OxyContin, Heroin and the Opioid Crisis

By Roger Chriss, PNN Columnist

The roles of heroin and OxyContin in the opioid crisis are frequently mischaracterized and misunderstood. Such is the case with a recent op/ed in The Washington Post.

“In the 1990s, when the industry began aggressively marketing prescription opioids such as OxyContin, heroin was a minimal presence in American life," wrote Keith Humphreys, PhD, a professor of psychiatry at Stanford University

This is an unfortunate and common error about the role of heroin in the opioid crisis. Humphreys is repeating what many politicians and policymakers have also claimed. It’s important to correct this error because otherwise we will misunderstand how to treat heroin addiction, what our options are for pain management, and how to create sound policies to address the opioid crisis.

In fact, the U.S. has long had a major problem with heroin. Mexican black tar heroin arrived decades before OxyContin, and opioid addiction is usually a result of recreational use starting during adolescence, with addiction due to medical care being uncommon.

According to the book “Dark Paradise” by historian David Courtwright, researchers estimated the number of heroin addicts in the U.S. during the 1990s at a half million or more, about the same level as in the mid-1970s. This is also close to the 626,000 heroin addicts that the National Institute of Drug Abuse estimates for 2016.

Fatal overdoses involving Mexican black tar heroin were increasing even before OxyContin was introduced by Purdue Pharma in 1996. Sam Quinones notes in “Dreamland” that Oregon’s Multnomah County had only 10 heroin overdose deaths in 1991, about the time Mexican drug dealers arrived in Portland, but by 1999 there were 111 heroin overdoses.

So the idea that “heroin was a minimal presence in American life” isn’t supported by data. Neither is the claim that heroin traffickers “set up shop in the areas of the United States with the highest prevalence of prescription opioid addiction.”

According to Quinones, the Mexican drug gang the “Xalisco Boys” went into communities that were not a part of the established drug trade and were not subject to turf wars or other forms of gang violence. They wanted to fly below the radar, to avoid detection by law enforcement, and deliberately avoided carrying guns, driving fancy cars, or living large.
So the Xalisco Boys went to smaller cities like Portland and rural communities like Appalachia that were specifically chosen because they were low risk. And they were there well before 1996 and the advent of OxyContin.

Humphreys makes an additional error with his claim that about 80 percent of Americans who became heroin addicts started out with prescription opioids, according to an assessment from the National Institutes of Health. The 80% statistic varies significantly with time and place. As I wrote in a previous column,  non-medical use of opioid medication was found in 50% of young adult heroin users in Ohio, in 86% of heroin users in New York and Los Angeles, and in 40%, 39%, and 70% of heroin users in San Diego, Seattle, and New York respectively.

It's also important to note that “prescription opioids” does not necessarily mean prescribed opioids. Many addicts don't have a prescription and steal, buy or borrow pain medication. The National Institute on Drug Abuse estimates that about 10 percent of patients legally prescribed opioids develop an opioid use disorder. And only about 5 percent of those who misuse their medication transition to heroin.

There is also a disturbing new trend in heroin use. A study in JAMA Psychiatry last year found that about one-third of heroin users had no prior experience with any opioid, prescription or otherwise. Heroin users often have extensive prior drug use with a variety of different substances, along with a history of severe childhood trauma or mental illness.

Humphreys’ claim that the “heroin-addicted were transfers from prescription opioids” ignores another route on the path to opioid addiction. In “Drug Dealer, MD,” Stanford psychiatrist Anna Lembke says some drug addicts switched from heroin to prescription opioids in the late 1990s and early 2000s because of the increased availability of the latter.

None of this is meant to exonerate OxyContin or Purdue Pharma. Barry Meier’s recent book “Pain Killer” does a good job of explaining the history of the company and why it is the focus of so many lawsuits. Purdue was fined over $600 million for the illegal marketing of OxyContin and important questions about the company’s actions remain to be answered.

Heroin addiction has been a major presence in American life for generations. The current opioid crisis may have been jump-started with prescription drugs, but heroin came long before OxyContin. It is better to view OxyContin as gasoline tossed on a smoldering fire, rather than blame OxyContin for heroin. The crisis is more complicated and pervasive than that.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Can Marijuana Improve Your Sex Life?

By Roger Chriss, Columnist

A new study by researchers at Stanford University, published in the Journal of Sexual Medicine, shows that marijuana use is associated with greater sexual frequency in both men and women. There has been a lot of enthusiasm about the findings, but relatively little understanding of what the research actually says.

Marijuana has intriguing medical potential, from symptom relief in terminal cancer patients to pain management in chronic conditions. And the possibility that it may improve sexual function is enticing in particular for people with health problems. Thus, it’s important to understand what any new results are really saying. So let’s use this paper as a case study on how to read a research paper.

We start with the study methodology. Because the gold-standard of a double-blind placebo-controlled randomized prospective trial is not possible with marijuana, the authors had to engage in data mining, the process of using an existing data set to ask new questions.

For a data source, the study uses the National Survey of Family Growth (NSFG), a large database assembled by the CDC. The study results were drawn from an analysis of 28,176 women (average age = 29.9 years) and 22,943 men (average age = 29.5).

It is important not to be impressed by these large numbers. Increasing a sample size beyond a certain point offers no additional reliability, and it may create more problems with confounding variables and hidden biases. Because the authors did not assemble this data themselves, there was no way for them to address these issues.

