Simple Solutions or Real Results
In a previous column (April 2018), I wrote about the genesis of the opioid crisis. While possibly informative, it provided little information about potential solutions currently being offered and identifying those whose major effect is more to make people feel good about doing something, whether effective or not. One of the points I made in the column was that the genesis of the current opioid crisis and its solutions are multifactorial. However, we continue to look for simple solutions while about 115 people die from opioid overdoses daily (NIDA, 2018b).
The US has 4.6 percent of the world’s population, but US residents consume 99 percent of all the hydrocodone and 81 percent of all the oxycodone prescribed worldwide (Compton, 2017). One effort to reduce opioid addiction and overdose is to legislate a limit of three days of opioids for acute pain, with a prescriber able to justify up to seven days. The thought is that if we limit the amount of opioids prescribed, we can reduce overdoses. Let us look a little bit more carefully at this.
Since many people begin using opioids originally prescribed for someone else, we can assume that fewer prescription doses available might reduce the availability of prescription opioids to those people for whom it was not prescribed. But the reality is that any effect this might have would be small. We already see what happens when this occurs: when individuals cannot obtain prescription opioids because of increased price and lesser availability, they turn to buying prescription and illicit drugs like heroin (with or without fentanyl) on the street. Fentanyl overdoses now surpass prescription opioids as the most common cause of opioid overdoses in the US (NIDA, 2018a).
Prescribing opioids is now limited to the treatment of acute pain, which is described as usually occurring suddenly and with a known cause like an injury, surgery, or infection. For example, pain from a wisdom tooth extraction, an outpatient medical procedure, or a broken arm after a car crash would be classified as known causes. Acute pain normally resolves as the body heals, but chronic pain, on the other hand, can last weeks or months past the normal time of healing (CDC, 2018).
I have spoken with two orthopedic surgeons who claim all the paperwork surrounding these three- and seven-day limits is overwhelming, and when the physicians’ time is already spent with nonproductive activities such as prior authorization and justifying their decisions to payers, the time for justifying the three- or seven-day opioid prescription is untenable. Both surgeons stated that as a result of the extensive surgery they perform, it is unreasonable to assume that none of their patients are likely to require more than a three-day supply of opioids, and some even more than a seven-day prescription.
Since opioids are schedule II drugs (DEA, n.d.), no refills are permitted. Should patients actually require opioids beyond the seven days, they would have to return to the physician, receive a hard copy of the prescription, and return to the filling pharmacy. These patients, by the very nature of the short-term pain resulting from their surgery, are least able to do so.
Prescription Drug Monitoring Programs (PDMPs)
Prescription drug monitoring programs (PDMPs) are statewide electronic databases that track all controlled substance prescriptions. Authorized users can access prescription data such as medications dispensed and doses. PDMPs improve patient safety by allowing clinicians to
- Identify patients who are obtaining opioids from multiple providers
- Calculate the total amount of opioids prescribed per day in morphine milligram equivalents (MME)
- Identify patients who are being prescribed other substances that may increase risk of opioid overdose (e.g., benzodiazepines)
However, because PDMPs are state-specific and not all states have PDMPs, it cannot provide information about controlled substances prescribed across state lines. An even greater problem is that they are not universally used by prescribers. In a survey in of emergency room physicians in Florida, on 88 completed surveys—62 percent attendings, 14 percent residents, and 21 percent extenders—it was found that only half used the PDMP only if they suspected patients would misuse the medication, 21 percent reported they rarely used the system, and only 3 percent reported using it every time they prescribed opioids (Young, Tyndall, & Cottler, 2017).
Furthermore, while opioid overprescribing is the target, the majority of opioid overdoses are caused by heroin and fentanyl. While fentanyl is a schedule II drug approved for the treatment of pain, most of the fentanyl involved in overdoses is illicitly manufactured in Mexico and China.
Further complicating the situation is that people on long-term opioid treatment for chronic pain—patients who are stable and do not meet the diagnostic criteria for an opioid use disorder, though they likely are physically dependent—will have to undergo nonconsensual tapers since opioid prescribing is now limited to acute pain. These patients tend to be older (72 percent were aged forty-five years of age or older and 29 percent were 65 or older; Gomes, Tadrous, Mamdani, Patterson, & Jurrlink, 2018), but the burden of opioid-related death falls disproportionately on younger adults (Frank et al., 2017).
Another strategy is to avoid higher risk formulations, but the data hints that the return on investment by prescribing extended-release or long-acting formulations may be low (Hwang et al., 2018).
There is a drug available that can reverse most opioid overdoses: naloxone. Even though it is an evidence-based practice, there are still groups that do not make it available because of cost or the belief that they will not run into an overdose situation. In my training workshops, I still find addiction treatment providers who do not routinely keep it on hand.
