Opi­oid pre­scrip­tions see drop

CDC says can’t link fewer pre­scrip­tions to il­le­gal drug use

Northwest Arkansas Democrat-Gazette - - NATIONAL - ABBY GOODNOUGH

WASH­ING­TON — The amount of opi­oid painkillers pre­scribed in the United States peaked in 2010, a fed­eral analysis has found, with pre­scrip­tions for higher, more dan­ger­ous doses drop­ping the most sharply — by 41 per­cent — since then.

But the analysis by the fed­eral Cen­ters for Dis­ease Con­trol and Pre­ven­tion also found that the pre­scrib­ing rate in 2015 re­mained three times as high as in 1999, when the na­tion’s prob­lem with opi­oid ad­dic­tion was just start­ing. And there is still tremen­dous re­gional vari­a­tion in how many opi­oids doc­tors pre­scribe, with far more pre­scribed per capita in parts of Maine, Ne­vada and Ten­nessee, for ex­am­ple, than in most of Iowa, Min­nesota and Texas.

Over­all, the analysis found that the amount of opi­oids pre­scribed fell 18 per­cent from 2010-2015, though it in­creased in 23 per­cent of the coun­ties.

“We still have too many people get­ting medicine at too high a level and for too long,” said Dr. Anne Schuchat, act­ing di­rec­tor of the CDC. She noted that the quan­tity of opi­oids pre­scribed in 2015 would be enough to pro­vide ev­ery Amer­i­can with roundthe-clock painkillers for three weeks.

A flurry of re­cent at­tempts to tamp down opi­oid pre­scrib­ing — in­clud­ing CDC guide­lines is­sued last year on pre­scrib­ing the drugs for chronic pain and new state and in­surer lim­its on how many pills doc­tors can pre­scribe — are not re­flected in the analysis, which did not look be­yond 2015.

But ear­lier ac­tions, like state crack­downs on pain clin­ics and pre­scrib­ing guide­lines re­leased by the Depart­ment of Vet­er­ans Af­fairs in 2010, may have con­trib­uted to the de­clines. The quan­tity of pre­scribed opi­oids fell in 85 per­cent of Ohio coun­ties from 2010-2015, for ex­am­ple, as the state tight­ened reg­u­la­tions for pain clin­ics and started re­quir­ing clin­i­cians to check data­bases to see whether pa­tients were get­ting opi­oid pre­scrip­tions else­where.

The de­cline doc­u­mented in the analysis also co­in­cided with the fed­eral govern­ment’s tight­en­ing of pre­scrib­ing rules in 2014 for one of the most com­mon painkillers: hy­drocodone com­bined with a se­cond anal­gesic, like ac­etaminophen.

In many states, in­clud­ing Ohio, re­stric­tions on pre­scrib­ing have co­in­cided with stag­ger­ing in­creases in over­dose deaths from heroin and its far more pow­er­ful, syn­thetic rel­a­tive, fen­tanyl. But Schuchat, point­ing to sev­eral stud­ies, said the CDC had found no clear-cut ev­i­dence that tighter pre­scrib­ing played a role in the ris­ing use of il­licit opi­oids.

“We do know that when you start people on pre­scrip­tion opi­oids, the risk of un­in­tended con­se­quences and il­licit use goes up,” Schuchat said. “But our staff has done in­ten­sive analy­ses to see whether chang­ing poli­cies for pre­scrip­tion drugs shifts people into il­licit use, and the an­swer is no.”

While the analysis found that the amount of opi­oids pre­scribed per capita re­mained ex­tremely high in many coun­ties in 2015, some ex­perts warned that averages could be mis­lead­ing.

“An enor­mous amount of opi­oid vol­ume is driven by a very small num­ber of pre­scribers,” said Dr. Caleb Alexan­der, co-di­rec­tor of the Johns Hopkins Cen­ter for Drug Safety and Ef­fec­tive­ness. “They need to be in­ter­vened upon, tar­geted with ed­u­ca­tional out­reach and, if nec­es­sary, pro­fes­sional or reg­u­la­tory sanc­tion. My sense is that’s not yet hap­pen­ing enough.”

At­tempts to re­strict opi­oid pre­scrib­ing have up­set many pa­tients with chronic pain who say their needs are be­ing ig­nored in the rush to stamp out the ad­dic­tion epi­demic.

“One group I think that has been af­fected with­out ques­tion is pa­tients who are com­pli­ant with their reg­i­men, who have a clear di­ag­no­sis and have been man­aged ap­pro­pri­ately, but now find they can’t con­tinue to re­ceive opi­oids that al­lowed them to con­tinue to func­tion,” said Dr. Daniel Carr, di­rec­tor of Tufts Med­i­cal School’s pro­gram on pain, re­search ed­u­ca­tion and pol­icy.

But others say there is very lit­tle ev­i­dence to sug­gest opi­oids are ef­fec­tive for chronic pain that is not caused by can­cer. The CDC pre­scrib­ing guide­lines pub­lished last year, which were op­posed by many pain doc­tors and drug in­dus­try groups, rec­om­mend that doc­tors first try ibupro­fen or as­pirin to treat pain. The guide­lines, which are non­bind­ing, also rec­om­mend lim­it­ing opi­oid treat­ment for short-term pain to less than a week.

“If you are on opi­oids longer than three months, your risk of be­ing ad­dicted in­creases by 15-fold,” Schuchat said.

One chal­lenge in cut­ting opi­oid use, Alexan­der said, is that while in­sur­ers are plac­ing new re­stric­tions on opi­oid pre­scrib­ing, many are strictly lim­it­ing or not yet cov­er­ing al­ter­na­tive treat­ments for pain, such as phys­i­cal ther­apy and acupunc­ture, or even other types of med­i­ca­tion that could help.

De­spite the na­tional de­cline in the amount of opi­oids pre­scribed, the analysis found that the av­er­age num­ber of days that opi­oid pre­scrip­tions were meant to last ac­tu­ally in­creased in 73 per­cent of the coun­ties from 2010-2015. Over­all, the av­er­age sup­ply grew about 14 per­cent, to 17.7 days’ worth from 15.5. Schuchat said that could be be­cause fewer doc­tors were start­ing new pa­tients on opi­oids — ini­tial pre­scrip­tions are of­ten smaller — and doc­tors in­stead were pre­scrib­ing largely to long­time pain pa­tients.

The top-pre­scrib­ing coun­ties as mea­sured by the amount of opi­oids pre­scribed per capita — in­clud­ing Surry County, N.C., and Clai­borne County, Tenn. — pre­scribed six times more opi­oids per capita in 2015 than the low­est-pre­scrib­ing coun­ties.

One weak­ness of the study, as Carr and the CDC re­searchers pointed out, was that it could not eval­u­ate the rea­sons for pre­scrip­tions, and how of­ten they were given for chronic pain ver­sus acute or end-of-life pain.

The analysis also did not in­clude opi­oid pre­scrib­ing data from about 13 per­cent of the na­tion’s coun­ties be­cause it was ei­ther in­com­plete or un­avail­able.

AP/TOBY TAL­BOT

This file photo shows hy­drocodone-ac­etaminophen pills, also known as Vi­codin, ar­ranged for a photo Feb. 19, 2013, at a phar­macy in Mont­pe­lier, Vt.

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