“One year ago, we pledged to cut nationwide opioid prescriptions by one-third. Already during my time in office, we have reduced the total amount of opioid prescribed by 34 percent. That’s a pretty amazing number.”
— President Trump, speaking at a drug abuse summit in Atlanta, April 24, 2019
During a recent speech on the administration’s efforts to ease the opioid crisis, President Trump asserted that his administration had already achieved its goal of cutting nationwide opioid prescriptions by one-third.
Trump’s original goal, declared on March 19, 2018, was to reach this target within three years. So obviously we were curious about whether the claim about reaching the milestone within a year was valid.
Here’s what we found out. It’s an interesting tale of how data generated in the administration loses its nuance the closer it gets to the president’s lips.
The president, after noting the goal to cut prescriptions by one-third, framed this achievement in personal terms: “Already during my time in office, we have reduced the total amount of opioid prescribed by 34 percent.”
But a White House fact sheet, issued the same day, pitched this less as an administration achievement and mentioned no goal, though it kept the time period: “In the first two years of the Administration, we saw a 34 percent decrease in the total amount of opioids prescribed.”
Finally, the agency that generated the statistic, the Department of Health and Human Services, was even more careful in its own fact sheet. It cast the percentage decline as tentative and requiring additional research: “From the President’s inauguration in January 2017 through February 2019, initial market data suggests that the total amount of opioids being prescribed monthly has dropped by 34 percent. While we need more data to confirm this snapshot, it shows we may have succeeded in meeting this [three-year] goal already.”
As you can see, it is a bit like a game of telephone, with the accuracy of the statement getting diminished with each retelling. Our eyebrows went up when we saw that the statistic apparently was based on monthly data points.
An HHS spokesman provided the numbers. The data reflected the nationwide prescribing of opioids measured in MMEs (morphine milligram equivalents — a measure of opioid amount/intensity), drawn from the IQVIA National Prescription Audit, a database for retail pharmacy and mail pharmacy channels only.
January 2017: 13,627,002,271
February 2019: 8,967,556,436
(Technical note: These numbers are not comparable to prescription data on the Centers for Disease Control and Prevention’s website because the IQVIA data does not include controlled long-term care environments — nursing homes and skilled-nursing facilities — or prescriptions for buprenorphine, which is primarily used for patients in treatment.)
That’s certainly a decline of 34 percent. Experts said that using an MME measure is probably the most useful (though a prescribing rate rather than raw numbers might be more informative).
But there are several problems.
First, two monthly data points are not especially useful to measure long-term progress. We were able to review all of the monthly data, though not publish it. February appears to experience big drops — it’s the shortest month of the year — and that happens to be the end point. A three-month rolling average shows a decline, though not as stark as 34 percent.
“Measuring the decrease using monthly prescriptions is absolutely legitimate,” said an HHS spokesman. “We focus on leading indicators to help us better and more quickly respond to this crisis, rather than waiting a year to evaluate what we are doing.”
But, more important, time did not start with the Trump administration. Opioid prescriptions have been declining for years, having reached a peak in 2010 or 2012, depending on what data set you use. The declines especially began to accelerate after the CDC in March 2016 issued new guidelines for prescribing opioids for chronic pain — 10 months before Trump took the oath of office.
HHS has published quarterly fiscal-year data for MMEs dispensed since the second quarter of fiscal year 2013. It shows that decline really sped up in early 2016, about the time the CDC guidelines were issued. The number of MMEs dispensed has fallen about 30 percent from the second quarter of the 2016 fiscal year (January-March) to the end of 2018.
Just looking at second quarter of fiscal year 2017 through the end of fiscal year 2018 — essentially Trump’s first two years — the decline amounts to 22 percent, from 41 billion MMEs a quarter to 32 billion MMEs.
Finally, we would argue that the president’s pledge was to reduce opioids by one-third in three years dating from his speech in March 2018, because he said: “We’re going to cut nationwide opioid prescriptions by one-third over the next three years.” We reviewed administration briefings after the speech and news coverage and can find no indication it was anything other than a three-year goal starting in 2018. Reporters identified 2021 as the end date.
That would mean at least a reduction of 12 billion MMEs — from 35 billion MMEs a quarter at the time of the speech to 23 billion. Backdating to the start of Trump’s presidency seems to be moving the goal posts, as the decline in MMEs on a monthly scale since Trump’s speech is about 20 percent, not 34 percent.
Asked whether progress should be measured from March 2018, the HHS spokesman replied: “While the March 2018 date marks the release of ‘President Donald J. Trump’s Initiative to Stop Opioid Abuse and Reduce Drug Supply and Demand,’ efforts to combat the opioid crisis were already well underway. The opioid epidemic has been a top priority for the Trump Administration since taking office in January 2017.”
Experts in the field said the decline in prescriptions is less impressive than it sounds because the trend significantly predates the Trump administration — and because the more important metric is reducing overdoses.
“By itself, the number of prescriptions is not a public-health outcome,” said Joshua Sharfstein, vice dean for public health practice and community engagement at the Bloomberg School of Public Health at Johns Hopkins University. “You can’t say ‘mission accomplished’ because the number of prescriptions has gone down.”
Sharfstein noted that even as prescriptions have begun to shrink in recent years, overdoses have soared. (Recent 12-month rolling provisional CDC data touted by the administration indicates the overdose increase may have plateaued and even begun to decline.) The reasons for this disconnection are in dispute among medical professionals, with some arguing that cutting back on opioid prescriptions may have led some people to switch to heroin or synthetic opioids. Other experts say the data does not support that analysis.
In any case, they said, Trump is wrong to suggest that this is an administration success story, even if the administration has taken steps such as pushing for a reduction in opioid manufacturing.
“I don’t think the Trump administration deserves credit for the more cautious prescribing of opioids,” said Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. “The reduction in prescriptions began in 2012 and improved a bit in 2016. Everything we are seeing is trending in the right direction, but no other country prescribes as much as we do.”
The Pinocchio Test
There are several problems with the way the president framed this statistic. He should have indicated the data was tentative, as HHS responsibly did, but instead he suggested that a goal had already been achieved. (As we noted, the goal posts also appear to have been moved.) Moreover, he once again took credit for a trend that started in the Obama administration in part because of actions taken under that administration.
The president earns Three Pinocchios.
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