We now have available to us evidence-based drugs that will reduce or eliminate opioid craving in those addicted to opioids and blunt the response to opioids if they use. While methadone was approved in 1947 (IOM, 1995), it was the only antiaddiction drug for the treatment of opioid dependence for many years until the approval of buprenorphine in its two best known forms, Subutex and Suboxone, the latter of which is buprenorphine plus naloxone. Originally, physicians were restricted to a thirty-patient limit the first year and one-hundred patients the second year. Physicians permitted to prescribe the drug had to go through an eight-hour course. Because of unmet need, the limit has been raised to 275 patients via the Cures Act (Sarpatwari & Kesselheim, 2015) and can also be prescribed by physician’s assistants and nurse practitioners after taking a twenty-four-hour course.
There are two interesting phenomena. The first is that of those physicians approved to prescribe (i.e., those who have a buprenorphine waiver), only less than half are actually prescribing (Thomas et al., 2017). This is further complicated by the reality that there are areas of the country, usually rural, where there are no buprenorphine-waivered prescribers. Interestingly, medical providers can prescribe buprenorphine only after completing an eight-hour training course and obtaining a waiver, while those same physicians can prescribe any schedule II drugs, including opioids, which are considered one of the causes of our current opioid crisis, without any special training.
So what are the solutions? Each of the “solutions” offered may have some benefit (along with some harm), but none is the answer to the opioid crisis. For the problem of an inadequate number of buprenorphine-waivered physicians, a long-term solution may be better medical school training and a short-term solution may be incentivizing more physicians to become waivered and having those who are waivered actually prescribe. More education should also be provided to the general public, not just headlines about the number of people dying from opioid overdoses. Reconsideration should be given to forced tapers of those patients who are stable on long-term use of opioids and do not meet criteria for an opioid use disorder.
For a significant part of the population, I believe that we are looking in the wrong place for solutions. Rather than just restricting availability and use, we should be considering the underlying issues that are much of the seedbed for the opioid crisis: unemployment and substandard living conditions including homelessness and lack of transportation and childcare. Should we do this, we will also reduce addiction in general and make a positive contribution to reducing crime.
Centers for Disease Control and Prevention (CDC). (2018). Opioids for acute pain – what you need to know. Retrieved from https://www.cdc.gov/drugoverdose/pdf/patients/Opioids-for-Acute-Pain-a.pdf
Compton, W. M. (2017). Research on the use and misuse of fentanyl and other synthetic opioids. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/research-use-misuse-fentanyl-other-synthetic-opioids
Drug Enforcement Administration (DEA). (n.d.). Drug scheduling. Retrieved from https://www.dea.gov/drug-scheduling
Frank, J. W., Lovejoy, T. I., Becker, W. C., Morasco, B. J., Koenig, C. J., Hoffecker, L., . . . Krebs, E. E. (2017). Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: A systematic review. Annals of Internal Medicine, 167(3), 181–91.
Gomes, T., Tadrous, M., Mamdani, M. M., Patterson, J. M., & Jurrlink, D. N. (2018). The burden of opioid-related mortality in the United States. JAMA Network Open, 1(2), e180217.
Hwang, C. S., Kang, E. M., Ding, Y., Ocran-Appiah, J., McAninch, J. K., Staffa, J. A., . . . Meyer, T. E. (2018). Patterns of immediate-release and extended-release opioid analgesic use in the management of chronic pain, 2003–2014. JAMA Network Open, 1(2), e180216.
Institute of Medicine (IOM). (1995). Federal regulation of methadone treatment. Washington, DC: National Academies Press.
National Institute on Drug Abuse (NIDA). (2018a). Nearly half of opioid-related overdose deaths involve fentanyl. Retrieved from https://www.drugabuse.gov/news-events/news-releases/2018/05/nearly-half-opioid-related-overdose-deaths-involve-fentanyl
National Institute on Drug Abuse (NIDA). (2018b). Opioid overdose crisis. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
Sarpatwari, A., & Kesselheim, A. S. (2015). The 21st Century Cures Act: Opportunities and challenges. Clinical Pharmacology and Therapeutics, 98(6), 575–7.
Thomas, C. P., Doyle, E., Kreiner, P. W., Jones, C. M., Dubenitz, J., Horan, A., & Stein, B. D. (2017). Prescribing patterns of buprenorphine-waivered physicians. Drug and Alcohol Dependence, 181, 213–8.
Young, H. W., II, Tyndall, J. A., & Cottler, L. B. (2017). Current utilization and perceptions prescription drug monitoring programs among emergency medicine providers in Florida. International Journal of Emergency Medicine, 10(1), 16.