A relentless focus on reducing the number and dosage of opioid prescriptions is wreaking hell on people in intractable pain—while failing to treat addiction or reduce overdose deaths. And, as a new study questions whether prescription opioid availability overall is actually declining, chronic pain patients continue to be thrown into the maw of a policy juggernaut that shows no signs of changing in response to failure.
In Oregon, a state Medicaid committee is now determining whether all existing chronic pain patients on opioids should be forcibly tapered starting in 2020 because of concerns about "overdose and death"—and all new prescriptions be limited to 90 days, with few exceptions, mainly for people who are dying. In Tennessee and several other states, some 50,000 pain patients may be left in opioid withdrawal as a chain of pain clinics shuts down, following the introduction of new state laws restricting prescribing and the indictment of top management for Medicaid fraud.
As Congress and state legislatures continue to debate, and states, pharmacies, and insurers enact new policies that squeeze patients even more, hospitals are experiencing actual shortages due to federal regulatory cuts in supply quotas and manufacturing issues. Yet the New York Times reported last week that overdose deaths hit an all-time high of 72,000 in 2017. More than two-thirds of these deaths—some 49,000—included an opioid, typically a non-pharmaceutical fentanyl.
Meanwhile, a new study published in the BMJ suggests that all of this may not even be reducing the number of people exposed to opioids during medical care.
The Centers for Disease Control and Prevention, using a commercial database, had earlier found that the overall quantity of opioids prescribed (as measured via equivalent doses to morphine) peaked in 2010 and had dropped by nearly a fifth by 2015. Another commercial database study found a further 12 percent decline between 2016 and 2017 alone. Reports from pain patients across the country and the enactment of numerous new restrictions also suggest tightening supply.
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So why are the findings in the BMJ study so different? The researchers looked at how many individuals received opioids—not just the total number of prescriptions or doses distributed. They used a huge database, with records from 48 million people with either private insurance, Medicare Advantage for people over 65, or Medicare Advantage for younger people with disabilities. The records covered the period between 2007 and 2016.
The authors found that 14 percent of commercially insured people had been prescribed an opioid within the past year. That number was 26 percent for Medicare seniors and 52 percent for those with disability, which sounds high but is less surprising given that people granted permanent disability benefits tend to be seriously ill and undergo many painful procedures. However, rather than falling as expected throughout the time period, these percentages didn’t budge.
“The studies are not actually contradictory,” says Molly Jeffery, the scientific director of the Mayo Clinic’s Division of Emergency Medicine Research and lead author of the BMJ study. What’s happening instead, she says, is that several different things are being measured. The implications are frightening for people with chronic pain.
Essentially, while the overall amount of opioids being prescribed is indeed shrinking, the people with the most complex medical problems—often, meaning the most severe pain—who receive the highest doses, seem to be taking the biggest hit. Meanwhile, the least-needed prescriptions—like someone prescribed 60 Vicodin following surgery who leaves 50 of them in the medicine cabinet where curious teens can later get them—may have barely been affected.
As Stefan Kertesz, professor of preventive medicine at the University of Alabama School of Medicine, put it in a Twitter thread, “The headline I would offer is ‘Large, well-documented US opioid Rx reductions have not involved changing a long-term American habit of sloppy short-term prescriptions, but instead reflect changes in care for a small number of sick people on long-term prescriptions.’”
Jeffery says, “It’s certainly a story we hear anecdotally that people are being limited to lower doses or being abandoned by physicians and that would show up the way it did in our data.”
The agony of chronic pain patients, who have begun to organize against what they experience as a war on them, bears this out. “It’s pretty horrible,” says Kate Nicholson, a civil rights attorney, pain patient, and advocate. “I hear lots of reports of people losing the ability to work and function. They were able to be employed, and now they’re bedridden. I hear lots of problems with medical decline and an increasing number of anecdotal reports of suicide.”
The data supporting the idea that most of the cuts are coming from doctors forcibly tapering or simply refusing to continue to prescribe opioids to existing chronic pain patients is now piling up. For instance, the same CDC report that found a 19 percent reduction in overall prescribing also showed a 48 percent cut in high-dose prescribing.
And the BMJ study found that 62 percent of all opioids dispensed went to the 3 percent of people who took them long-term, amongst people with private health insurance. Among people with disabilities in Medicare Advantage, the 14 percent of people who took opioids chronically used 89 percent of the drugs in that group.
