Primary Care Corner with Geoffrey Modest MD: Decreasing opiate prescriptions

by Dr Geoffrey Modest

 

Some (likely) good news about prescription opioids from the CDC (see https://www.cdc.gov/mmwr/volumes/66/wr/mm6626a4.htm?s_cid=mm6626a4_w ).

 

— Opioid prescribing in the United States between 2006 and 2015 peaked in 2010 at 782 morphine milligrams equivalents (MME) per capita then decreased annually to 640 MME per capita in 2015

— there was pretty striking variation by US county, from 203 MME in the lowest quartile to 1319 MME in the highest; multivariate adjustment for many risk factors for opiate prescribing (more non-Hispanic white population, higher rates of uninsured and Medicaid, lower educational level, higher unemployment, living outside the urban areas, more dentists and physicians per capita, more diabetes/arthritis/disability, higher suicide rates) only accounted for 32% of the variation in prescribing [ie, there was much more to it than the expected risk factors… ?perhaps issues like the specific medical cultures in the different areas? other major differences in accident rates, which might reflect very different occupational exposures in different areas??….]

— Prescription rates also increased from 72.4 to 81.2 prescriptions per 100 persons between 2006 and 2010, then declined to 70.6 per 100 persons from 2012 to 2015, a 13.1% decrease.

— High-dose opioid prescribing (daily dose of >90 MME) has decreased much more dramatically: 11.4 per 100 persons in 2010, then 6.7 per 100 persons in 2015.

— The average days supplied of opiates increased 33.0% from 13.3 in 2006 to 17.7 in 2015 [presumably from decreased prescriptions for shorter term opiate prescriptions].

Commentary:

— the situation is still dire: opioid-related deaths from overdoses continues to increase, with 33,091 deaths in 2015, approximately half involving prescription opioids, though a good part of this problem is from heroin laced with fentanyl or other very high potency derivatives.

— Approximately 2 million individuals in the United States have opioid use disorder associated with prescription opioids, with an estimated economic cost of $78.5 billion

— though the opioid prescription rate has decreased since 2012, it still is three times higher than in 1999 (180 MME per capita) and is four times higher than in Europe in 2015.

— It is likely that the decreased prescriptions for opiates of late is related to increased awareness among clinicians, policies implemented by states to decrease opioid prescriptions, use of prescription monitoring programs, and other local efforts. An initial concern, which has not borne out, was that decreasing prescription opioids would lead to more use of more dangerous illicit drugs. However it does seem that these more restrictive policies have decreased the amount of opioids prescribed, prescription opioid involved overdose deaths, and also all opioid involved deaths (see Dowell, D. Health Affair (Millwood). 2016, 35(10):1876).

— but, unfortunately, such data do not take into account the other half of the picture: what is the effect of lower prescription rates on patient outcomes?? are more patients functionally impaired or incapacitated by lower doses of opiates? are fewer patients able to work or lead productive lives? what are the effects on their families? their communities?

 

So,

— as most of us in clinical practice know, is usually very difficult to convince patients already on chronic prescription opioids to stop taking them entirely, let alone decrease the dose significantly; patients often state that they need these meds to function. So, in many ways, the biggest long-term solution really is to dramatically decrease the number of new patients who are put on opiates. This involves a concerted effort by surgeons to avoid automatically prescribing opiates for surgery/pain (some patients do fine on non-opiates, with studies suggesting for example equal efficacy of NSAIDs for renal colic), emergency rooms to significantly decrease opiate prescriptions (which often make it very hard for us in primary care to stop prescribing them), as well as us in primary care avoiding using opiates whenever possible. There are many non-opiate approaches, medical and psychological (e.g. cognitive behavioral therapy, yoga, etc.) which may do well (see below). And, at least my experience in Boston is that many clinicians are prescribing opiates much less readily than previously.

— As mentioned in prior blogs (see below), once giving opiates to both young people and elderly seems to lead to more likelihood of continued opiate use/prescription subsequently.

— So, to me it is quite impressive that over the last five years there is been such a significant decrease in overall opiate prescriptions, but especially in those on higher doses (which may be associated with increased mortality), the apparent number of short-term prescriptions, as well as the increased documentation of nonopiate approaches which seem to help.​ But i am still concerned that at least some patients are now being undertreated for their pain….

 

See:

blog of study which found benefit for cognitive behavioral therapy for low back pain

blog of study finding pain control for knee pain through an internet-based home program

blog of a study showing that in older patients, those prescribed opiates for similar conditions were more likely to continue on opiates later

blog of a study finding that teens at low risk of illicit drug dependence who were given legitimate prescription opiates as 12th graders were 3-fold more likely to have opiate use disorder at age 23

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