By John Palmer
Even as the Trump administration claims to be taking control of the U.S. opioid epidemic, a new report says that fewer prescriptions are being written for addictive painkillers—and that may be due, in part, to hospitals and physicians being more aware of and willing to try alternative treatments.
According to data from the Danbury, Connecticut–based IQVIA Institute for Human Data Science, opioid prescriptions in general declined by 10.2% in 2017. Prescriptions for the highest doses fell by 16.1% in 2017 as well, and dropped more than 33% since January 2016. The report also found that prescription opioid volume has decreased every year over the past five years in all 50 states.
The study, Medicine Use and Spending in the U.S.: A Review of 2017 and Outlook to 2022, shows that prescription opioid volume had increased annually since 1992, peaking in 2011. Then a series of regulatory and legislative restrictions, combined with tighter clinical prescribing guidelines and greater reimbursement controls, resulted in declines averaging 4% per year from 2012 through 2016.
“The U.S. opioid epidemic is one of the most challenging public health crises we face as a nation, and our latest report provides novel insights and evidence as part of that ongoing societal discussion,” said Murray Aitken, IQVIA senior vice president and executive director of the IQVIA Institute for Human Data Science, in a written statement. “Our research and analytics revealed that 2017 saw new therapy starts for prescription opioids in pain management decline nearly 8%, with a near doubling of medication-assisted therapies (MAT) for opioid use dependence to 82,000 prescriptions per month. This suggests that healthcare professionals are prescribing opioids less often for pain treatment, but they are actively prescribing MATs to address opioid addiction. These opioid details, as well as more general evidence-based findings, are explained in this study.”
These are medications that help temper cravings, although they may not completely stop addiction.
So-called new patient starts are considered to be an important indicator of future opioid use if the usage is for chronic pain or if a patient becomes dependent on opioids.
The IQVIA report also found that in 2017, 23.3 billion fewer morphine milligram equivalents (MME)—a measure used to describe the potency of an opioid—were dispensed to patients on a volume basis. This amounted to a 12% drop from the previous year and a decrease from 240 billion MMEs in 2011, according to IQVIA.
Also, the report states that prescription opioid usage was about 22 pills, or 134 MMEs, per adult American in 1992 and rose to a peak of 72 pills or 1,011 MMEs in 2011. But usage has since declined to 52 pills, or 676 MMEs, per adult.
A change in protocol
What exactly does this data mean, and why are prescriptions decreasing?
It appears the recent press given to the opioid epidemic, as well as the attention of government officials and policymakers, is beginning to affect medical practice. The White House declared the opioid crisis a public health emergency, and Congress is considering legislation that would address a mix of insurance coverage, payment issues, prescription regulations for Medicaid beneficiaries, and prevention strategies.
Two years ago, the Centers for Disease Control and Prevention (CDC) issued prescribing guidelines that focused on chronic pain except for cancer and end-of-life care. The guidelines are targeted at primary care physicians in particular because family doctors write the vast majority of prescriptions for painkillers.
According to Patrice Harris, MD, AMA president-elect and chair of the AMA Opioid Task Force, the decrease undoubtedly reflects physicians’ commitment to best practice when it comes to prescribing.
“There are fewer prescriptions primarily because physicians have been making more judicious prescribing decisions—in line with AMA and other medical society recommendations,” Harris says. “In fact, two years ago, our then-President Steven Stack, MD, wrote in an open letter to physicians that, as a profession, we ‘must accept responsibility to re-examine prescribing practices.’ We have done that. Our focus is on ensuring patients’ pain care.”
However, Harris points out that decreasing prescriptions without increasing comprehensive pain care simply replaces one opioid for another. She mentions a recent CDC report indicating that opioid-related deaths continue to climb from synthetic opioids such as heroin and fentanyl.
“We continue to work with the administration and Congress in support of patient-focused efforts to reduce opioid-related harms and enhance access to treatment,” she says.
Those efforts are sorely needed, says Rebecca Parker, MD, senior vice president of advocacy and leadership for Envision Physician Services. She is a board-certified emergency medicine physician practicing in the Chicago area.
“First, the opioid crisis itself has highlighted a crucial need for solutions—in which physicians play a part,” Parker says. “For years, the CDC has followed the epidemic and led the industry in providing data and information. Drug overdoses are now the leading cause of unintentional death in the United States with over two-thirds of the deaths due to opioids. And the media coverage of the number of drug overdoses and opioid-related deaths has certainly shed light on our nation’s plight with opioids.”
