Steep Cuts in Opioid Prescribing ‘Raises More Questions’

By Pat Anson, PNN Editor

Several studies in recent years have documented how opioid prescribing has declined significantly in the United States, with per capita consumption of opioid medication recently falling to its lowest level in two decades.

For the first time, a new study by the RAND Corporation breaks the decline down by medical specialty, showing that some doctors may have gone too far in their effort to reduce opioid prescribing and lower the risk of abuse and addiction.

“Oftentimes when I do studies, I think we have a clear answer. This one in my mind raises more questions,” says Bradley Stein, MD, a senior physician researcher at RAND and lead author of the study published in the Annals of Internal Medicine.

Stein and his colleagues looked at opioid prescriptions filled at U.S. pharmacies in 2008-2009 and compared it to prescriptions filled in 2017-2018. Over that period, per capita morphine milligram equivalent (MME) doses for opioids fell by over 21% nationwide.

What surprised researchers is that many doctors treating patients with cancer pain, acute trauma pain or surgery pain significantly reduced their opioid prescribing even though most federal and state guidelines didn’t call for it.

The influential and much criticized 2016 CDC opioid guideline, for example, only applies to primary care physicians who treat chronic non-cancer pain. Yet emergency physicians, psychiatrists and oncologists cut their opioid prescribing significantly more than primary care providers and pain specialists.

MME Decline By Medical Specialty (2008 to 2018)

• -70% Emergency Physicians

• -67% Psychiatrists   

• -60% Oncologists  

• -49% Surgeons 

• -41% Dentists    

• -40% Primary Care Providers

• -15% Pain Specialists     

Stein attributes the steep decline in opioid prescribing not just to the CDC guideline, but to state regulations and insurance company policies. While some of the decline was appropriate, he thinks it may have gone too far.   

“There are probably populations where a decade ago, someone may have given 30 days of opioids, where maybe 3 days or 7 days would be fine. Or maybe they didn’t need to prescribe it at all,” Stein told PNN. “But there are other populations for whom several days of opioids may very well be appropriate. And those are individuals that probably we should not be seeing substantial decreases in. An example is individuals with late-stage cancer.”

The CDC guideline specifically says it is “not intended for patients undergoing active cancer treatment, palliative care, or end-of-life care.” But in practice, many of those patients are being forced to follow the CDC’s recommended dose limits. Some get no opioids for pain relief. A recent study in Oregon found a significant decline in opioids being prescribed to terminally ill patients being admitted to hospice care.

“The blunt policy approach that called for reduced opioid prescribing across-the-board clearly affected some medical specialties more than others. But even patients receiving palliative care have felt the negative impact of opioid policies that have lacked nuance and depth,” says Dr. Chad Kollas, a palliative care specialist in Florida who has called federal opioid policy an “abject failure” because it has not reduced overdose deaths. 

“Patients with cancer and sickle cell disease who are fortunate enough to have a palliative care physician still face challenges filling prescriptions for controlled pain medications at many pharmacies.” 

PNN readers may be familiar with the story of April Doyle, a terminal breast cancer patient who posted a tearful video online after she was denied opioids at a Rite Aid pharmacy in 2019. Doyle went to another pharmacy and her prescription was filled, but only after a lot of unnecessary physical and emotional pain. She died the following year. 

Geographic Variability

Another surprise uncovered by RAND, a nonprofit research organization, is the extreme variability of opioid prescribing from state to state and county to county.

The map below shows a checkerboard pattern across the United States, with counties in blue showing a 50% or more decline in opioid prescribing, and counties in red showing a 50% or more increase from 2008 to 2018.

Change in County Per Capita MME (2008-2018)

RAND CORPORATION

Per capita opioid prescriptions declined the most in large metropolitan counties (-22.6%) and in counties with higher rates of fatal opioid overdoses (-34.6%).

But even in states that were hit hard by the opioid crisis, such as West Virginia, Ohio and Kentucky, there are blue counties where prescribing fell significantly right next to red counties where opioid prescriptions spiked. Kansas and Missouri have more red counties than blue.  

“It was eye-opening to see the variation across states and counties,” said Stein. “We’re seeing variation by payer. We’re seeing variation by community. We’re seeing variation by type of prescriber. And I think this is a reminder to us all that this is probably an issue where one-size-does-not-fit all.  

“And I think coming to a better understanding of that will help us make sure that while we’re appropriately decreasing the amount of opiates being prescribed for people whose pain we can manage effectively in different ways, the decrease has been greater than it needs to be for some populations. We need to make sure that people who need adequate pain management get it.”

The RAND study was funded by grants from the National Institutes of Health.

Should Heroin Be Used to Treat Addiction?

By Pat Anson, PNN Editor

Some Canadian doctors are using novel approaches to treat opioid addiction, everything from safe injection sites to opioid vending machines to prescription heroin.

A new proposal would take the concept a step further by establishing the first clinical guideline for using hydromorphone and pharmaceutical grade heroin to treat people with severe opioid use disorder. The idea is to provide a safer supply to opioid addicts who currently use illicit heroin, counterfeit pills and other street drugs, which are often laced with fentanyl.

"Offering injectable opioid treatments is an effective way for clinicians to address the toxicity of the fentanyl-adulterated drug supply and help people achieve stability so they can focus on other aspects of their lives to get well, such as housing, employment, and connecting with family," says Dr. Christy Sutherland, Medical Director of PHS Community Services Society in Vancouver, BC.

Sutherland is one of the co-authors of the guideline, which is published in the Canadian Medical Association Journal. In 2018, nearly 4,500 Canadians died from opioid overdoses, with about 75% of the deaths involving fentanyl, a synthetic opioid that’s become a scourge on the black market.

