Opioid Prescriptions Reach A 15-Year Low

August 29, 2018 / Thomas Cohn, MD

The number of opioid prescriptions in the United States has fallen dramatically, and prescriptions now sit at their lowest levels since 2003 according to new data from the Food and Drug Administration.

The data shows that 74 million metric tons of opioid analgesics were dispensed in the first six months of 2018, down more than 16 percent from the first six months in 2017. Although opioid prescriptions have been declining for the past couple years, the bigger decrease in 2018 is likely linked to lawmakers, doctors and patients working against the problem of opioid dependence.

“These trends seem to suggest that the policy efforts that we’ve taken are working as providers, payers and patients are collectively reducing some of their use of prescription opioid analgesic drugs,” said FDA commissioner Scott Gottlieb, MD.

Not All Good News

If we just look at the headline, it’s easy to infer that this is good news. Fewer patients relying on passive and potentially dangerous treatment options should be a good thing, but there are some drawbacks. For starters, the opioid crackdown is undoubtedly hurting a section of patients who use these medications properly and need them to control their discomfort. I’ve talked to patients who have found it harder to get the medications they rely on, and it’s troubling. Good people are getting caught up in the crackdown on opioids.

Perhaps more shocking is that despite the sharp drop in opioid prescriptions, opioid overdoses continue to rise. Although the data from 2018 wasn’t available, nearly 49,000 Americans died from opioid-related overdoses in 2017. This includes overdoses from fentanyl and heroin, which can be eventualities for individuals who become addicted to opioids.

“It isn’t necessarily the case that more people are suddenly switching from prescription opioids to these illicit drugs. The idea of people switching to illicit drugs isn’t new as an addiction expands, and some people have a harder time maintaining a supply of prescription drugs from doctors,” said Gottlieb. “What’s new is that more people are now switching to highly potent drugs that are far deadlier. That’s driven largely by the growing availability of the illicit fentanyls.”

Police data shows that a record amount of fentanyl (1,640 pounds) and heroin (5,500 pounds) have been seized by law enforcement this year, and we’re not even two-thirds the way through the calendar year.

Clearly we’re still losing the war on opioid overdoses, even if we hear headlines that suggest prescriptions are at a 15-year low. Chronic pain patients are caught in the crossfire, and overdose-related deaths continue to surge. We need to invest more money into understanding and treating chronic pain conditions in order to really make a difference.

NIH Issues New Plan To Tackle Opioid Crisis

June 12, 2018 / Thomas Cohn, MD

Earlier today, the National Institutes of Health issued its new plan for taking on the opioid crisis in America. The plan is titled Helping to End Addiction Long-term, or HEAL. The plan has two main goals:

Fund projects that will help develop or facilitate treatments for opioid addiction and overdose.

Fund projects that are meant to improve the management of pain through research into how acute pain transitions to chronic pain, as well as research nonaddictive pain treatments.

“Like most other pioneering scientific initiatives, HEAL will focus on a range of objectives, from short-term goals to research priorities that will take longer to bear fruit,” the authors wrote. “Yet, all will be aimed at the same ultimate vision: a nation of people with far less disabling pain and opioid addiction.”

Treating Addiction and Overdose

For starters, researchers want to take a closer look at how we’re currently battling addiction and overdose. Through their research, they found that there are three main drugs prescribed to help wean people off of opioids. Researchers found that most people living with opioid addiction never get started on these treatments, and of those that do, half of them relapse within a year.

“Research to reformulate these medications to improve adherence, as well as to develop new, more flexible therapies, is needed to help those who have opioid use disorder,” the authors wrote.

The NIH also wants to fund efforts to create better drugs for reversing overdoses, especially among individuals who overdose on fentanyl. The current reversal drug is naloxone, and it isn’t as effective as experts want it to be when the overdoser has other drugs or alcohol in their system.

Treating Addiction Before It Starts

The second part of the initiative focuses on coming up with better pain treatment plans and stopping pain before it become chronic. This is what we’ve been championing for on the blog for years. We need to treat addiction at the source, and the underlying reason behind addiction is unaddressed pain. We need to find better ways to treat and manage pain conditions so they don’t progress to the point where opioids are needed.

Funding for both parts of the plan will come from a $500 million grant that Congress set aside for the NIH in the 2018 budget

Opioids Are On Trial

April 23, 2018 / Thomas Cohn, MD

In a federal courtroom in Ohio a mammoth court case is being assembled. The victims of opioid abuse are going to be fighting the drug manufactures and distributors of opioids. The battle is for payment for the cost opioids have had on the communities. The injured parties range from individual communities to the federal government, and they are seeking money to cover the cost of all the problems related to the opioid epidemic. Simply put, this is the opioid equivalent to the tobacco lawsuit that sought damages for the effects of smoking. The case is being heard in federal district court in Cleveland, Ohio.

The Court Case

The plaintiffs are suing for relief from all the companies responsible for placing opioid medications into the community. The suit has wide ranging claims from that drug companies created a public nuisance, to that they used deceptive advertising. Others are claiming that companies violated consumer protection laws of many states. Further claims go as far as to suggest that the pharmaceutical companies, wholesalers and distributors acted like a criminal enterprise and had predatory practices to create sales and addiction.

The opioid epidemic is now killing more people than motor vehicle accidents. The big drug manufacturers of opioid medications have a long history of trying to persuade the public that these drugs are safe and rarely cause problems with addiction. They have spent huge sums to create a market for their products. The current cost to the public from the opioid epidemic is now running at $500 billion dollars a year. The costs are being paid by everyone in society. The medical costs are huge and stressing budgets at every level of government. Police and first responders are spending millions on everything from drugs to reverse overdoses to the expense of taking care of the dead. Furthermore, jails are becoming packed due to drug-related crimes, and the loss of productive members to society is staggering.

