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Docs Not Solely Responsible for Patients' Opioid Abuse, But Prescription Pads Do Play a Role, Says Researcher
Are America’s physicians responsible for the soaring rate of opioid abuse and overdose deaths across the country?
“Not exclusively,” says Dr. F. Perry Wilson. “But we can’t deny that somewhere in the chain of events that leads to opioid abuse lies a prescription pad.”
Wilson, a MedPage Today clinical reviewer, recently examined data that helps shed at least some light on the question. Wilson’s interest was piqued after a study appeared in the journal Pain that found “growing evidence that opioid prescribing in the United States follows a pattern in which patients who are at the highest risk of adverse outcomes from opioids are more likely to receive long-term opioid therapy.”
The Pain study said there is “evidence of greater opioid receipt among…patients with a breadth of psychiatric conditions” – including existing and previous opioid abuse.
“Those who got opioids were more likely to have an antecedent history of opioid use disorder, substance use disorder, and a host of other psychiatric problems,” Wilson wrote in MedPage Today. “They were also significantly more likely to have received psychotropic medications.”
Although it looked at a huge database of more than 10 million patients covering the decade 2003 to 2013, the Pain study lacked a broad spectrum of patients. It relied mostly on employer-insured patients (people with jobs and with income) and didn’t included the tens of millions of other Americans who fall into a host of other categories – including unemployed and so on.
Wilson decided to look more deeply at the phenomenon of opioid prescribing to attempt a better grasp of the role America’s doctors play in all categories of patients.
“So opioid prescriptions are going to some high-risk individuals,” he asked. “But how many of those would turn into chronic users?”
The Pain study concludes that after 18 months, only 1.3 percent of individuals transition from one-time to chronic use, based on prescription records.
“How do we think about that 1.3 percent?” Wilson asks. “It may seem like a small percentage that isn’t worth worrying about, but multiply that by the number of prescriptions we’re handing out per year: about one for every person in the country.”
That’s 4.2 million Americans at risk of opioid dependence and abuse from being initially prescribed opioids by a doctor.
“And also realize that 1.3 percent is an underestimate,” Wilson says. And he points out that the Pain study captures mostly productively employed people, and only those on chronic prescription opioids.
“Most opioid abuse comes from sources other than the individual’s doctor,” Wilson said.
Most non-medical users of prescription opioids get them from friends or family, not their doctor, according to numerous studies, some going back over a decade. The greatest source, by far, is for free from friends and relatives (see chart) for most categories of user. And a 2008 study found that diverted drugs were the major source of opioid overdoses.
Of course, there have been numerous suggestions from various medical sources recently that the opioid prescribing habits of America’s doctors have played a significant role in the opioid abuse epidemic. Long-term opioid therapy for all but a few chronic conditions has been declared too risky by numerous agencies.
For example, the CDC published its new CDC Guideline for Prescribing Opioids for Chronic Pain last March. The guideline, which provides recommendations for prescribing opioids for patients 18 and older in primary care settings, has had quite an impact on many physicians – some quite positive, others not so much.
“Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care,” says the CDC.
Prescribing opioids longer-term received some pretty harsh words from the agency.
It’s unknown how many people move from a prescription to abuse and how fast that happens, on average. The Pain study attempted to answer those questions, but its limitations prevented an easy answer.
“The major unknown,” Wilson says, “is the rate of transition from licit to illicit opioid use. And that data is harder to find than, well, street fentanyl nowadays. We also need to know the reason for that initial opioid prescription. It is a very different thing to receive oxycodone after you have your wisdom teeth removed and to receive it for chronic low back pain, and the risk of transition to opioid use disorder is much higher in the latter.”
The bottom line, however, is that there’s just not enough data to support major finger-pointing at prescribing physicians. Wilson does say that prescription pads play a role in the drama, but probably not the leading one.
Here at Novus, we can say with certainty that a large number of patients seeking our help with opioid withdrawal point at an early painful condition, operation or injury treated with opioid painkillers – treatment that got out of hand.
We’re also pleased that research into the problem of prescription drug dependence continues to gain serious attention.
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