An interesting 'contrarian' point of view surfaced in the ASHP daily briefing today asserting that the "feds got it wrong" about prescribing of opioids being a cause for the opioid epidemic. Specifically a New York Post op-ed piece by Dr. Josh Bloom asserts that a "one-size-fits-all" approach advocated by the CDC is, in fact, making the problem worse.
I feel the need to point out a few problems with that point of view:
1) Irrespective of why someone first takes an opioid (treatment of pain versus recreational use), the information we have strongly indicates that the initial source of much of what is on the street started out as a legitimate prescription supply. A CDC website indicates that over 259 million prescriptions for opioids were written in 2012, enough for every person in the US to have a prescription supply. Presuming that to be the case, it is hard to make a case that prescribing of opioids for patients in pain is not a proximate cause of the presence of large amounts of those medication in the marketplace. A recent article from West Virginia documents shipments of Oxycontin into West Virginia sufficient to have supplied every man, woman and child in the state with 433 pills! And those were all going to pharmacies and being issued under prescription. One "mom and pop" drug store is documented to be going through over five times as much OxyContin as a Rite-Aid up the street that has a much larger market. Investigations by the State Board indicates good record-keeping. The number of legal opioid deaths in 2014 increased 2013 numbers by 16.3%. Somebody is prescribing this stuff!
2) A very interesting discussion of opioids and chronic pain (Volkow N, McLellan T, Opioid use and Chronic Pain: Misconceptions and Mitigation Strategies N Engl J Med 2016;374:1253-63) makes it clear that, while opioids may be part of the treatment of chronic pain, they may not represent the best treatment and may well be self-limiting. I really recommend this to your reading. The assertion that limits are driving legitimate pain patients to heroin seem disingenuous.
3) Even if every opioid death represents recreational use, it still represents a dramatic increase in the opioid death rate.
4) Even if every opioid death represents recreational use, much of it still represents prescription activity.
5) The CDC guidelines to which the contrarian point of view refers exclude active cancer treatment, palliative care and end-of-life care. They call for careful and considered use of opioids in chronic pain, use of non-pharmacological pain mitigation strategies where possible, and regular follow-up assessment of patients to ensure that pain management is meeting its goals. They understand and acknowledge that without this kind of care, physicians will have difficulty distinguishing between those who have legitimate pain management needs, and those who are "shopping" to feed their addiction.
6) I do share the position that curbing overall availability of opioid pain medications may harm patients who have chronic pain that is effectively managed by opioids.It certainly potentially harms those groups excluded from the CDC guidelines. So it is not clear that the DEA action to reduce opioid production will have its intended effect. There is certainly no guarantee that the patients who really need the opioids will be the people who get them, without concerted effort by a variety of stakeholders.
At the end of the day, this is a far more complicated problem than can be resolved by unilateral solutions. We need to think about how we, as the drug experts, fit into the more complete solution.
What do you think?
Oh yeah... Happy Holidays!
Dennis A. Tribble, Pharm. D., FASHP
Ormond Beach, FL
DATdoc@aol.com
The opinions expressed in this blog are my own, and are not necessarily those of my employer nor of ASHP.