A crisis of opioids and the limits of prescription control: United States

Abstract

A rise in addiction and overdose deaths involving opioids in the United States has spurred a series of initiatives focused on reducing opioid risks, including several related to prescription of opioids in care of pain. Policy analytical scholarship provides a conceptual framework to assist in understanding this response. Prior to 2011, a 'policy monopoly' of regulators and pharmaceutical manufacturers allowed and encouraged high levels of opioid prescribing. This permissive policy fell apart in the face of adverse outcomes brought to public attention by an 'advocacy coalition' consisting of officials, thought leaders, journalists and interest groups who shared common beliefs. This coalition has generated a more cautious prescribing regimen that has incentivized involuntary termination of opioids in otherwise stable patients, with resultant reports of harm. Its emphasis on dose reduction, regardless of outcomes, mirrors in some ways the prior focus on minimizing pain scores, regardless of outcomes. Central to the present analysis is that policies cannot be comprehensively rational; rather, they emerge from a range of actors and agencies constrained in their ability to assimilate complex data, evaluate the data objectively and to command necessary resources in an iterative, rapid response fashion. The imbalance between strong prescription control and weak pain and addiction treatment expansion exemplifies the policy scholar's notion of 'bounded rationality'. Results have been suboptimum: opioid prescriptions have fallen, but harms to pain patients and overdose deaths have risen. US policymakers could revise the course through a more thoroughgoing engagement with patients, families and communities now coping with both pain and addiction.

Opioid deaths in Ontario, Canada

“…The number of deaths from overdose involving prescription opioids in the US has slowed its rise against a backdrop of declining national opioid prescribing rates 1. However, fatalities involving only prescribed opioids such as oxycodone remain unchanged at approximately 10 000 yearly since 2011 4. As frontline clinicians and researchers, we suggest that policies focused heavily on curbing prescriptions—when not accompanied by comprehensive approaches to tackle both addiction and pain—invite multiple deleterious consequences.…”

“…Among 42 249 US opioid related deaths from overdose in 2016, 40% included a potentially prescribed opioid,1 and one third of these also included heroin or fentanyl 4. As uncritical opioid prescribing is understood to have spurred this crisis, policy makers have embraced interventions to reduce prescribing, including clinical guidelines, quality metrics, prescription drug monitoring programmes, payment barriers, opioid dose and duration limits, and the development of crush resistant opioid formulations 456. Some similar responses have emerged in Canada 7…”

“…Firstly, reductions in prescription opioid supply are associated with a shift in use to illicit and often more potent opioids, such as heroin and fentanyl 45. After opioid prescribing rates peaked in the US in 2010, they subsequently declined and were accompanied by a levelling of deaths from overdose involving prescription opioids 1.…”

“…Although recent clinical guidelines encourage non-opioid alternatives for chronic pain, many patients nonetheless rely on opioids for effective pain management 46. Reductions among long term recipients seem to account for declining opioid prescriptions in the US, but the percentage of Americans receiving shorter courses remains roughly constant 11.…”

Prescribers or Multidisciplinarians? An Evaluation of Brief Education for General Practitioners on Chronic Pain Management

“…Pharmaceutical manufacturers underwrote pain advocacy organisations, medical societies, medical education and guideline development to influence prescribing culture (Davis & Carr 2016; Organisation for Economic Cooperation and Development [OECD] 2019). Continuing medical education (CME) for CP claimed that 'judicious' opioid prescribing strategies could prevent prescription opioid analgesic (POA) patients from being transformed into addicts (Dyer 2019;Kertesz & Gordon 2018;Kuehn 2017;Madras 2018;OECD 2019). A composite model of CP care soon emerged, highlighting specialist multidisciplinary and interventional care combined with opioids titrated to symptoms (Sullivan & Ballantyne 2016).…”