JATH Educational Consortium. LLC
Carolyn Concia, NP
Thomas F. Kline MD, PhD
January, 2020. draft
The word “opioid misuse” is being misused. Misuse is a term created by those wishing to promote non-science based agendas, like “overdose deaths” leaving off the critical adjective “Heroin overdose deaths” Misuse is being used by the federal agency SAMHSA along with “abuse” to fuel the moralists who believe pain is not important enough to be treated with our drug of choice opiates. Misuse/Abuse is defined as “not taking the prescription as the doctor prescribed it”. This is not addiction.
The issue then centers on just how common is real addiction, the “junkie”, the “dope fiend”? If is is common, it supports that if misusing the you are on your way to death and addiction. If it opiate addiction is rare it supports the genetic theory that there are only a certain number of people who have the genes that will allow the true addiction, the life threatening “seeking behavior without regard to any consequence”. Heroin (diamorphine) addiction occurs at the rate of 4/1000 people.
It is critically important. If you can addict just anyone, then the various wars on drugs, five in all beginning with Eisenhower should have been effective by now. By reading the newspapers this does not seem to be the case.
Looking at the frequency of heroin addiction the following studies are reviewed. Is it rare or not?
A 1982 study of 145 burn treatment centers representing 20,000 burn patients found after prolonged injections of opiates for pain control there were only 22 people who became addicted (1)with intense seeking behavior, JATH’s definition of true opiate addiction.
In 2010, the highly regarded Cochrane Collaborative reviewed 26 long term opiate use studies and concluded: “serious adverse events, including doctor prescription triggered opioid addiction, were rare”(2).
A recent study at Loyola showed only one person addicted out of 1100 cases given postoperative opiates (3) close to our estimate of 4/1000 addicting in the general population. Three of the 1000 will addict in teenage years (and what are we doing about that?) leaving 1/1000 yet to trigger an addiction exactly confirmed by the Loyola study (3)
A carefully designed epidemiological study studying occurrence rates of addiction was conducted by the respected epidemiologist Lee Robins at Washington University in 1977. She studied 700 soldiers returning from Vietnam on high dose, pure, I.V. heroin.(4) Expecting nearly 100% addiction, she was “surprised” to find though 100% had withdrawal symptoms , 100% did not addict — in fact only 2% addicted. A startling finding by a respected researcher.
Jim Mintz studied smaller cohort of Vietnam heroin users in 1979 at the Brentwood VA and replicated the findings of Robins
Population statistics also support the rarity of addiction. The rate of addiction in 1915 when the Harrison Act was passed was 3/1000. NIH figures now show a similar rate of addiction today of 4/1000,unchanged in 100 years.
Neuroscience research at NIH, Montreal, Bonn, and Sydney to name a few, show consistent evidence that true addiction is a genetic mu opioid receptor polymorphism running strongly in families affecting the gene A118G.
Opposing views such as the CDC recent March 15, 2016 guidelines and groups opposed to the notion of rarity of addiction (5) with the position that nearly anyone can become addicted, but they did not cite data.
The studies above and epidemiological data show less than 1% of people will become addicted after either short or long term exposure, including those with prolonged exposure to high dose IV heroin by US Army soldiers in Vietnam. This fits the idea that the addiction is triggered not created. The genes were lurking there all the time. Reducing supplies of opiates on the street by the federal government will not help, since the majority of the opiate addicted people are already addicted leaving high school.
The low rate of addiction appears real and constant over time irrespective of opiates on the street. Given the rarity of addiction, the question arises as to ability and mechanisms for addicting of the remaining 99% of the American population currently targeted for lower opiate doses but who do not possess the inherited mu opioid receptor polymorphisms for addiction and cannot addict even if they try.
This is not a popular or well known idea, but there is no other explanation for why other addictions vary from year to year, decade to decade, but opiate addiction is the same nearly every year. From a medical standpoint it has to be genetic. If it were not the “flood” of opioid pain medicine would have produced and increase in receptor disease addiction (junkie) by now.
The highly regarded brain researcher and Director of NIH Drug Abuse (NIDA) Nora Volkow, MD said in a 2016 New England Journal of Medicine article, “Unlike tolerance and physical dependence, opiate addiction is a not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with preexisting vulnerabilities” (6)
Thomas F. Kline, M.D, Raleigh NC
Carolyn Concia, NP, Portland Oregon
Erin O. LeBlanc, Raleigh NC
Corresponding author: email@example.com
1. Perry S, Heidrich G. Management of pain during debridement: a survey of U.S. burn units. Pain 1982;13:267–80
2. Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Long-term opioid management for chronic noncancer pain. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD006605.
3. Shah, AS, et al. Rates and Risk Factors for Opioid Dependence and Overdose after Urological Surgery. Journal of Urology 2017; May 12, PMID: 28506855 (ahead of print)
4. Robins, LN. Vietnam Veterans Three Years after Vietnam: How Our Study Changed Our View of Heroin. Problems of Drug Dependence 2010;19:203–211 (reprinted exactly from 1997 Proceedings of the Thirty-Ninth Scientific Meeting of the Committee on Problems of Drug Dependence)
5. Leung, PTM, MacDonald, EM,Juurlink, DN. 1980 Letter on the Risk of Opioid Addiction.” New England Journal of Medicine 2017;376:2194–2195.
6. Volkow, N and McLellan,A. Opioid use in chronic pain — misconceptions and mitigation strategies. New England Journal of Medicine 2016;374:1253–63
REPORTS OF ADDICTION GREATER THAN 1%
None found as of this date
REPORTS OF ADDICTION LESS THAN 1%
9900 Volkow N., Head of the NIH of drug abuse: Addiction occurs in “only in a small part of people”
9901 Jane Ballantyne: “ during opioid treatment of several and short-term pain, addiction occurs very rare
9902 deadly trend NEJM XXX “although the majority of current heroin uses report having used prescription opioids non medicinely, before having heroin use, (but not the other way around) heroin use among people who use prescription opioid is rare, and the use of heroin appears to be rare
9903 Senator Jacob Jabits, New York, in 1956 said, “I estimate that the rock bottom minmie number of nitrogen addicts is less 60,000” (60000 divided by 160 million is 3 per 1000, there for, rare.)
9904 paper by Dickinson, it paul, “the risk of addiction is higher if one takes drugs(duh) but isn’t as big in other
9905 Substance abuse and mental health accretion (samsa) and the cocrain review “ only 2% of those who use a prescription opioid , whether presciprtion, or illegal, developed a pain-use disorder” with range from over use to addiction cromsic review “ patients with intractable pain… with long term high dose opioids, produced addiction in less than 1%
9906 2016 report in the NEJM XXX