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.

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.

Doctor Killed For Not Prescribing Pain Pills To Patient

August 7, 2017 / Thomas Cohn, MD

Last week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated. Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.

Opioid Dependency and Prescription Length

April 10, 2017 / Thomas Cohn, MD

A new study conducted by the University of Arkansas on opioid use has been recently published by the Centers for Disease Control. It is somewhat of a curious study since it was based on record analysis of prescription records for opioids. The results will likely be twisted by the press soon to announce how bad these drugs are and how addictive they can be.

The question the study sought to answer was – “If a patient gets a certain amount of drug prescribed on a first visit, will they still be taking that drug a year later?” The numbers are somewhat surprising, but in reality it does not really say anything about opioids, addiction or pain. All it really says is that for some people there may be limited options to treat pain, and maybe it is very effective for some people.

Continued Opioid Use

The patients studied were all 18 and over, cancer free, studied June 2006 through September 2015 and did not have a history of opioid abuse. Here’s a look at the results:

A person who received 1-day supply of medication had a 6% chance of being on opioids for a year or longer.

With a 5-day supply, they had a 10% chance of being on opioids in a year.

With a 10-day supply the odds go to a 20% that they will be still using opioids in a year.

A 30-day supply had about 30% chance of being on the medications a year later.

So if you start on opioids, and have it for over 10 days, 1 in 5 of those people may still be on those medications. However, it also means that 80 percent will not still be on those drugs.

Interpreting The Results

Several messages can be inferred from this data. First, acute pain should be treated with the least amount of medication for the shortest length of time. If at all possible, avoid the use of opioids for acute pain and find other less addictive and dependency causing medications. Second, many people do not use these medications long-term and can use them responsibly. Lastly, pain is very complex, and since some medications are highly addictive, try to avoid them and use the multiple other ways to treat pain including everything from chiropractors, to physical therapy, to exercise, and to injections.

The study also may be an analysis of the treatments available for severe pain. Some of the most effective treatments sometimes are the least healthy and can cause dependency. Opioids have been around for hundreds of years. Our knowledge of pain is limited, as are the solutions. Since it is such a huge medical problem, we really need to spend more on research and solutions. We know there is an opioid crisis with addiction. We need research solutions and new treatments. Now is the time to spend on research, as it may provide better solutions for more people than some of the recent government spending recommendations.

The Politics Of Pain

October 31, 2016 / Thomas Cohn, MD

The problems with opioids have been all over the news. Now it is the political season, and the politics of pain have occasionally been making news. It’s generally about how awful the pharmaceutical companies have been and how they have been behind the current problems. Whenever we try to point blame, it is worth remembering that both the problems and solutions are complex. Drug companies may have recognized the market for pain medications but without a demand for the product, even with the best sales, the problems would not have developed. Further, doctors have also been blamed, always over prescribing pain medications.

The treatments for pain are as varied as the causes, as there is not a single treatment that works for all. Unfortunately, the culture in the U.S. often wants a quick fix, and if a pill helps, most want that solution. The harder solutions of modifying activity and exercise often have few takers. The easy solution is taking an opioid medication, and when people started to realize that it helps temporarily, many people have insisted on being prescribed these medications.

Patient rights and quality care have also been an issue in prescribing medications. Countless times patients have said it is their right to take certain medications and that if a patient has pain, it is the obligation of a healthcare provider to prescribe opioids to control their symptoms. Now with multiple sites providing online evaluations and ratings of care providers, patients dissatisfied with not being prescribed certain medications will rate a provider badly.

Prescribing Opioids

The politically correct position currently, at least for healthcare managers, politicians, and lawmakers, is to say opioids are always bad and doctors should not be prescribing these medications since they only cause addiction and death. The truth is obviously more complex, but these medications are appropriate for certain people, especially when all other treatments for pain have failed.

Years ago, the pharmaceutical companies were notably behind the push to have opioids more widely prescribed. Today, we have a better understanding of the problem with these medications, and we have some alternatives in management of pain. As cynical as it was for drug companies to push for prescribing medications, now the push for more addiction management due to opioid problems. One of the most important solutions to reducing opioid usage is to fund research for better treatment alternatives and to discover more about what causes ongoing pain.

The opioid crisis is real and it affects an alarming number. Yes, there is a need for stemming the crisis, but most of the money being proposed is to go for addiction treatment, and often people who directly profit are behind the treatment programs. Another group is pushing for legalizing marijuana for the treatment of pain, and many of those pushing the hardest will again directly profit if this is legalized. Those in the trenches trying to appropriately diagnose and treat pain, and those who are suffering from pain currently have little financial support. Even though a third of the population struggles with pain, very few resources are being targeted towards a better understanding of the mechanisms behind pain and new treatment alternatives. Pain is not glamorous, and there is no high profile celebrity pushing the cause for better treatments. Unfortunately, there are many people pushing causes related to pain for personal profit, from addiction treatment centers, pharmaceutical companies, to disingenuous entrepreneurs pushing for legalizing marijuana. When looking for solutions, they need to be based in the best interest of those in pain.