By Sarah Wakeman, MD
September 18, 2018
In the face of a growing crisis of overdose deaths, predominantly driven by opioid-related fatalities, there has been a tremendous focus on decreasing the prescribing of opioid pain relievers. The reason for the drive to reduce prescribing is pretty simple; when we looked at the onset of the current crisis of opioid-related deaths, it was strongly correlated with rising rates of prescription opioids and treatment admissions for prescription opioid use disorder. As policy makers and clinicians looked at this correlation, a simplistic narrative emerged. If increased prescribing rates “caused” the overdose crisis, then reducing prescribing should curtail deaths. Unfortunately, as the saying goes, “For every complex problem there is an answer that is clear, simple and wrong.” As prescribing rates have decreased over the past five years, we have seen opioid-related deaths increase significantly.
Supply- vs Demand-Focused Solution
It is unarguable that the changes in prescribing practices related to opioids, which began in the 1990’s, were dramatic, not based on sound evidence, and associated with harm. While some patients who were vulnerable to developing opioid use disorder were at risk from increased exposure through direct prescribing, an additional, and likely larger driver, was the flood of excess pills into the community and an increase in nonmedical use of opioid pain relievers by people who got them from friends or family members. As rates of nonmedical and medical use of prescription opioids ballooned, we saw the demand side of the opioid equation swell. Yet, rather than addressing this through demand-focused solutions, efforts aimed at reducing opioid prescribing focus solely on the supply. When supply is restricted and demand is unaddressed, people using prescription opioids predictably transition to unregulated and far more dangerous opioids—namely heroin and illicitly manufactured fentanyl. The end result of this is a rapid increase in deaths.
Intent of the 2016 CDC Guidelines
While some policies have directly limited access to prescription opioids by setting dose or duration limits, other approaches have been focused on providing guidelines for prescribers. The most recognized of these were the CDC opioid prescribing guidelines which came out in 2016. The intent of these guidelines was to offer a framework for thinking about how to safely prescribe opioids based on the best, albeit limited, evidence which exists. These guidelines urged caution in initiating chronic opioid therapy for nonmalignant pain, especially at high doses exceeding a threshold of 90 milligrams of morphine equivalents. Recognizing that chronic opioid therapy often begins with the treatment of acute pain, the guidelines recommend using the lowest dose and least amount of opioids necessary. Specifically, the guidelines suggest that three days of opioids for most acute pain conditions will be enough, and an initial prescription should not exceed seven days. The guidelines also urge clinicians to assess for opioid use disorder and when that diagnosis is identified, to ensure that patients are treated with evidence-based interventions, like medication treatment with buprenorphine or methadone. Importantly, the guidelines encourage shared decision making and remind clinicians that they should involve patients in all decisions including whether to start or continue opioid therapy.
Misapplication of the Guidelines
What the guidelines don’t recommend is involuntarily discontinuing or tapering opioids or discharging patients from care. Yet unfortunately, there are examples of the guidelines being misapplied, resulting in the same actions which are explicitly discouraged in the actual text. The guidelines specifically recommend that patients should never be discharged from care because of an unexpected finding in the prescription drug monitoring program, in toxicology testing, or because a patient has a substance use disorder. In any of these circumstances discharging a patient would be an example of patient abandonment and would be likely to lead to increased harm. In addition, the guidelines acknowledge the complexity of managing established patients already taking high dosages of opioids. In those cases, the guidelines encourage continual re-evaluation of the risks and benefits of treatment and offering patients voluntary, slow tapers. For patients who remain on high opioid dosages, rather than recommending forced dose reductions, the guidelines suggest establishing goals with the patient for continued opioid therapy.
Harm to Patients
These recommendations are far from the black-and-white policies being enacted in some states or by some payers. Insurance companies, and even some states, are either considering or implementing 90 mg morphine equivalent dose ceilings for opioid therapy. These sorts of policies demand across-the-board tapering of people on chronic opioid therapy absent patient consent or buy-in. In addition, a growing climate of fear around opioid prescribing has led to some physicians to opt out of prescribing altogether, resulting in the exact sort of patient abandonment the guidelines urge against. Lastly, physicians are woefully unprepared to diagnose or treat substance use disorder. Without the necessary toolkit to manage the chronic illness of addiction, all too often patients are not offered lifesaving treatment.
Addressing the overdose crisis is critically important. Doing so effectively will require nuanced approaches and a massive increase in resources and attention focused on reducing demand through effective treatment and harm reduction. Thoughtful prescribing is absolutely important, but alone, is unlikely to reduce opioid-related deaths. Misguided changes to prescribing however, including rigid policies limiting access across the board to prescribed opioids, not only won’t help, but very likely will harm patients with chronic pain and those with opioid use disorder.
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Dr. Sarah Wakeman is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital (MGH), co-chair of the Mass General Opioid Task Force, and clinical lead for the Partners Healthcare Substance Use Disorder Initiative. Dr. Wakeman is also an assistant professor in medicine at Harvard Medical School and course director for Understanding Addiction, part of a free online CME program from Harvard Medical School to help train medical providers in best practices for working with OUD patients. Twitter
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