Government Limiting Physician’s Patient Opioid Treatment


As the number of deaths from opioid overdoses continues to climb in the U.S., the administration is considering legislation aimed at reducing the number of prescriptions being written for the painkillers.

On average, overdoses of prescription opioids kill about 46 Americans a day, according to the Centers for Disease Control and Prevention. That number has continued to rise despite a decline in recent years from a 2012 peak in the number of retail opioid prescriptions written in the U.S.

More than half of the states in the country already have passed laws governing how long patients can get opioids or how strong a daily dose can be, among other restrictions. On the federal level, several bills have been introduced that aim to limit opioid use, including a proposal to limit first-time opioid prescriptions to three days, but none of the legislation has yet come to a vote.

Some people say legal limits aren't the best way to tackle the problem of over prescription. They worry that rules that limit physicians' ability to treat each patient as they see fit end up depriving many patients of the pain relief they need.

Richard S. Larson, a professor at the Univ. New Mexico School of Medicine argues that strict government regulation is the only way to significantly reduce the prescription of opioids. A professor of anesthesiology at the Mayo Clinic counters that legislated limits on prescriptions can do more harm than good.

Prescription opioids are a major contributor to the epidemic of opioid addiction and overdose deaths afflicting the U.S. The Centers for Disease Control and Prevention estimates that over 40% of opioid-related deaths involve a prescription opioid.

While many observers have noted the need to limit the aggressive marketing practices of drug makers and lax controls on the distribution of opioids, they sometimes overlook another serious issue: the overprescribing of legal opioid drugs by physicians, dentists and other health-care providers. Without strict government regulation, that problem won't be solved.

Three personal experiences in the past two years have emphasized this point. About 18 months ago, a friend had his wisdom teeth extracted. Without consultation with the dentist, he received a prescription, before the extraction, for three weeks of the opioid hydrocodone. Similarly, I had outpatient surgery, and later a periodontal procedure, for which I also received prescriptions for hydrocodone, before the procedures and without consultation with the providers.

In all three cases, the prescriptions were NOT filled. A few days of ibuprofen and Tylenol were more than adequate for our pain management. But this experience isn't unique: Over 80% of patients receive opioids after low-risk outpatient surgeries—and too many of those prescriptions are filled.

Research shows that the seemingly compassionate use of opioids to minimize pain in minor medical procedures like these ultimately increases the number of chronic opioid users and overdoses. Once dependent, many users resort to cheaper illicit opioids, such as heroin and fentanyl.

More Needs to be Done

The challenge is to limit the number of new addictions without denying treatment to patients who suffer from debilitating chronic pain in situations like cancer or the nerve pain that can be caused by spinal-cord injuries, multiple sclerosis or other conditions.

For several years now, education and training of health-care providers to improve prescribing habits has been required, and it hasn't had enough of an impact. Moreover, the CDC could find no evidence demonstrating broad benefit from strategies such as health-care providers assessing the possible risk of each patient misusing prescription opioids, or the opioid management plans some providers practice, or testing the urine of patients to determine if they're abusing opioids. Efforts on the part of individual health-care systems are inconsistent, and an external incentive is needed to motivate systems that have no such programs.

Although the steps already being taken are important, they aren't enough. To get significant results, they need to be augmented by the creation of regulations that encourage intelligent, safer prescribing practices.

A Three-day Limit

I believe—and these are my opinions and not those of my institution—that two key steps should be adopted immediately to limit overprescribing of opioids.

First, restrict prescribing practices in key situations. Specifically, we should limit outpatient prescriptions for acute pain (as opposed to chronic pain) to three days and prohibit outpatient prescriptions to adolescents. Use of narcotic painkillers before high-school graduation strongly predicts later opioid misuse, as well as heroin use. Also require the lowest effective dose in the form of immediate-release tablets, which cut the risk of dependency.

To allow for opioid use when it's truly needed, these requirements could be modified after consultation with a pain specialist. But payments to health-care providers by the Centers for Medicare and Medicaid Services should be reduced or eliminated when opioids are prescribed in violation of these standards and others, including those of the CDC.

Second, health-care systems should be required to create opioid stewardship programs that monitor the prescribing habits of providers, with the results reported to state medical and dental licensing boards. Earlier experience with the standardization of antibiotic prescribing shows that such a system can be effective. Providers would risk losing their license if they prescribe inappropriately.

Improving access to a wider range of options for pain management, as some suggest, by boosting insurance coverage for alternative treatments is a step that should be taken. But it won't make a significant difference in over prescription of opioids, because physician and dentist behavior are too entrenched.

The only thing that will change prescribing behavior significantly is a new set of rules that are strictly enforced.

Source: WSJ-Richard S. Larsonour text here ...

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Sunday, 24 March 2019