A sanity check of the data is the next step. This study looks at sexual frequency at various levels of marijuana use. A check of the International Encyclopedia of Human Sexuality shows that “on average, men and women engage in sexual intercourse approximately six times per month.”

This is consistent with the Stanford study findings, but with a caveat: recall of the previous month’s sexual activity or marijuana use may be imperfect. Some researchers try to get around this problem by having participants keep written logs or by using apps, but this study did not.

It is also important to keep in mind that the study variable of sexual frequency is an imperfect number. You cannot have sex 0.73 times!  Any change in sexual frequency has to occur in increments of one per unit time. In this study, the unit time is a 4-week period. The increase reported in the study represents the smallest possible increase, or one additional sexual event. The authors found that regular marijuana use was associated with one more sexual event every four weeks.

The study mentions the use of the NSFG data as a limitation. The authors note that “survey responses were self-reported and represent participants only at a specific point in time.” But there is a deeper issue here. As noted above, the data set may contain flaws, biases, or other issues beyond the control or even the awareness of the authors. Formally speaking, randomness is lost. In election polls, for instance, pollsters follow strict protocols to ensure randomness because doing so makes for more reliable results.

In practice, large data sets often contain many associations because life is complicated and even seemingly simple activities like sex are subject to a variety of influences. So posing questions to large data sets requires caution, or as statisticians sometimes say, “give me a large enough data set and I can prove anything.”

The Stanford study’s conclusion is that a “positive association between marijuana use and sexual frequency is seen in men and women across all demographic groups.”

But in an interview with The Washington Post, the authors qualify that by noting that the study “doesn't say if you smoke more marijuana, you'll have more sex,” appropriately warning that correlation is not causation.

Spurious Correlations

But the mantra of “correlation does not imply causation” is simplistic. In reality, association does not even imply direction. It is equally reasonable here to say that greater sexual frequency is associated with increased marijuana use. But changing the word order alters the implication.

The second problem is that the association may be meaningless, an artifact of our data-rich world. Such spurious correlations can even be a source of entertainment. For instance, coital frequency may be correlated with living in an even-numbered zip code or marijuana use may be associated with banana slug activity.

Not to make light of overdoses, but there is even a spurious correlation between deaths caused by opioids and the price of potato chips:

SOURCE: TYLERVIGEN.COM

These associations could be tested, but a positive result would probably not get the kind of media attention the Stanford study is receiving.

Moreover, sexual activity is influenced by a wide range of factors. It is possible that regular marijuana users have a lifestyle more conducive to sex, making lifestyle a lurking variable that affects both sexual frequency and marijuana use. Or it may be that daily marijuana users have more disposable income, more time to enjoy the effects of marijuana, and a more drug-tolerant work situation. In this case, marijuana use would act as a proxy for other potentially causal factors that influence coital frequency.

Because these issues are always found in large data sets, the potential for finding meaningless associations is ever-present. Or as statisticians say, “if you torture the data enough, you can get it to confess to anything.”

Thus, a study of this nature has inherent limitations that mean its results must be interpreted with caution. As the authors note in their conclusion, “the effects of marijuana use on sexual function warrant further study.”

So our final task is to consider what would constitute further study. Obviously, this result needs to be confirmed, ideally with a prospective study that controls for confounders. If the result is reproduced, then the hard work of identifying the causes begins. Once identified and confirmed through human testing, then and only then can we say that marijuana increases sexual frequency. For now the best we can do is read such studies with care and caution.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Women Who ‘Catastrophize’ More Likely to Get Opioids

By Pat Anson, Editor

Women who complain or focus negatively on their pain – a psychological condition known as catastrophizing -- not only feel chronic pain more intensely, they are more likely than men to be prescribed opioids for the same condition, according to a new study.

"Our research underscores how psychological factors such as negative thoughts or emotions have the capacity to influence how we experience pain and the likelihood that someone will be taking prescribed opioids," said Beth Darnall, PhD, a clinical associate professor at Stanford University School of Medicine and senior author of the study published in the journal Anesthesiology.

"The findings suggest that pain intensity and catastrophizing contribute to different patterns of opioid prescribing for male and female patients, highlighting a potential need for examination and intervention in future studies."

Previous studies have found that pain catastrophizing can have a powerful influence on a patient’s sensory perception, and may magnify the intensity of chronic pain by as much as 20 percent.

In their retrospective study, Darnall and her colleagues analyzed clinical data from nearly 1,800 adult chronic pain patients at a large outpatient pain treatment center. Most of the patients said they were prescribed at least one opioid medication.

For women, pain catastrophizing was strongly associated with having an opioid prescription, even when there were relatively low levels of pain. Pain intensity was a stronger predictor of opioid prescriptions in men.

"Our findings show that even relatively low levels of negative cognitive and emotional responses to pain may have a great impact on opioid prescribing in women," said lead author Yasamin Sharifzadeh, a medical student at Virginia Commonwealth University.

It was Sharifzadeh who first sought to study the relationship between pain catastrophizing and opioid prescriptions as a third-year undergraduate student at Stanford, where the research was conducted. She says more research is needed to understand sex differences in pain so clinicians can develop better treatments for both men and women.

“If physicians are aware of these gender-specific differences, they can tailor their treatment,” she said. “When treating chronic pain patients — especially women — they should analyze pain in its psychological aspect as well as its physical aspect.”

Previous studies have found that women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and to use them for longer periods. Women may also become dependent on medication more quickly than men, according to the CDC.