January 25, 2018
Opioids are among the most scrutinized medications modern physicians can prescribe. As we noted in our first post on this topic, opioids were not always widely consumed, largely out of doctor-driven concerns about their addictiveness.
They again became popular after formulations of hydrocodone and oxycodone came to market between the 1970s and 1990s. The sudden spike in their prescription, coinciding with the healthcare sector's perception of an undertreated crisis in pain management, dramatically contributed to a rise in fatal overdoses.
According to the U.S. Centers for Disease Control and Prevention (CDC), deaths from prescription opioids quadrupled between 1999 and 2015, paralleling overall sales. In that timespan, a half million people died from all drug overdoses in the U.S., with fentanyl and its analogues accounting for twice as many per year as cocaine (20,000 versus 10,000) by 2016.
As the main prescribers of opioids, doctors have considerable influence on their use. While working with physicians to curb opioid prescriptions may seem like an obvious solution, these medications still have specific value in healthcare and accessibility to them is crucial for some patients. Considering the many factors at play, physicians are working toward a consensus on appropriate opioid prescription practices while navigating structural challenges to consistent and safe prescribing.
The best-known opioid prescribing guidelines for health providers come from the CDC. Several states have implemented restrictions on how physicians incorporate opioids into treatments, and these legal limits are usually based on CDC guidance.
More specifically, state laws may cap the duration and dosage of opioid prescriptions for acute pain, corresponding to the CDC's position that opioid supply will rarely need to exceed seven days. Since opioid regulation is often state-driven, there is great variance in the requirements with which physicians must comply, depending upon where they practice.
This inconsistency in opioid prescribing across the medical profession is further compounded by differences in:
A 2016 article in the CDC Morbidity and Mortality Weekly Report (MMWR) noted opioid prescriptions per capita continued rising from 2007 to 2012. Long-term trends in prescribing have also varied between specialties, with patients facing different probabilities of receiving opioids depending on which physicians they see.
There is no consensus on whether a physician's specialty or other factors determines what is prescribed. According to a literature review published in Pain Research and Management, studies have produced conflicting results about the relative likelihoods of specialists and general practitioners prescribing opioids. Accordingly, it may be the case that the idiosyncrasies of individual doctors (e.g., their trainings, experiences, licenses) are more accountable for the overall variance in patient prescription levels.
Since the prescribing patterns and history of a patient's physician can influence his or her probability of opioid addiction, doctors can benefit from looking to share norms and best practices for more standardized treatments. Peer-to-peer calls between specialty and state-matched physicians are a valuable way to ensure physicians work together towards reinforcing safe prescribing measures while adhering to up-to-date guidelines and research.
Advanced Medical Reviews, a nationally recognized and URAC-accredited independent review organization, has a nationwide network of physicians to complete both peer-to-peer calls and drug utilization reviews. AMR's physician reviewers examine patient records to assess and discuss prescribing recommendations with providers across all specialties. Clear prescribing guidelines coupled with patient-specific peer-level conversations can optimize patient care and reduce the risk of opioid misuse and abuse.
Opioid prescription levels have been shown to be disconnected from the health characteristics of the specific populations in question; the CDC identified no overall change in reported pain from 1999 to 2014, despite the jump in prescriptions during that time. Prescribing is instead strongly influenced by nonmedical factors, such as location.
Consider that higher opioid prescribing is positively correlated with small cities or large towns with higher numbers of people who are uninsured or unemployed. These correlations can partially account for rural portions of states such as West Virginia and New Hampshire being disproportionately affected by opioid overdoses. In charting these regional disparities of opioid use, the CDC cited "lack of consistency among providers when prescribing opioids" as a contributing cause.
Why do doctors' opioid prescription behaviors vary widely? In addition to specialty and location, the specific conditions of patients they serve can result in different approaches to the same situations.
For example, a pair of physicians writing for STAT in early 2017 cautioned against strict limits on opioid prescribing sought by the Centers for Medicare and Medicaid Services. They argued that blocking all prescriptions above a certain threshold would ignore the numerous factors contributing to opioid addiction, including life opportunities, age and biology.
In other words, it would enact a one-size-fits-all policy ignoring differences in patients. It might also expose stable patients to inhumane pain levels if their prescriptions were prematurely curtailed.
Addressing the nuances of pain management has been a challenging factor in the search for generally applicable guidelines for tapering of patients on opioids. Tapering recommendations have emerged in recent years, with an eye toward more consistent prescription of opioids and better management of the chronic pain for which opioids are so often prescribed.
Opioid tapering is inherently challenging due to the effectiveness of the medications for some conditions and the extent of withdrawal experienced by many patients. The aforementioned MMWR features some of the CDC's guidelines for tapering for physicians, which include:
A 2017 study published in the Annals of Internal Medicine concluded that reductions in opioids prescribed for chronic pain might result in better quality of life for patients through less pain and more mobility. It also highlighted the benefits of alternative treatments such as buprenorphine regimens, behavioral therapies and even acupuncture. The CDC itself has endorsed some of these options in its own guidance, along with the use of nonopioids such as ibuprofen, acetaminophen and others, when appropriate.
The Annals of Internal Medicine report still needs corroboration, since not all its studies were controlled and double-blinded. Still, it points the way to ongoing reevaluation of the opioid pain management curve. Tapering will need to include considerations of meaningful improvement from taking opioids, dosage levels and abuse/overdose risks.
Recent efforts by states such as New Jersey (enacted a strict limit on opioid prescription supplies) and cities like New York (committed $3 million to opioid management programs, including buprenorphine therapy) demonstrate the broad spectrum of current opioid responses. As new approaches to managing the opioid addiction epidemic enter the picture, it will be critical for physicians, payers and even communities to work in tandem with one another and utilize all available resources, including independent medical review providers, to find the best way forward.
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