Language and the opioid debate

This field runs on vocabulary that carries more freight than it can support. Some notes on terms we use carefully, or do not use.

“Pain refugee”

Our own founding document uses it. It is journalistic rather than clinical, and it returns no results in the medical literature. We use it in quotation marks with attribution, or say what we mean: patients losing access to opioid therapy. The plain version is bad enough — 40.7% of audited primary care clinics said they would not prescribe to a patient already on long-term opioids — and a borrowed term invites the reader to discount the whole claim.

“Opioid epidemic” as one thing

There have been at least three overlapping crises with different populations, drivers and remedies: prescription-driven harm peaking around 2010, a heroin phase, and an illicitly manufactured fentanyl phase that now accounts for nearly seven in ten overdose deaths. A policy designed for the first, applied during the third, is the story of the last decade.

“Dependence” and “addiction”

Physical dependence — tolerance and withdrawal on cessation — is an expected pharmacological consequence of sustained opioid therapy and occurs in patients taking medication exactly as prescribed. Opioid use disorder is a clinical diagnosis with defined criteria involving loss of control and continued use despite harm. Collapsing them makes every long-term patient look like a case, and it is the confusion that does the most damage in a clinic.

“Deaths of despair”

A powerful phrase for a contested mechanism. The mortality trends are not disputed. Whether economic and social distress explains them is: analyses range from “less than a tenth, quite possibly zero” to something like 9–29% of the rise among prime-age white Americans, and critics note that drug deaths follow a period pattern consistent with a changing supply rather than the cohort pattern a distress explanation predicts.

“Doctor shopping”

It sounds like a described behavior and functions as an accusation. The best available analysis identified 0.7% of purchasers averaging 32 prescriptions from 10 prescribers — and stated that “very few of these patients can be classified with certainty as diverting drugs for nonmedical purposes.” Some are; some are people who lost a prescriber and are looking for another.

Potency multiples

“A hundred times more potent than morphine” is a phrase that does real work in public communication and needs its hedge kept on. The CDC and DEA sources that publish these figures say they are estimates, and that analog potency has not been evaluated in humans. We reproduce the hedge, and we do not blend a ratio from one source with a ratio from another to make a bigger number.

More: what is not established.