heroin user from shooting up.

More Crazy Laws in California

Jeffrey Singer: It got to a point where the CDC issued a clarification saying that politicians are misinterpreting the guidelines. They clarified that what they issued were merely guidelines. The AMA has complained about it. In California, they changed the past law so that now if a person dies of an overdose from opioid overdose and they are found to have a prescription pain reliever in their system, if they could trace who the doctor who prescribed the last opioid to that person, that doctor could be charged with homicide in addition to, of course, losing their license.

Bob Zadek: You have to be kidding.

Jeffrey Singer: No, I’m not kidding. That’s a law in California. They can be charged with involuntary manslaughter. I’m not sure about the exact legal status. The licensing board is required to review them and possibly take their license away.

And of course, as you know, there are patients who are nonmedical users who fake pain in order to get a prescription and there are also nonmedical users who steal out of someone else’s medicine cabinet. There’s a doctor’s name on that prescription. So this has continued to fuel the fear and many doctors are not prescribing any opioids at all. I can understand that, but this is not helping patients. And it’s certainly not making the fentanyl heroin users stop using.

Bob Zadek: I want our audience to take a step back and just do a mind experiment. Imagine you are in the kind of pain each and every one of us has experienced. Think back to this experience and imagine pleading to a doctor and the doctor says “I have the perfect solution but I will go to jail if I prescribe it.” Imagine how you would feel. The professional who you pay to help you is prohibited under pain of imprisonment from giving you the help. Imagine the extremes you will go to to get that drug to seek relief.

Bob Zadek: Jeff mentioned this guideline issued by the CDC. Regular listeners to my show will recall that the administrative state uses guidelines with great effectiveness. Remember back to 2011 when President Obama and his Department of Education, sent the famous “dear colleague” letter to school administrators reminding them that they have to take claims that a woman was raped seriously? And if they don’t, there is a danger of them losing their federal aid. It caused the entire university system in America to start to violate the rights of the accused for a decade, until that was fixed by president Trump’s Department of Administration. So guidance letters are sinister.

Jeff, tell us the work that you at CATO to bring this to the attention of legislation.

Jeffrey Singer: We are publishing numerous studies and policy briefs. We are having conferences constantly at the Cato Institute. We are feeding this to Senators and Congressman. That’s all we can do. It is our job to publish studies and reports that tell the truth and guide what policy should be. On October 3rd, we are having a live-streamed conference at CATO.