The New Reefer Madness: Hysteria against opioids won't help patients who suffer from chronic pain

In the 1930s, a moral panic was instigated  by churches and built upon the idea that "too many" young people were falling under the influence of marijuana. In 1937, the film Reefer Madness was produced, and its purpose was to frighten any who saw it into believing that pot would drive its users to rape, to kill, and to die.

One of the leaders of this war on grass was Harry Anslinger, the first commissioner of the (pre-DEA) Federal Bureau of Narcotics. Anslinger found two bogey men with which to whip hysteria against marijuana. First, he asserted that using weed caused white women to have sex with black men. In fact, Anslinger terrified the white community by telling its citizens that "reefer makes darkies think they're as good as white men."

The second bogey man with which Anslinger scared "respectable people" into opposing marijuana was that it was more deadly than cocaine or heroin. Not surprisingly, the hysteria produced a call for new laws, and marijuana was outlawed in 1937.

In 2016, the laws against marijuana are being relaxed across the country, with certain states now removing all restrictions on the recreational use of pot, and many others passing laws to make marijuana available for medical purposes. Most of the hysterical fears about pot have proven unfounded. Looking back, it's easy to shake one's head at how silly it all was, until you consider that, as part of the war on drugs, many who were arrested for pot possession and dealing ended up with long prison sentences. And those in jail are disproportionately people of color. In fact, Maia Szalavitz says that it is impossible to separate the fear of pot from the racism that undergirded it.

If you were to run a Google search on the word "epidemic," especially under a "news" search, what would pop up are pages and pages of articles that combine the words "opioid" and "epidemic" in the same headline. With the announcement on June 2 that Prince died of an accidental Fentanyl overdose, many of those headlines now feature the words "Prince," "opioid" and "epidemic" in the same sentence, linking the musician's death with the spate of overdose deaths attributed to opioid overdoses.

But, when one reads the scientific data on opioids and the number of users, several things become clear. The first is that the media seems to be suffering from "Vizzini" syndrome as explained to him by Inigio Montoya in The Princess Bride: "You keep using that word. I do not think it means what you think it means." And it is this casual use of words such as "epidemic," "addict," and even "opioid" that is contributing to a common belief in the American public, which is that we are in the midst of a prescription pain medicine crisis of epic proportion, and that if we do not do something quickly, the sky is most definitely going to fall.

I am not denying that people are dying from overdoses of opioids. They are. And in 2014, more of them died in one year than previously, although what many media have not reported on is that the data from 2012 and data from a 50-year period, while showing increases in the number of deaths, also show that the increase is not uniform across the states. Some states reported higher rates of death, some reported lower, and some recorded no statistical difference. One might have thought that the entire nation was in the grips of a public health disaster due to opioids, but the actual numbers vary.

One of the words that causes confusion is the word "epidemic." For many, an epidemic connotes the idea that huge portions of the population are suffering. We have been warned about flu epidemics, or epidemics of SARS. Some may picture in their heads the legacy of the 1919 Spanish Flu Pandemic, where so many people died in a short period of time that cities like Philadelphia reported that bodies were stacked up like cordwood waiting to be taken for burial. Or we may picture the Black Plague epidemic of 1348, where 33-50 percent of Europeans perished during a year of spreading plague.

Yet, that's not what epidemic means.  According to a medical dictionary, an epidemic is "the occurence of more cases of a disease than would be expected in a community or region during a given time period." Epidemics do mean that there has been an increase in cases of disease, but they do not, as the media seems to use the word, mean that nearly everyone is sick. One headline in a recent newspaper carried the headline, "Opioid-related deaths surge, pushing morgues to capacity." That headline implies the bodies stacked up like cordwood, and that there is mass death and destruction taking place because of opioids.