What we have here is what economics geeks will immediately recognize as a Pareto distribution—more popularly known as the 80/20 rule. It’s found in numerous populations, where a small minority accounts for the vast majority of consumption. For example, more than 80 percent of all alcohol sold is imbibed by the 20 percent of drinkers who drink heavily.
Reducing consumption in that group is a good thing when you’re talking about alcoholism. But when you’re talking about pain treatment, the biggest consumers may be exactly the people who should be taking these drugs.
This is not to say that there may not be many people who would benefit from reducing their dose or stopping entirely, and it’s not to say that high doses aren’t riskier for some patients. But research shows that the risk that appears to be associated with high doses is actually more strongly connected with the type of people who tend to take such doses—people with addiction and/or people with complex pain conditions and multiple psychiatric and physical problems. And there’s no data suggesting that forcing people to stop the medication improves anyone’s quality of life—while there is increasing evidence of harm.
“Pain clinics often see extremely vulnerable people and when the clinic closes, tons of people are left in extraordinary agony,” Kertesz says, “Some will die most assuredly. Unfortunately, opioid withdrawal itself can be lethal and the resulting distress can result in suicide or seeking illegal substances.”
While some studies suggest that voluntary tapers may help patients and improve lives, none have demonstrated that forced tapers are either safe or effective. We already know that when people on opioid maintenance treatment for addiction stop their medication—either by choice or otherwise—the death rate is nearly doubled.
To a government whose focus is on cutting a specific number of doses, chopping the head off a Pareto distribution is tempting: You will see rapid and large reductions by targeting the small number of consumers who use most of the product.
But if the idea is to reduce risk of new addiction, which studies suggest largely begins when young people misuse drugs that were prescribed to others or when they get large prescriptions of their own, this is exactly the opposite of what should be done.
Chronic pain patients on high doses are already exposed to opioids; it’s acute pain patients who may not have been. And contrary to popular belief, once someone is already taking opioids long term for chronic pain, their risk of addiction doesn’t continue to rise. That’s because people either like the “high” or they don’t—they rarely suddenly shift from hating the numbness and nausea to finding it euphoric. They either immediately take to an opioid rapidly, they tolerate the drug because it relieves pain, or they stop. (Ironically, drop out due to side effects is a big problem in clinical trials of opioids).
For instance, a 2012 study gave 242 adult twins a shot of a pharmaceutical fentanyl and asked them about the experience (I don’t know how this passed an ethics board, either). It found that only about 29 percent really liked it: The rest said the experience was either mixed, neutral, or, for 16 percent, outright unpleasant. Prior research has shown that initial drug-liking predicts misuse: Why would you pursue something that you don’t enjoy? During active addiction, liking sometimes declines, but if it’s not there early on, addiction rarely occurs.
Of course, some chronic pain patients on high doses may actually be people with addiction who are selling some of their drugs to support themselves—but this is obviously not the case among the many high-dose patients with documented physical findings and years-long histories of appropriate medical use. Outside of the few remaining pill mills that sell prescriptions for cash, it is now clearly extremely difficult to get opioid doses from the medical system that are outside the guidelines set in 2016 by the CDC. And cutting off addicted patients doesn’t cure them either, it just increases their risk of overdosing on street drugs.
“It might be well-intended but the combination of all of our policies has convinced many physicians and health systems that a subset of their patients are liabilities," Kertesz says. "And what do you do with liabilities? You contain or eliminate them.”
That seems to be exactly what is happening in Oregon: A 14-member committee that includes a chiropractor, three acupuncturists, and just one pain patient representative (and, apparently no one specializing in addiction) is considering forcibly tapering all Medicaid patients taking opioids for chronic pain. This is not congruent with the CDC Guidelines—which recognize that some patients in chronic pain will continue to require opioids—nor does it have any scientific basis.
It’s essentially an experiment by a state health department in one-size-fits-all medicine, carried out on the poorest and sickest patients without consent—one that really would never pass an ethics board if proposed by actual scientists. Patient protests do seem to have caught the panel’s attention and slowed the momentum of the proposal—but it has not been dropped.
So long as we remain laser-focused on cutting prescription numbers rather than helping people with pain and with addiction, the toll of death, disability, and agony will continue to rise. Almost 50,000 a year and counting.
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