This is an extremely complex case that is moving forward in court. It is likely that this litigation will go on for years. There will probably be a settlement at some point but there will be no winners. Opioids do have some uses but they have been over-prescribed and have caused huge problems of addiction. As a pain practitioner, my wish is that more money is spent on pain research and non-opioid management. Hopefully we will stop losing lives and money to addiction and gain better pain treatment.

Opioid Prescriptions Dropped Significantly in 2017

April 19, 2018April 19, 2018 / Thomas Cohn, MD

New data shows that the number of prescriptions for opioid painkillers filled in the United States last year fell drastically, representing the biggest drop in 25 years.

The decline comes amid prescription restrictions and public education campaigns to help spread awareness of how opioids, when used incorrectly, can have harmful side effects. The report on the findings, which was released Thursday, shows a nine percent average drop nationwide in the number of prescriptions for opioids filled by retail and mail-order pharmacies.

Each state and Washington D.C. had at least a five percent decrease in opioid prescriptions. Declines were higher than 10 percent in 18 states, including all of New England, West Virginia and Pennsylvania.

“We’re at a really critical moment in the country when everybody’s paying attention to this issue,” said Michael Kleinrock, research director at IQVIA Institute for Human Data Science, which released the report. “People really don’t want them if they can avoid them.”

Drop In Opioid Prescriptions

Opioid prescriptions have been rising steadily since the mid-1990’s, with use peaking in 2011. The US far outpaced levels of other wealthy countries where national health systems are more strict about narcotic control. Overdoses and deaths from prescription opioids have been soaring in recent years, but advocacy groups, physicians and patients have been fighting back with increased educational strategies.

With all this said, opioids still do play an essential role in pain management for patients with chronic conditions. We are not against opioids when they are part of an integrated pain management plan, the problem becomes when doctors don’t take the time to educate their patients about their risks or conduct follow up checks to ensure patients aren’t in over their heads with their medication.

The downturn in opioid prescriptions is both good and bad. It’s a good sign that pill-mill doctors are getting exposed for what they are, but there’s also a decent chance that some chronic pain patients are struggling to get access to the medications they dearly need. It’s a double-edged sword, and there’s no perfect solution, but we should continue to push patient education so every person who takes a painkiller for their issue knows exactly what to expect and how to avoid a potentially serious issue.

Opioids For Long-Term Pain Relief

March 12, 2018 / Thomas Cohn, MD

The latest copy of the Journal of the American Medical Association has a lead article on the use of opioids in the long-term management of low back pain. The article is a study of some 200 people who were managed either with opioid-type medications or without them. The conclusion was that there was no difference in level of function with the use of opioid medication.

There is a large problem with this study, since it does not distinguish between the wide variety of patients who have back pain. Back pain can be due to everything from spine problems to nerve damage and residual surgical issues. As it has been preached multiple times, opioids are only one tool in the treatment of back issues and there are often many different strategies to control pain.

Opioids and Back Pain

The reality of life is that many different things can cause pain, and treatment should be aimed at the cause of pain. Depending on what is causing the sensory complaints, management will vary based on the individual’s needs. A combination of strategies is often necessary to treat every different component contributing to a problem. Treatments may be simple, such as ongoing exercise, to complex, including injections and surgery. Sometimes simple strategies fail and the only medication that does help are opioids. Since these drugs have tremendous problems, they often are not a good solution especially for long-term use. Pain specialists often know a wide realm of treatment options and can help lead one to better choice or a combination of choices.

The biggest problem with the use of opioids is that they are cheap and they have been pushed in the United States as a great, inexpensive tool to manage any type of pain. It takes a lot of work to manage pain, and in this country many have opted out of the challenges. On top of the drug companies pushing these medications, often the insurance companies are equally complicit by not allowing treatments that may be more expensive. Everything from physical therapy, massage, chiropractors, acupuncture and even fitness centers with athletic trainers are often more beneficial than many medications and may well be cheaper. However, most insurance companies turn a blind eye towards alternative treatment strategies. Now that opioids are a problem, insurance companies still want to say no to alternatives to drugs, but are not willing to pay for the better alternatives.

Alternative Treatment Options

The important message from the study of opioids is that for most people there are better treatment strategies than these drugs for the management of pain in the long term. For short-term, these medications may be okay. For surgery and several days immediately afterward it may be reasonable to use them. After that time period, medications that are not addictive may be used with the strategy to return the body to normal functional patterns. The body needs to move and relearn normal movement and function. As the body moves and functions as it was originally designed, the body acts appropriately and does not generate pain sensory signals.

If you have a body that cannot move and function normally due to permanent changes, these may constantly send sensory signals that are interpreted as pain. Designing treatments that bring the body as close to normal motion and function as possible can reduce pain. This is difficult and requires significant effort; rarely is there a magic pill that performs this function. If one gets past the thought that life is pain free and then focuses on making life as close to ideal motion and function, then one can improve their quality of life.

The last take home message is that medicine needs to understand that some people honestly have tried everything available to treat their problems and nothing has worked. If they have worked with a legitimate pain expert, sometimes it is found that opioid medications are appropriate in the management of a problem long term. This should be considered a last option in most cases. Hopefully our culture will get a more realistic understanding of opioids in the management of pain and all those involved in treatment will support the use of reasonable alternative strategies. Initially it may not be cheaper, but a healthier society is likely the final outcome.