How to end the “opioid paradox” – Pain News Network

ByDonald L. Leech

Dec 9, 2021


“Overall, the country’s response to the oral opioid crisis has been to tighten patient supplies and impose institutional and practitioner quality indicators based on the number of tablets. Governments, payers, and pharmacies have assumed authority to limit opioid prescribing, often indiscriminately, based on a misinterpretation of Centers for Disease Control guidelines or on the basis of no actual guidelines. », They wrote.

“The pill count has become a de facto standard used by healthcare organizations to highlight their success in reducing opioid use, but there is no discussion of how these reductions affect outcomes. for patients. A critical issue is that agencies imposing political restrictions do not measure and are not accountable for patient outcomes. Mandatory opioid prescribing limits may be too low to adequately control pain, or too high to reduce oversupply.

The three authors say more innovative and comprehensive approaches are needed to better manage the supply of prescription opioids, prevent diversion, and resolve the opioid paradox.

“This involves immediate action to address the use, storage, return and harm reduction of opioids, with a particular focus on patients and communities,” they explained.

Reduce demand

In recent years, federal and state agencies, health care organizations, and insurers have created new guidelines for the treatment of pain, many of which take a unique approach to prescribing opioids that ignores the conditions. needs of an individual patient.

“Legislative, regulatory and insurer limitations on the prescribing of opioids alone have not achieved the intended goals and are considered unlikely to achieve them. One of the reasons is that they place strict restrictions on an extremely heterogeneous patient population, ”the authors said.

Rather than limiting or withholding opioids after surgery – which has become increasingly common – Drs. Kharasch, Clark and Adams urge anesthesiologists and surgeons to provide patients with enough opioids for adequate pain relief, as undertreated acute pain can develop into chronic pain and become a risk factor for drug abuse. opioids.

Lower doses of opioids may be effective in treating postoperative pain, the authors say, when combined with multimodal strategies that also use non-opioid drugs and therapies. The same goes for the use of long-acting opioids such as methadone, which can lead to less postoperative pain and relief that lasts for weeks or months after a single dose.

Appropriate disposal of leftover pills

Hundreds of millions of opioid pills are distributed to patients but are not used each year, according to the authors. Most of the remaining pills are kept by the patients and few are stored safely. Only a fraction is properly disposed of or returned.

“The current difficulty of returning prescription opioids contrasts sharply with the ease of obtaining them. It is illogical and dangerous,” said Drs. Kharasch, Clark and Adams said.

They believe that pharmacies dispensing opioids should be required to provide patients with instructions for proper return and disposal; addresses and telephone numbers of disposal stations; and a self-addressed, prepaid envelope for returning unused pills. Disposal stations should be available year round, not just on “prescription recovery” days.

Another innovative approach would be opioid “buy-back” programs, similar to the gun buy-backs used by law enforcement agencies to get unnecessary guns off the streets. A pilot opioid compensation program found that 30% of operated patients were willing to participate in buyouts, selling their remaining opioids for up to $ 50.

Partial fillings

Kharasch, Clark and Adams also suggest a more partial filling of opioid prescriptions. A 2016 federal law allows patients and clinicians to request partial fillings for hydrocodone, oxycodone, and other strong Schedule II opioids. Partial filling for the weaker opioids in Table III-V has been permitted for decades, but is not widely practiced.

According to one estimate, 36 million postoperative opioid prescriptions could be partially filled each year. One obstacle for partial refills is the additional paperwork and cost to pharmacies, estimated at $ 15 for each prescription.

“Opioid partial refills may be the most effective intervention to deplete America’s medicine cabinets of unused prescription opioid pills, reduce the opioid pool, improve the prescription opioid ecosystem, and prevent abuse, embezzlement and death, ”the authors said.

Kharasch, Clark and Adams focus on reducing diversion, even though less than one percent of legally prescribed opioids are diverted, according to the DEA. Partial fillings may reduce leftover pills in medicine cabinets, but it will do nothing to prevent wholesale theft of opioids from hospitals, drugstores and the pharmaceutical supply chain.

The authors also subscribe to the myth that most street addicts start with prescription opioids and pain patients refuse opioids “switch to street drugs” and counterfeit pills containing fentanyl.

But Kharasch, Clark, and Adams have some interesting ideas on how to tackle the opioid paradox, including the long-standing recognition that current opioid reduction strategies have been a complete failure.

“Attempts to address the problem by limiting the supply of patients on their own have not been successful and the pool of prescription opioids remains large. Further efforts to reduce the pool are needed, both by decreasing demand (reducing pain through better treatment) and facilitating the elimination and return of opioids, ”they concluded.