In a dramatic shift in physician behavior, the number of new opioid prescriptions issued each month in the US has taken a nosedive, to less than a half. However, the number of high-risk prescriptions remains worryingly high, according to researchers at Harvard University.
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Patients who have never been prescribed opioids before or have been off them for six months or more are called opioid-naïve. In the new study, out of 20 million people who obtained at least one opioid prescription between 2012 and 2017, 10 million are now opioid-naïve.
In this group, the number of physicians who prescribed opioids went down by an astonishing 30% while there was a 54% decline in monthly prescriptions for opioid drugs, from 1.63 % of monthly patients to 0.75%, by the end of the study.
The number of overall and high-risk opioid prescriptions also decreased from March 2016 onwards – when the CDC guidelines were published.
The overuse of prescription opioid drugs has produced a massive epidemic of opioid misuse in the US, killing 70 000 people over the last year. Therefore, intensive efforts have been made, including pressure on lawmakers, to reduce the number of first-time opioid prescriptions, which often introduce patients or others to these drugs.
One major result was the U.S. Centers for Disease Control and Prevention (CDC) guidelines issued in March 2016, to curb risky opioid prescriptions. They recommend the use of other therapeutic modalities such as physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) wherever possible to help relieve pain.
High-risk prescriptions may be defined as a daily dose equivalent to 50 mg or more of morphine (50 morphine milligram equivalents (MME) a day). In the case of people with very severe pain, the maximum recommended dosage is 90 MME.
The guidelines recommend that no opioid at any dosage be prescribed for over three days, with one week being the absolute maximum.
The current study was based on the monthly analysis of 63.8 million privately insured patients aged 18 to 64 years between the years 2012 and 2017.
Despite the obvious reduction in opioid prescriptions, the actual percentage of high-risk prescriptions remained the same, surprisingly. About 115 000 of almost 16 million prescriptions fitted this category.
Even more worryingly, there were about 7700 prescriptions at doses above 90 MME – a dose which is associated with significant danger of both fatal and nonfatal overdose - despite the new guidelines.
Another group of healthcare providers apparently refused to prescribe opioids entirely, rather than take on the responsibility of using them appropriately. This fear is fueled, says Stefan Kertesz, an addiction specialist from the University of Alabama, by the high-powered attention on physicians from multiple stakeholders and regulatory bodies.
Kertesz commented, “In that situation, physicians tend to see the patient who might need opioids as a potential threat to the physician’s own professional survival.”
This “all-or-nothing approach” was not acceptable, since it could deprive some patients of adequate pain relief, suggested the study authors.
Another concern was that insurers sometimes misuse these guidelines to force patients to use lower opioid dosages, even for those who have achieved good pain control without addiction or misuse. In fact, Kertesz and other medical experts are lobbying for a confrontation with these agencies to safeguard patient well-being.
And finally, lack of access to prescription opioids could lead to an increase in heroin-overdose and related deaths over the following five years, before reducing new opioid addiction as intended.
It is well-known that most overdose deaths due to opioids occur with synthetic street drugs like fentanyl, though the initial exposure in a large number of cases is through prescription opioids.
The insurance claims were taken from the Blue Cross–Blue Shield (BCBS) Axis after removing all identifying details. This includes the widest collection of data relating to medical professional claims, commercial insurance claims and information about the cost of medical care.
Investigators looked at estimates of new monthly prescriptions issued to opioid-naïve individuals, those who were prescribed opioids in high doses or for prolonged periods, and the number of physicians who issued first-time opioid prescriptions to the opioid-naïve.
However, researchers could not comment on whether the clinical decision on opioids was appropriate in any case, as the data provided was non-specific.
The challenge we have in front of us is nothing short of intricate: curbing the opioid epidemic while ensuring that we appropriately treat pain. It’s a question of balancing the justified use of potent pain medications against the risk for opioid misuse and abuse.”
Nicole Maestas, Senior Investigator
The study shows that more thought needs to be put into the way a physician decides to prescribe or withhold opioids in a given clinical scenario, and also on the dose and duration of therapy, if given.
The study was published on March 14, in The New England Journal of Medicine.
Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012–2017. NJEM. 14th March 2019.