To address the U.S. opioid epidemic, policies and guidelines have focused primarily on reducing opioid prescribing and restricting supply. Accordingly, opioid prescribing decreased 38% in the past decade.
Nevertheless, fatal opioid overdoses actually increased 300% during that period. The U.S. Centers for Disease Control and Prevention reports that more than 73,000 people died from an opioid overdose in the past year - one person every 7 minutes; the highest number on record. Increasing fatalities despite decreased prescribing has been termed the "opioid paradox".
In a special article published Online First in Anesthesiology, the official peer-reviewed journal of the American Society of Anesthesiologists, Editor-in-Chief Evan D. Kharasch, M.D., Ph.D., Editor J. David Clark, M.D., Ph.D., and former U.S. Surgeon General Jerome Adams, M.D., M.P.H., introduced their groundbreaking new concept, a prescription opioid ecosystem, to combat the opioid crisis and the opioid paradox. This concept goes far beyond simple restriction of opioid prescribing, to encompass a comprehensive approach designed to shrink and better manage the pool of prescription opioids in medicine cabinets of the country. "It involves immediate action to address opioid use, storage, return, and harm reduction, with a specific focus on patients and communities," they explained.
Restricting opioid prescribing alone has not succeeded. And tight restrictions on prescriptions can take pills from people who need them while leaving illicit "street" supplies available. Such patients my turn to illicit supply chains, such as fentanyl, as sources of opioids, resulting in overdose, according to these physicians.
A crucial component of the opioid ecosystem is the pool of unused prescription opioids which is available for misuse by patients, friends, or family, or for diversion. Diversion may be well-intentioned (to help others in pain), or by theft, or by giving or selling pills to others.
The size of the opioid pool is influenced not just by supply (prescribing), but also by demand (patient need) and, importantly, by return or disposal of unused drugs, Drs. Kharasch, Clark and Adams noted. To address the opioid paradox, they propose to right-size the opioid pool by:
Reducing demand -; The authors urge anesthesiologists and surgeons to use patient-specific regimens that provide adequate pain relief after surgery, rather than withholding needed opioids, because undertreated acute pain can result in persistent, or chronic postsurgical pain. Persistent postsurgical pain causes suffering, and, can be a risk factor for opioid misuse.
For example, multimodal strategies (using two or more drugs or techniques that act by different and complementary mechanisms) may provide better pain relief and enable smaller opioid prescriptions. So too may the use of longer-lasting pain drugs for surgery such as methadone, which can result in less postoperative pain and opioid use with benefits that last for weeks to months after a single dose.
Reducing "leftovers" -; Hundreds of millions of opioid pills are dispensed to patients but go unused each year. Most are just kept by patients. Few pills are safely stored, and only a fraction are disposed of or returned, to remove them from harm's way. "The current difficulty of returning prescription opioids contrasts markedly with the ease of obtaining them. This is illogical and unsafe," Drs. Kharasch, Clark and Adams stated.
They believe that regulations should require pharmacies dispensing opioids to provide:
- Instructions for proper return/disposal (preferably on the label, not as a handout)
- Addresses/telephone numbers of disposal stations
- A preaddressed, prepaid envelope for returning unused pills in an inactivating substance (e.g., activated charcoal)
Research suggests opioid buy-backs are likely to be even more successful, according to the article.
Reduced dispensing -; The article suggests that a better approach to shrinking the pool is already possible: partial filling of opioid prescriptions. A federal law enacted in 2016, the Comprehensive Addiction and Recovery Act, allows both patients and clinicians to request partial filling of prescriptions for schedule II (strong) opioids. Partial filling for schedule III–V (weaker) drugs has been permitted for decades. Giving patients less to take home, with fewer potential leftovers, would reduce the unused opioid pool. But it would still let patients with ongoing pain, who need their full prescription, to have it fully filled and with no questions asked.
"A caveat about shrinking the prescription opioid supply, particularly given the number of individuals with existing opioid use disorder, is that we not repeat past unintended consequences," the authors cautioned. "Shrinking of the prescription opioid pool will need expansion of programs for medication-assisted therapy of opioid use disorder."
"This new paradigm of an opioid ecosystem, with its various new components, offers the possibility of saving lives, improving health, and reducing costs", concluded the authors.
Kharasch, E.D., et al. (2021) Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology. doi.org/10.1097/ALN.0000000000004065.