Monday, September 3, 2018

The perils of (too) sharply reducing opioid prescriptions

The ongoing opioid epidemic in the U.S. (and elsewhere) has at least some of its origins in the over-prescription of opioid painkillers. So there is a lot of interest in how, and how much, to cut back on prescribing these drugs.  The two articles below raise some flags about cutting back too sharply, and warn of the long road ahead in any event (partly because people in chronic pain and people who have become addicted to prescription painkillers sometimes enter the market for illegal narcotics when they lose their prescriptions).

Sally Satel directs my attention to this article in Politico:

How the opioid crackdown is backfiring
Hundreds of chronic pain patients responding to a POLITICO survey describe being refused opioid prescriptions they had relied on for years with sometimes devastating consequences.

"Many of POLITICO’s respondents described being tapered off narcotics too quickly, or worse, turned away by doctors and left to navigate on their own. Some said they coped by using medical marijuana or CBD oil, an extract from marijuana or hemp plants; others turned to illicit street drugs despite the fear of buying fentanyl-laced heroin linked to soaring overdose death numbers. A few, like Fowlkes, contemplated suicide."

And here is an article by some of my Stanford colleagues that explores a model to make some predictions. It is forthcoming in The American Journal of Public Health (AJPH) (and published online first):

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic
Allison L. Pitt, MS, Keith Humphreys, PhD, and Margaret L. Brandeau, PhD

"Objectives.To estimate health outcomes of policies to mitigate the opioid epidemic.

Methods.We used dynamic compartmental modeling of US adults, in various pain,opioid use, and opioid addiction health states, to project addiction-related deaths, lifeyears, and quality-adjusted life years from 2016 to 2025 for 11 policy responses tothe opioid epidemic.

Results.Over 5 years, increasing naloxone availability, promoting needle exchange,expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years.

Conclusions.Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation. (Am J Public Health.Published online ahead of print August 23,2018: e1–e7. doi:10.2105/AJPH.2018.304590)"

Note the contrast between these views and those of the Department of Justice as expressed by Deputy Attorney General Rod Rosenstein in yesterday's post.

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