The first study is a randomized trial comparing one year outcomes for people in the VA with significant back, knee or hip pain symptoms. One arm received standard opioid therapy while the other arm of the trial received non-opioid pain medication.
Question For patients with moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use, does opioid medication compared with nonopioid medication result in better pain-related function?
Findings In this randomized clinical trial that included 240 patients, the use of opioid vs nonopioid medication therapy did not result in significantly better pain-related function over 12 months (3.4 vs 3.3 points on an 11-point scale at 12 months, respectively).
A year out, there was no functional, clinical or statistical difference in the treatment arms.
There is a growing body of evidence that opioids are not particulary better pain killers in some common situations than less dangerous alternatives. This is an important but not an amazingly surprising result in this paper. Serious caveats need to be put into place about generalizabilibility but for the relevant population, this is more of a confirmation than a shocking result.
Now the second paper looks at the impact of Naxolone, an overdose counter-acting drug and asks if widespread availability of the drug changes mortality rates?
Naloxone access may unintentionally increase opioid abuse through two channels: (1) saving the lives of active drug users, who survive to continue abusing opioids, and (2) reducing the risk of death per use, thereby making riskier opioid use more appealing…. We exploit the staggered timing of Naloxone access laws to estimate the total effects of these laws. We find that broadening Naloxone access led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality….We also find suggestive evidence that broadening Naloxone access increased the use of fentanyl, a particularly potent opioid.
This is a big deal as there has been a massive public policy push Naxolone/Narcan out into the community as far and as quickly as possible. The theory of change is that fast and broad access to counter-OD drugs will save lives on net by reversing ODs. And from there, a logic model can be constructed where the OD reversal can be an entry point to treatment or diversion services.
That is not the story that the evidence in this paper is showing.
It is showing that in areas with presumably high density of Narcan carriers, the cost of overdosing borne by an addict has gone down and thus riskier behavior leading to more overdoses increases. This is very similar to the economic logic of increased risk taking with the proliferation of better anti-HIV medication or more macabre that the way to decrease auto accidents is to put a big knife in the steering column of every car. The last fifty pages of the paper looks at a wide variety of robustness checks and sensitivity analysis. The methodologists that I trust are telling me that the methods are solid and the evidence base is strong.
I think the policy implication is that if there is one last dollar available to spend on opioids, it would be better spent on preventing people from being addicted either by limiting initial exposure to opioids upstream or by funding more and better addiction treatments.
Finally, this is a major piece of new information. It is making me move my priors but it is still conflicted with other recent studies (Rees et al, 2017)(3) and there may be a problem of abstracting the drug market and addiction details too far. We need good evidence to inform effective policy. This is strong but not completely conclusive evidence. We should think hard about the value of these laws versus other policy options even as we seek more evidence as to what works.
(1) Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis PainThe SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872–882. doi:10.1001/jama.2018.0899
(2) Doleac, Jennifer L. and Mukherjee, Anita, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime (March 6, 2018). Available at SSRN: https://ssrn.com/abstract=3135264
(3) Rees, Daniel I., Joseph J. Sabia, Laura M Argys, Joshua Latshaw, and Dhaval Dave.
2017. “With a little help from my friends: The effects of Naloxone access and Good Samaritan
laws on opioid-related deaths.” NBER Working Paper No. 23171.