FROM THE LAWHERN FILES:
NORMAN J CLEMENT RPH., DDS, NORMAN L.CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, JOSEPH SOLVO ESQ., REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, SHELLEY HIGHTOWER, BS., PHARMD., LEROY BAYLOR, ADRIENNE EDMUNDSON, JAY K.JOSHI. MD., MBA., NATASHA DUVALL PHARMD., WALTER L. SMITH BS., LEROY BAYLOR, BS., MS., MS., BRAHM FISHER ESQ., MICHELE ALEXANDER, CUDJOE WILDING BS, DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS
Sally Satel is a psychiatrist, a resident scholar at the American Enterprise Institute, and a visiting professor in the Department of Psychiatry at Columbia University’s Vagelos College of Physicians and Surgeons.
POLICY AND PRACTICE PRESCRIPTIONS
Up to 18 million Americans who rely on prescription opioids are now caught in the debate over the proper limits of treatment. “I am heartbroken for anyone who may have overdosed on opioids or lost someone who did,” Texas-based pain
advocate Andrea Anderson told me, “but as someone who has helped hundreds of people suffering chronic pain in the last four years, withholding opioid medications from them just doesn’t make sense.”
So how do we inject more sense into prescription-opioid policy and practice?
First, like old generals, we must stop fighting the last war. Opioid prescribing peaked in 2010 and 2011, and has since been in long-term decline — decreasing by 40% between 2011 and the end of 2020, according to the IQVIA Institute for Human Data Science. The total amount of opioids dispensed as measured in MMEs fell by 60% over the same period, with fewer pills being dispensed per person.
Meanwhile, opioid-related deaths began to surge in 2013 — several years after physicians began their sustained cutback on pain-reliever prescriptions. These crisscrossing trends suggest that the opioid crisis of the last decade has not been driven by prescription medications, but predominately by illicit heroin and fentanyl, which have been involved in over 62,000 deaths as of July 2020. Wholesale restrictions on prescription opioids will thus do little to combat the nation’s opioid-overdose problem.
Second, the CDC must rewrite its guideline to counteract the overzealous application of the 2016 version. In summing up the guideline’s impact, the American Medical Association wrote, “by placing so much emphasis on reducing opioid prescribing, the CDC has caused considerable fear in the patient and medical community that opioid therapy for pain will automatically cause opioid-use disorder, overdose, and death.” The agency’s attempts to clarify its guideline in 2019 did not do enough to assuage this fear; it’s now time for a more authoritative directive.
In a promising move last summer, the CDC appointed a new slate of outside experts, including critics of the earlier guideline, to craft a new version. The rewritten guidelines should give primacy to the idea that all pain care must be individualized and that, so long as the benefits of opioid medication exceed the risks, doctors should not be pressured by hard thresholds for chronic and short-term prescriptions.
Third, physicians need better training in treating patients who are experiencing chronic pain. Their education should cover opioid prescribing, pain management, screening for psychiatric conditions and problematic treatment with opioids in the past (excellent patient-assessment questionnaires now exist), and screening for past substance abuse or addiction. Doctors needn’t avoid using opioids in patients who appear vulnerable to addiction, but they must prepare for the possibility of having to monitor these patients more closely. They should also be trained to detect new-onset opioid abuse and addiction that occurs during the course of care, as well as how to manage these problems or refer patients to specialized care.
Fourth, patients’ well-being must take precedence over pill counts. States, health plans, pharmacy chains, and insurers must therefore avoid imposing rigid standards on permissible dosing. Likewise, they should deem unethical forced dose tapering of patients who are benefiting from opioids and taking them responsibly. As one protocol out of the Stanford University School of Medicine advises, “the focus should never be solely on opioid reduction.” Instead, “pain treatment should be applied to facilitate not only goals for pain and opioid reduction but improved function and quality of life.”
Fifth, health-care systems should revitalize interdisciplinary pain-management programs. In 2019, HHS called for the revival of such programs, which offer an array of medical, physical, and psychological therapies for pain in one location. Interdiciplinary clinics had flourished in the 1970s but were replaced with scattered, “carved out” services by the late 1990s as a cost-containment strategy.
Even if revived, the benefits of these programs will be thwarted unless insurers cover needed services. Examples of such services include physical therapy, occupational therapy, behavioral therapy, therapeutic exercise, procedures like steroid injections or surgically implanted spinal stimulators, and medications — including non-opioid pain relievers, anti-convulsants, anti-depressants, and musculoskeletal agents, in addition to opioids.
FOR NOW, YOU ARE WITHIN