Map of life expectancy at birth from Global Education Project.

Thursday, July 07, 2016

Opioid Prescribing Policy

A major political deal in my former home state of Massachusetts has been reform of opioid prescribing regulations, and you can read all about it here. This law had strong bipartisan support from the Democratic legislature and Republican governor as well as the Massachusetts Medical Society. The opioid abuse epidemic has gotten the attention of lots of state governments and many of them had passed laws like this a few years ago.

Speaking of the Massachusetts Medical Society, they publish the New England Journal of Medicine which today has this from Ellen Meara and colleagues. Alas, they can't find any evidence that these laws do much good at all, if any. Their data came from people under 65 who receive Medicare benefits because of disability. That's obviously not representative of the general population but on the other hand they have high rates of receiving opioid prescriptions and account for a highly disproportionate share of related adverse events. Furthermore, there is no obvious reason why these state laws would not affect opioid prescribing to them as much as it would to others.

There are several sorts of provisions they looked at, many of which are components of the Massachusetts law. These include limiting the quantity of initial prescriptions, requiring prescribers to consult a Prescription Drug Monitoring Program (which tells them if patients are also getting prescriptions somewhere else), and various other provisions. But it turns out that there is no meaningful difference in long-term prescribing, high levels of prescribing consistent with addiction and overdose risk, multiple prescribers, or actual overdose, when states adopt these laws.

Now maybe they take more effect over more years, maybe they have a small effect that the study couldn't detect, and maybe non-disabled people are different. But the takeaway seems to be that this problem is not solved by trying to impose restrictions on physicians. We need to change the culture and practice of medicine, and that means for one thing doctors' skills to communicate with patients and manage pain without overusing opioids. The legislature doesn't have any magic bullets.


JenBob said...

I don't like opioids. I don't like the way they make you feel. On the other hand, I find them handy when my sciatica wakes me up in the middle of the night.

Physicians are gun-shy about prescribing them unless you have an obvious, objective and demonstrable need that an uninterested observer would understand.

That's why I hoard them...for those times when I need them. It really pisses me off that those who abuse them have made it so difficult for the rest of us to have access to these drugs when needed.

Cervantes said...

Hey JB, you have pain with a specific pathophysiological cause, and you are able to use opioids only on occasion when you experience an exacerbation. Chronic pain is a different thing -- it doesn't have an observable physical cause, it's a malfunction of the nervous system. Long-term opioid prescribing just doesn't work for that. You shouldn't blame abusers though, people get hooked without ever meaning to. Addiction is hard to understand if you haven't been there.