New opioid prescription control framework is a 'funhouse mirror image' of prior monopoly

Jul 25 2018

A rise in addiction and overdose deaths involving opioids in the United States has spurred a series of initiatives focused on reducing opioid risks, including several related to prescription of opioids in care of pain.

In a critical analysis of U.S. opioid policy, published today in Addiction, University of Alabama at Birmingham Professor Stefan Kertesz, M.D., and University of Utah Professor Adam Gordon, M.D., describes the swing in U.S. policies from encouragement of opioid prescribing to today's increasingly rigid restrictions as simplistic responses to a complex human challenge.

"Neither the policies of yesterday nor those of today can be entirely rational," Kertesz explained. "The scholarly literature tells us that is reality. Our task was to explain how our collective irrationality has changed over time when it comes to opioids."

The paper lays out some of the factors that lead policymakers to look for easy answers to complex problems, including pain and addiction. Most importantly, they have limited resources, time and attention. The result, they write, is that insurers, legislators and other regulators are influenced by "highly-informed advocates who can sway policy by predigesting data in ways that often reflect their own interests."

Coming at a time when the United States reels from more than 64,000 drug overdoses and lawsuits have been filed against drug manufacturers, the article may prove controversial.

In the paper, Kertesz and Gordon criticize reckless overprescribing as one of several factors that contributed to a U.S. addiction crisis. But, they say the typical narrative that unscrupulous drug companies duped physicians and innocent patients is simplistic. It neglects most efforts to understand how and why people use drugs or the communities from which they come. It presents doctors and patients as victims, rather than as people who also made decisions they may regret today.

Further, they argue, a simplistic narrative has led to simplistic policy responses, where controlling prescriptions has come to look like the easy answer. They cite two major reports from 2017 that called for opioid prescribing restrictions. Both touched on addiction treatment, but neither demanded new funds to pay for treatment.

The result is a situation in which opioid prescriptions are "subject to an array of conflicting, high-stakes imperatives from an alphabet soup of regulators, employers and payers" who see reducing prescriptions as an easy numeric target, and very often the only target worth pursuing. They praise a 2016 Guideline on prescribing opioids from the Centers for Disease Control and Prevention but note that it has been turned into a weapon against patients with pain, many of whom are now seen as liabilities by pharmacies, insurers and doctors.

"We have been doing addiction care, education and research for over 20 years. We know the harms done by reckless opioid prescribing. Opioid prescribing influenced by financial gain, corporate influence or by just poor doctoring are real concerns," Gordon said. "But, we have also personally witnessed and otherwise appreciated an increasingly brutal effort to reduce prescriptions and reduce doses, without patient consent or in a non-patient-centric way. That's wrong, too."

The authors described a policy shift from minimizing pain scores as the "5th Vital Sign" to minimizing "milligrams prescribed" (i.e., opioids).

"The new prescription control framework is a funhouse mirror image of the prior monopoly," Kertesz wrote in the new piece. "What was virtuous under the prior regime was to chase a number -; the pain score -; using opioid prescriptions, even as naysayers pointed out that people were being harmed. What is virtuous under the new regime is to chase new numbers -; opioids prescribed -; even as naysayers point out other people harmed."

The authors concluded by calling for enhanced systems of care for vulnerable populations. They favor restraint in starting opioids and greater efforts not to traumatize the patients who currently receive them.

Kertesz and Gordon are internal medicine physicians who have focused their research and clinical work on the primary care of patients with addiction and other vulnerabilities.