"Opioid use disorder is a public health emergency nationwide; unfortunately, resources for the treatment of opioid addiction have been scarce and guidelines outlining best practices for innovative treatments have been lacking. This guideline is a blueprint for health practitioners to step up and provide evidence-based care," says Dr. Nadia Fairbairn, British Columbia Centre on Substance Use and the University of British Columbia, Vancouver, BC.

Heroin is classified as a Schedule I controlled substance in the United States, making it illegal to prescribe. But pharmaceutical grade heroin (known as diacetylmorphine) is legal in Canada, UK and several other European countries.

Studies have found that heroin-assisted treatment is effective in treating opioid addiction in patients who have failed at other treatment methods, such as methadone.

Under the proposed guideline, injectable heroin (diacetylmorphine) and hydromorphone (Dilaudid) could be used to treat severe opioid addiction in patients who do not respond to oral medication or use illicit injectable opioids.

It would be up to each Canadian province to decide whether to adopt the guideline.

Pharmaceutical heroin and safe injection sites are controversial issues in the U.S. But a recent analysis by the RAND Corporation advocates their use to combat opioid addiction.

“Given the increasing number of deaths associated with fentanyl and successful use of heroin-assisted treatment abroad, the U.S. should pilot and study this approach in some cities,” said Beau Kilmer, co-director of the RAND Drug Policy Research Center. “This is not a silver bullet or first-line treatment. But there is evidence that it helps stabilize the lives of some people who use heroin.”

What About Pain Patients?

Pain patient advocates in Canada were taken aback by the proposal to liberalize the use of heroin to treat opioid addiction. Opioid pain medication is increasingly difficult to obtain in Canada, as it is in the United States, because of restrictive guidelines.

“It is indeed shocking. Pain patients continue to be marginalized, stigmatized, ignored and left to suffer,” said Barry Ulmer, Executive Director of the Chronic Pain Association of Canada.  “I do think it is ridiculous to say opioid use disorder is a public health emergency. The population they are addressing no doubt has to be addressed, but in terms of numbers it is minuscule to those suffering pain, yet the number of dollars expended for both is just out of whack.

“People suffering pain cannot obtain help or even maintain access to medication they have been stable on for years. Something is sadly wrong. What is a public health emergency is the epidemic of undertreated chronic pain. They should get their blinders off. We have well over 1 million Canadians suffering from high impact pain, yet they are pretty much marginalized.”

One of those Canadians is Dan Wallace, a retired military veteran and police detective who lives with chronic knee and shoulder pain.

“I applaud the efforts made and others that are contemplated for the near future that would allow those who are addicted to obtain legally prescribed heroin that would keep them from the tainted street drug supply,” Wallace said. “Where I have a problem is with the complete dismissal of medical care to the many legacy patients who were previously prescribed opioids to manage their pain.”

Wallace used opioid medication for over 20 years before being tapered. He now has trouble walking and sleeping because of what he calls “a tortuous and cruel degree of pain.”

“I and others like me aren’t looking for a handout of free heroin because we haven’t been able to control ourselves and have become addicts. No one deserves to be treated like throw-away patients yet pain patients are just that. Why is it that their lives matter while simultaneously ours do not?” Wallace asks.

“I have never abused any substance in my life. Does my suffering ever help a single person who will now be getting prescribed heroin so they don’t have to buy illegal street drugs? Health Canada should be deeply ashamed at the needless suffering, disability, and deaths of pain patients they have caused.”

Medical Marijuana Not Reducing Demand for Rx Opioids

By Pat Anson, Editor

A new study by the RAND Corporation is throwing some shade on theories that medical marijuana reduces demand for prescription opioids and saves lives by lowering rates of opioid overdoses.

RAND researchers analyzed data from 1999 to 2010 and found a 20 percent decline in opioid overdose deaths associated with the passage of state medical marijuana laws. That is in line with previous studies. However, when researchers extended their analysis through 2013, they found that the association between medical marijuana and lower rates of opioid deaths completely disappeared.

Researchers say there are two possible explanations for this. First, states that recently adopted medical marijuana laws are more tightly regulating dispensaries -- which may have reduced access to cannabis. Second, beginning in 2010, the primary driver of the overdose crisis became illicit opioids such as heroin and fentanyl, not prescription opioids.

“This is a sign that medical marijuana, by itself, will not be the solution to the nation's opioid crisis," said Rosalie Liccardo Pacula, co-director of the RAND Drug Policy Research Center and co-author of the study published in the Journal of Health Economics.

"Before we embrace marijuana as a strategy to combat the opioid epidemic, we need to fully understand the mechanism through which these laws may be helping and see if that mechanism still matters in today's changing opioid crisis."

The RAND study also found little evidence that states with medical marijuana laws experience reductions in the volume of legally prescribed opioid medication.

"If anything, states that adopt medical marijuana laws... experience a relative increase in the legal distribution of prescription opioids. This result suggests that our findings are not driven by a decrease in the legal supply of opiioids," researchers found.

While many patients are using medical marijuana products to treat their pain, researchers say they do not represent a significant part of the opioid analgesic market.

"Either the patients are continuing to use their opioid pain medications in addition to marijuana, or this patient group represents a small share of the overall medical opioid using population," said Pacula.

Although 29 states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use, marijuana remains illegal under federal law. Attorney General Jeff Sessions recently ordered U.S. Attorneys to resume enforcing federal laws that outlaw the cultivation, distribution and possession of marijuana. Session rescinded the Cole memo, a lenient policy adopted by the Justice Department in 2013 that instructed U.S. Attorneys not to investigate or prosecute marijuana cases in states that have legalized cannabis..