Georgia Southern faculty published in New England Journal of Medicine for Opioid Crisis Research
Andrew Kolodny, M.D. of Brandeis University, and Robert Bohler, Ph.D. of Georgia Southern University, were recently featured in the New England Journal of Medicine (NEJM). Their perspective entitled, Screened Out—How a Survey Change Sheds Light on Iatrogenic Opioid Use Disorder, published in November of last year, examines an oversight in the National Survey on Drug Use and Health (NSDUH) concerning iatrogenic, or treatment-induced, opioid addiction. The two have decades of experience in the field of addiction and first started collaborating while Bohler was a student at Brandeis, earning his Ph.D. in social policy.
Kolodny and Bohler (Jiann-Ping Hsu College of Public Health) have studied the opioid crisis since the mid-1990s. They were consultants for some of the early litigation against pharmaceutical companies. Some of that litigation was successful, improving the public’s understanding of the industry’s role in causing the crisis. Even so, the two remained perplexed by a statistical incongruity that indicated a larger problem.
“One of the things that we talked a lot about is that, as opioid prescribing surged in the late 1990s, we saw a sharp increase in indicators that are associated with an increase in opioid use disorder, such as opioid-related treatment admissions, cases of neonatal opioid withdrawal syndrome, and opioid overdose deaths,” Bohler said. “However, we never had federal surveillance data showing this actual sharp increase in opioid use disorder among the general population.”
The confusion remained until recently when Bohler discovered a paper authored by U.S. Department of Health and Human Services affiliates. The paper reported that until 2021, the NSDUH survey asked patients taking their prescription opioids as prescribed to skip the questions regarding opioid use disorder. The exclusion of this population resulted in one of the government’s primary tools for collecting data on opioid use and a significant source informing opioid policy, reporting low rates of opioid addiction for the majority of the opioid crisis, even as overdoses and associated adverse outcomes skyrocketed.
To illustrate precisely how inaccurate the U.S. government was in its estimations, compare the survey’s rates of opioid use disorder in 2019 and 2022, one year after including patients taking medicines as prescribed: 1.6 million and 6.1 million, respectively.
The exclusion of prescription-compliant patients from the survey left nearly 5 million people unaccounted for.
According to Kolodny and Bohler, the answer is a simple yet complex misunderstanding. For far too long, doctors, policymakers, and the general public were led to believe that addiction arises from a moral flaw within the user and that one cannot get addicted while properly following their prescription.
“The main thing that has been misunderstood by the public and even by the federal government, which may help explain why the tool was broken, is that for many years, many people have been under the impression that the opioid crisis is a drug abuse problem,” Kolodny said. “This is a problem of people misbehaving and taking dangerous drugs because it feels good. It’s a narrative pushed by the drug companies. I think it’s one of the reasons why the survey, NSDUH, was asking patients prescribed opioids to skip the assessment for whether or not they could be addicted,” he added.
The data proves the notion that addiction cannot result from a prescription to be false. As Kolodny and Bohler point out in their NEJM perspective, more than half of the estimated 4.8 million Americans with OUD arising from a prescription do not misuse their medication.
The duo agree that the root of the problem lies in the overprescribing of opioids. America prescribes more of them than any other developed country. Even with prescription rates declining over the last 5 years, they worry that the issue may not be garnering enough attention in light of the surge of fentanyl and other illicit opioids.
“There has rightly been a lot of attention on deaths involving illicitly manufactured fentanyl because fentanyl is involved in the majority of opioid overdose deaths, and that’s been increasing ever since 2014 when fentanyl entered the illicit opioid supply,” Kolodny said. “Even though that should definitely be one of our focuses, it may have taken away focus on this decrease in opioid prescribing that’s been happening since 2012.”
Despite the lack of clarity surrounding opioid addiction, the situation has improved. The CDC (Centers for Disease Control) has introduced prescribing guidelines, and states have implemented prescription monitoring programs with mixed results. Additionally, the rates of those newly addicted have gone down. Kolodny and Bohler are cautiously optimistic.
“There is still a lot we need to understand about the epidemiology of OUD and how it has evolved over time,” Bohler said. “It’s interesting. I think that if we had made this survey change back in the early 2000s, we would have seen a sharp increase in opioid use disorder. Hopefully, we can keep more accurate data on the situation and see those decreases over time.” He added that with the dramatic increase in OUD, the government needs to ensure that everyone has access to treatment, even those taking medicines as prescribed.
Additionally, Kolodny emphasizes the need for accurate information. “To effectively tackle any disease epidemic, you need good information about how many people currently have the disease, how many people are getting the disease each year, and where they are.”
Hopefully, this survey change will improve not only accuracy but understanding as well.
Last updated: 1/14/2025