The pendulum swings

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Recently, there has been an explosion of studies, lawsuits and newspaper articles highlighting what many are calling America’s opioid crisis or epidemic.

While the term opioid includes illegal drugs like heroin, it also encompasses a variety of prescription painkillers, including OxyContin, Percocet and Vicodin.

The Centers for Disease Control (CDC), referring to our nation’s “opioid overdose epidemic,” notes that deaths from overdoses of these types of drugs have more than quadrupled since 1999.

Some of these deaths are of abusers who steal prescription drugs from family members or pharmacies, obtain prescriptions illegally, or buy the drugs on the black market.

But it appears that ordinary older adults are among the biggest users and victims of these addictive drugs.

The Inspector General of the U.S. Dept. of Health and Human Services recently reported that nearly one-third of all Medicare beneficiaries received, on average, five prescriptions or refills of opioid painkillers in 2015.

One study found that more than 300,000 Medicare recipients battle with something called opioid use disorder. Nearly one in four patients on long-term opioid therapy in a hospital, rehab or nursing home struggles with addiction, according to the CDC.

What surprises me in all this reporting is that no one seems to recall that, about a decade ago, there was a drumbeat of studies and articles on the subject of pain management that led to a relaxing of the barriers to prescription opioid use.

Many of these reports decried the inadequate recognition of pain as a widespread problem, and the costs to patients and to the nation’s economy of what was then called the under-treatment of pain.

I know we ran a number of articles on this topic in the Beacon at the time, including one about a major report on the subject issued by the well-respected Institute of Medicine (now called the National Academy of Medicine). That report was actually mandated by the 2010 Affordable Care Act, showing that the concern over under-treatment had been around for some time.

The IOM report, which came out in 2011, opened by noting that acute and chronic pain affects “at least 116 million U.S. adults burdened by chronic pain alone.” Its authors were so concerned by this fact that they described the following as an “underlying principle” of the report: “Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions.” 

Among the report’s recommendations were calls for our healthcare system to take more seriously the issue of pain and those suffering from it, and to address the “significant barriers to adequate pain care,” which included “the regulatory and cultural barriers that inhibit the medically appropriate use of opioid analgesics.”

The report did not ignore the risks of addictive drugs. Calling it a “conundrum,” the authors noted the serious potential for abuse, and raised questions about the drugs’ long-term use. But the report’s authors said they believed “when opioids are used as prescribed and appropriately monitored, they can be safe and effective.”

I have not seen any studies or articles attempting to connect the issuance of that report in 2011 to today’s current epidemic.

But it seems likely to me that the study, and the many supportive statements from other pain management professionals that followed, tilted our healthcare system toward a more relaxed approach to the use of opioids for otherwise intractable or chronic pain.

I think the intentions at the time were completely honorable, and indeed, that the report addressed a real problem of widespread untreated pain at the time.

The devil is in the details. The report and its aftermath seem to have not just raised the consciousness of the medical profession to the need to manage pain, but to have led to a disregard by those in the supply chain of the addiction risk posed to patients by these medications, and to turning a blind eye to those who greedily exploit those with addictions for personal gain.

I speak of greed because recent reports indicate that literally hundreds of millions of pills have found their way from wholesale drug distributors to the black market nationwide.

For example, the Washington Post, reporting on a lawsuit filed against drug distribution companies by the state of West Virginia — which has the highest opioid overdose rate in the country — said that 40 million pills were shipped by distributors to West Virginia’s Cabell County, whose total population is only 96,000 (that’s over 400 pills per person), and 66 million pills were sent to Kanawha County, with a population of 190,000.

Furthermore, the deputy administrator of the Centers for Medicare and Medicaid testified before Congress in February that the agency “is aware of potential fraud at the prescriber and pharmacy levels through ‘pill mill’ schemes,” as reported by the Associated Press.

My fear is that lawsuits like this and related publicity will cause the pendulum to swing too far the other way (a problem we seem to be having in this country in several other respects as well).

There should be ways to limit the distribution and over-prescribing of addictive painkillers without making them inordinately difficult for those in true need to obtain them.

One good step towards this was taken recently by the CDC. It has issued “guidelines” for doctors writing prescriptions for opioid painkillers.

Among other things, they recommend that doctors weigh benefits against risks and discuss both with patients, start with the lowest necessary dose and increase slowly and only if needed, limit opioid therapy to a 3- to 7-day period in most cases, and offer additional treatments to patients with a history of abuse or dependence problems.

These sound to me like common-sense guidelines that should have been in place for years. Let’s hope coupling this reasonable guidance with a crackdown on illicit activities will help us strike the right balance this time.