There’s reason for optimism, however.
“Through this combination of public health initiatives, coupled with a better understanding of the effects and risks of opioids and research showing the efficacy of non-opioid medications and alternative treatments to opioids, physicians and other clinicians have been able to decrease opioid prescriptions,” says Parker. “Physicians and their patients are able to work together, along with legislators and policymakers, to deliver the highest quality of care and minimize opioid use.
Unfortunately, the recent escalation of deaths has been secondary to illicit drugs like heroin and fentanyl, which are now the leading cause of opioid deaths. We must address addiction and mental health resources as we move forward.”
ER doctors tend to be on the front lines of the opioid crisis, as they usually are the ones to receive people coming to the hospital in search of pain medications. They also often see the most acute cases that require immediate treatment.
“Physicians in the emergency department see overdose events every day along with patients with painful injuries and diseases,” says Harris. “Let’s not forget that primary care physicians and many other specialties also treat patients with pain as well as with substance use disorders every day. We all have a role to play.”
Parker agrees. “Emergency physicians serve as the safety net to the healthcare system,” she says. “We see all patients, regardless of age, disease state, or ability to pay. Although they make up only 4% of the physician workforce, emergency physicians see the entire healthcare system and disease states.
In emergency medicine, pain is the most common sign/symptom of patients accessing emergency care. As such, we are continually determining which circumstances warrant the use of opioids, non-opioid medications, or alternatives to medications, as well as identifying patients who have an addiction or are at risk for substance abuse and helping them manage their pain effectively.”
Stepping up to find a solution
How can hospitals step up their game in helping prevent opioid dependence? Reports claim that “medication therapies” for opioid dependence have doubled every month. What are some examples of these therapies, and why have they not been used more in the past?
“Hospital-based physicians, such as those whom Envision Physician Services supports, connect patients to outpatient treatments, including medical-assisted treatment programs,” says Parker. “Ongoing research is evaluating buprenorphine programs, which are a newer approach, to gauge the effectiveness of these and other MAT programs. These programs require infrastructure outside the hospitals and funding, which have been barriers in the past, along with clear evidence that they are effective.”
According to Harris, doctors looking to ramp down their own opioid prescriptions have to look to other alternatives, but they also must find ways to get hospital administrators to institute a systemwide program.
“We hope that physicians approach the issue not as one of automatically reducing opioid prescriptions, but of ensuring that patients receive optimal pain care,” she says. “There are non-opioid alternatives; patients must have access to them in their health insurance plans. Some hospitals are doing excellent work in pain stewardship programs, such as the University of Chicago, Geisinger Health System, and the Kaiser Permanente Medical Group in Northern and Southern California, to name a few.”
Of course, evidence-based care and treatment forms the foundation of medical training, but doctors also face challenges from insurance companies when prescribing treatments.
“When non-opioid alternatives, ranging from physical or behavioral therapy to lidocaine patches and other non-opioid pharmaceuticals, are denied by health insurance companies or pharmacy benefit management companies, patients and physicians have fewer options,” Harris says, adding that a comprehensive plan begins with getting all staff involved, not just doctors.
Specialists, Parker says, play an integral role in caring for patients and educating them about the risks of opioid addiction. “Physicians in several of our specialties, including algiatry, surgical, emergency medicine, and women’s and children’s services, are on the front line of the epidemic,” she adds.
For example, the use of prescription opioids and illicit drugs among pregnant women has risen dramatically in recent years.
“Women’s and children’s specialists can help treat opioid addiction during pregnancy and the resultant effects, such as neonatal abstinence syndrome,” notes Parker. “They also encourage parental support and presence and engage in patient education.”
Also, in the surgical realm, multimodal opioid-sparing analgesics and regional blocks have been proven to reduce postoperative opioid administration, especially in complicated trauma patients, she says.
Hospitalists help manage pain in the inpatient setting and identify patients at risk for addiction to facilitate follow-up with appropriate treatment centers. They also play an important role in patient education about acute versus chronic pain and the appropriate treatment modalities, which includes the risk of opioid addiction.
“Algiatrists (pain management specialists) are essential in helping patients manage their chronic pain,” Parker says. “They confirm diagnoses and help develop long-term pain management approaches for patients with their primary care physicians, and identify and refer opioid use disorder patients to addictionology and behavioral health specialists.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.