As America continues to battle the worst opioid crisis the world has ever seen, it has gained an ally – the pharmaceutical industry. The industry is finally stepping up and supporting limiting prescriptions for opioid painkillers to seven-days for acute pain management, PhRMA CEO Stephen J. Ubl announced on 27 September.

This comes after the Centres for Disease Control and Prevention (CDC) released guidelines last year, recommending limiting both the strength and duration of the first opioid prescription a patient is given.

Both the trade group, PhRMA and American pharmacy giant CVS have agreed to limit prescriptions to seven days, for new pain management patients. PhRMA’s announcement after a meeting of the White House’s opioid abuse commission explained, “too often, individuals receive a 30-day supply of opioid medicines for minor treatments for short term pain.”

CVS has also announced that it will provide opioid prescription patients with counselling on the risks of addiction, including emphasis on the importance of storing medications safely and securely at home and disposing of unused ones correctly, to minimise the risk of them falling into the wrong hands.

The announcements are also in lieu with a new proposal from the Centres for Medicare and Medicaid Services to enforce hard limits on opioid doses.

PhRMA CEO Stephen J. Ubl. Photo credit: Alissa Ambrose/Stat
PhRMA CEO Stephen J. Ubl. Photo credit: Alissa Ambrose/Stat

It is not just patients; the biggest casualties are secondary drug users

Although the sale of opioid prescriptions seen in 1999 to 2014 has quadrupled, there has been no change in pain reported by Americans – rather, addiction rates are increasing.

According to estimates from the CDC, 0.7% to 6% of individuals who take opioid prescriptions are addicted. Therefore, perhaps the biggest consequence of the crisis is the sale, theft, and sharing of the painkillers, notably between young adults. Many people become addicted after taking leftover pills initially prescribed to someone else.

"There are millions of prescription bottles sitting in our bathroom cabinets and on our bedroom nightstands right now, including far too many prescription opioids that ultimately are used non-medically," explained Dr Caleb Alexander, co-director of the Johns Hopkins Centre for Drug Safety and Effectiveness. In 2016, there was a surplus of 3.3 billion unused pills.

“We’ve been watching the epidemic get worse, hidden in plain sight, for far too long, and these types of policies are necessary to reduce the incredible oversupply of prescription opioids,” Alexander said.

Always take the pro-patient approach

Previous CDC guidelines were “voluntary” but are now in the progress in becoming “enforceable” and they include preventing prescriptions for opioids over 90 milligrams from being sold unless and until physicians seek exceptions.

However, this would mean that many patients who currently need to take such high levels of drug could be left without it. Additionally, there are concerns that restricting prescriptions will lead to a Prohibition-era style criminal drug trade, which would be far more dangerous than what is currently happening.

Some doctors are suggesting that instead of putting the drug as the focus of abating the crisis, it may be more helpful to identify patients who are at an elevated risk before prescription and consequently explore how these risks can be reduced.

The more painful the surgery, the more likely addiction is, according to a report by the research firm QuintilesIMS Institute for Healthcare Informatics
The more painful the surgery, the more likely addiction is, according to a report by the research firm QuintilesIMS Institute for Healthcare Informatics

For instance, in surgical patients, according to a report by the research firm QuintilesIMS Institute for Healthcare Informatics, the more painful the surgery, the more likely addiction is. Patients who had undergone a colectomy were at the highest risk with 18% becoming long-term users. Knee replacement surgery patients followed them at 17% and hysterectomy patients at 7%.

Finally, and probably the most troubling is the increasingly inhumane treatment of patients with chronic pain upon ceasing prescriptions. It is possible that fearing investigation, doctors may terminate prescriptions for patients on long-term opioids.

In fact, many physicians have spoken openly about patients who having lost access to their medication have become bedridden, some even suicidal. In this case it becomes a struggle of ethics for doctors – is the death of one patient in order to protect the lives of others acceptable?

Finding the middle ground

Surgeon General Dr Vivek Murthy says, “we cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications. … We are trying to find an appropriate middle ground.”

Dr Patrice Harris, chairwoman of the American Medical Association's opioids task force acknowledges the struggle saying, "when patients seek physician help for an opioid use disorder – or need comprehensive care for chronic pain – one-size-fits-all limits, such as blanket prior authorization protocols, may cause delays in care that could severely harm patients."

Ubl, on the other hand is very firm, “We’ve always supported physician autonomy and the preservation of the physician-patient relationship but as you know, given the scope of this crisis, we believe it’s the right thing to do.”

"There's a lot of other things you can give that can help, but at the end of the day, if someone is in a lot of pain, opioids are part of the mainstay. We know there's a problem. The question is: What do you do about it? How do you keep these people from transitioning to long-term use?" anaesthesiologist Dr Eric Sun summarised. MIMS

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