Tuesday, March 15, 2022

Opioid prescription reductions and suicides

 Addictive drugs are repugnant, but painkillers are essential pharmaceuticals.  In an effort to reduce addiction, guidelines have been formulated that reduce prescription, and these sometimes backfire when applied to patients with unbearable pain.

The NY Times has the story:

What the Opioid Crisis Took From People in Pain  By Maia Szalavitz

"Though even some doctors are confused on this issue, addiction and physical dependence are not the same thing. Addiction, according to the National Institute on Drug Abuse, is compulsive drug seeking and use that occurs despite negative consequences. But pain patients like Mr. Slone are not considered addicted when medication improves their quality of life and the risks of side effects like withdrawal are outweighed by the relief medication offers.

"For people with chronic pain, research is only beginning to show how widespread the damage from opioid prescription cuts is. One study examined the medical records of nearly 15,000 Medicaid patients in Oregon who were taking long-term, high doses of opioids. Those whose medications were stopped were three and a half to four and a half times as likely to die by suicide compared to those whose doses were stable or increased. Another study, which included the medical records of over 100,000 people, found that drastically reducing a patient’s opioid dosage increased the risk of overdose by 28 percent and increased the risk of mental health crisis requiring hospitalization by 78 percent.

"Many opioid prescribing cuts were made under the auspices of guidelines published by the Centers for Disease Control and Prevention in 2016 to fight the overdose crisis. These guidelines recommend avoiding opioid prescriptions if at all possible and, when prescribing them for chronic pain, generally keeping the dosage below 90 morphine milligram equivalents, or M.M.E., per day 


"The C.D.C. is now updating those recommendations, admitting that the result has too often been unsafe changes in care.


"By 2019, the authors of the original guidelines warned in The New England Journal of Medicine that they were being misused, saying, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.” That year, the Food and Drug Administration cautioned that it had “received reports of serious harm,” including suicides, associated with patients who suddenly had their medication discontinued or abruptly reduced.

"But by then, states had passed legislation giving some of the recommendations the force of law. The National Committee for Quality Assurance, which provides standards for insurers, government agencies and medical organizations, made keeping doses within the guidelines into a metric — incentivizing doctors to taper or stop seeing high-dose patients. Insurers, pharmacy chains and government agencies also use the guidelines to inform restrictions, and law enforcement uses them when prosecuting physicians for running “pill mills.”

"If these policies had reduced the death toll, some might argue that they are warranted. But they have not. Measured by the number of prescriptions written per capita, medical opioid use rates in 2020 were down to levels last seen in 1993, before OxyContin marketing helped spark the crisis. However, overdose deaths are still increasing dramatically, driven by illegally manufactured synthetic opioids and many who formerly got pharmaceuticals from doctors and now resort to dealers."

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