It is also crucial to note that heroin is not only considered an opioid, the figures for "prescription opioid overdose" included heroin deaths, depending on the source. The numbers are not easy to interpret. For example, the Centers for Disease Control (CDC) says that 43,982 people died from drug poisoning in 2013. But, the number of deaths from opioid medicine was 16,235 and the number of deaths from heroin overdose was 8,257. If you add those two last numbers together, you see that there are thousands of drug poisoning deaths that are not accounted for through opioids or heroin. It's why you can read in some articles that there are 28,000 opioid-related deaths per year in one place, 16,00 in another, or that there were 44,000 drug deaths. The media has not been as careful as it needs to be in distinguishing heroin deaths from opioid deaths, nor even talking about what causes the other drug deaths.

In a document put out by the CDC, the number of deaths caused by opioids and heroin is emphasized, although at one point, after continually referring to the "drug overdose deaths of 47,055" in 2014, someone would have to read further to see that the percentage of these deaths caused by opioids and heroin is 61 percent, leaving 39 percent unaccounted for.

But, the CDC also includes this information: "Historically, CDC has programmatically characterized all opioid pain reliever deaths (natural and semisynthetic opioids, methadone, and other synthetic opioids) as "prescription" opioid overdoses." In other words, reporting that 28,000 people died from "prescription opioid overdoses" would be accurate in words, but not in fact. The CDC counts heroin as a "prescription opioid." Thus one reads constantly about the epidemic of "prescription opioid" deaths, which sounds as if people are going to their doctors, having prescriptions written willy-nilly, and then going off and dying. That is not the case. The study also documents that it is near impossible to distinguish "legitimate" and "illicit" Fentanyl. Some people are acquiring Fentanyl through legal means; some are buying it on the street. Autopsies do not account for the difference. So, again, while it is common to lump everything together under the term "prescription opioid," those numbers also include street drugs that were never issued through a prescription pad.

It is also important to look at the figures in context. 28,000 deaths is significant. The  number most often cited is 44 people per day. But compare that number to deaths from cancer, and you see that the annual death rate from cancer is 480,000 or 1200 per day. There is a huge difference between 44 per day and 1200 per day. And, consider that alcohol is responsible for 88,000 deaths per year, and one-third of traffic fatalities involve drunk drivers. Alcohol is not banned. But because of the emphasis on the word "epidemic" when referring to overdoses, many Americans have not been able to put the numbers in context. And, to further complicate matters, the CDC admits that someone who died from a combination of heroin and prescription opioids in their system would go into both sets of statistics, thus making the "heroin" deaths and "opioid" deaths numbers confusing as some people appear to be counted twice.

It is impossible to talk about a media narrative of "epidemic" without asking whether what is driving the repetition of scary words like "epidemic" and "crisis" and the driving of this narrative isn't motivated by similar concerns about marijuana in the 1930s. The issue of race had a huge impact on the criminalization of marijuana, a fear that a drug associated with people of color had infiltrated the minds of white youth. In terms of heroin, each study that looked at the demographics of the heroin abuse has shown similar statistics about who is using that drug now.

In a study entitled "The Changing Face of Heroin Abuse", researchers made an effort to understand how people were coming to use heroin--whether, as has been reported, the gateway is prescription opioids--and who was using heroin in 2014. While the study showed that prior to the 1980s, those who initiated heroin abuse, whites and people of color were equally represented. In the past decade, however, 90 percent of those beginning heroin are white. In addition, "our demographic data show that the demographic composition of heroin users entering treatment has shifted over the last 50 years such that heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas."

In other words, new heroin users are primarily white and primarily living in the suburbs. The new emphasis on opioid abuse as public health crisis corresponds with an increasing percentage of those drug abusers being white and suburban. It bears asking whether the constant emphasis in the press being in crisis and an out-of-control epidemic has more to do with WHO is being affected rather than the number of people affected.

This is part one of two-part article. In the second part, Lorraine Berry will look at the connections between opioid medicines that are prescribed for chronic pain patients and opioid medicines that are used recreationally. She will also look at the phenomenon of "addiction," and how the involvement of middle class youth in the heroin "epidemic" has had a huge impact on government and legal response to these statistics.