Cutbacks in Opioid Prescribing Are Not Working

By Pat Anson, Editor

Where is the evidence that reduced opioid prescribing is lowering rates of addiction and preventing overdose deaths?

Opioid prescribing has been in decline for years, but overdose deaths from heroin and fentanyl are soaring around the country, particularly in the East and Midwest. The Centers for Disease Control and Prevention reported this week that 33,091 people died from opioid overdoses last year, a 16% increase from 2014.

Most of the increase was attributed to heroin and illicit fentanyl. For the first time, deaths involving those illegal opioids now outnumber those from prescription opioids.

Yet doctors remain under enormous pressure from lawmakers, regulators, hospitals, insurers, medical societies and the media to reduce their opioid prescribing. Two recent examples come from healthcare providers in Pennsylvania.

Geisinger Health System, a large healthcare provider with nearly 1,600 physicians serving over three million people in Pennsylvania, is preaching the benefits of reduced prescribing.

"Opioids are not the answer," Mellar Davis, MD, a palliative care physician at Geisinger, said in a news release. "Chronic pain rehabilitation, exercise, cognitive behavioral therapies, acupuncture, yoga or tai chi are all better options than opioids.”

PinnacleHealth Medical Group, a smaller network of more than 200 primary care providers in central Pennsylvania, released an update on the opioid reduction program it began in 2014. Opioid prescribing by PinnacleHealth physicians has fallen by 20 percent, and a spokesperson says there is some evidence the program is helping to reduce overdoses in its coverage area.

“According to our internal data, our admissions for overdoses have declined in our primary zip codes.  This data was not tracked by what type of drug (prescribed or street) that led to the overdose,” Kelly McCall, public relations manager for PinnacleHealth said in an email.

“While the medical group initiative would not be the sole reason for this decline, as PinnacleHealth is part of several community wide initiatives to curb drug abuse, it does demonstrate that the reduction initiatives haven’t caused an increase in misuse of other drugs and has been part of multiple system-wide efforts to address drug misuse.” 

With so many doctors cutting back on opioid prescribing, overdose deaths in Pennsylvania should be falling, right?

Wrong.

According to a lengthy and detailed report by the U.S. Drug Enforcement Administration, drug-related overdose deaths increased by over 23 percent in Pennsylvania last year.

Heroin was involved in over half of those deaths (55%), followed by fentanyl (27%), cocaine (24%) and the sedative Xanax (21%).

Prescription pain medications such as oxycodone (19%) and hydrocodone (6%) play a relatively minor role in Pennsylvania’s overdose epidemic.

Sadly, Pennsylvania’s heroin and fentanyl crisis has only worsened in 2016. On a single day in Philadelphia last month, nearly 50 people overdosed on a “bad batch” of heroin that was most likely mixed with illicit fentanyl.

Pennsylvania lawmakers have responded to this crisis by going after pain medication. Governor Tom Wolf signed legislation last month that reduces the number of painkillers than can be prescribed in emergency rooms and to minors, establishes mandatory education in safe prescribing for doctors, and creates more drop-off locations for unused prescription drugs.

All of that is well and good – and may prevent some deaths – but there is no evidence that it will have much of impact on the overall problem. It also serves as a diversion from the real issue, which is fentanyl and heroin.

While it is often argued that many heroin users start out with prescription opioids, the vast majority are not legitimate pain patients. They obtained the pain meds illegally, used them non-medically, and got hooked. Taking opioids away from pain patients has not stopped people from using heroin or fentanyl – and it may actually be making the problem worse by forcing some patients to turn to streets drugs for pain relief.

But the head of the Centers for Disease Control and Prevention still sees the two problems as being "intertwined."

"The epidemic of deaths involving opioids continues to worsen," said CDC Director Tom Frieden, MD. "Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems. We need to drastically improve both the treatment of pain and the treatment of opioid use disorders."

“Reducing opioid prescribing is not going to save many lives at this point, even though it gives many officials a chance to look like they are doing something,” Stefan Kertesz, MD, a primary care physician and an associate professor at the University of Alabama School of Medicine, recently told PNN. “If we have been reducing prescribing for several years, and the misuse of prescription pain relievers is near all-time lows… and overdoses are either staying very high or skyrocketing, then we need to change our assessment of the problem and refocus our response.”

It’s not just Pennsylvania that has gone down the wrong rabbit hole. In October, the CDC released a report complimenting Blue Cross Blue Shield for its efforts to reduce opioid prescribing in Massachusetts. The CDC said over 21 million fewer opioid doses were dispensed to Blue Cross Blue Shield members in the state from 2012 to 2015.

What happened to overdose deaths during that period? Fueled by fentanyl and heroin, opioid overdoses in Massachusetts more than doubled – which neither the CDC nor Blue Cross Blue Shield were all that eager to discuss.  The CDC told Pain News Network it will "take time" before overdoses start to decline and that “assessing what happened before and after the policy at the mortality level is inappropriate."

CDC Guidelines Causing "Passive Genocide"

The message is clearly going out to doctors around the country that they better cutback their opioid prescribing, even though reducing the supply of pain medication has had little or no impact on addiction and overdose rates. Some critics believe the CDC’s own prescribing guidelines, which discourage opioid prescribing for chronic pain, have actually caused more harm than good.

“The CDC guidelines have become an epidemic. More and more organizations and offices have signed on with them and people are being treated shamefully and unethically,” says Janice Reynolds, a retired nurse, pain sufferer and patient advocate. “These so called guidelines are a major part of the passive genocide of people living with pain. The stress related to them is also increasing the number of diseases and deaths we are seeing. I am sure if someone really looked at it, we would see more deaths from them than the so-called addiction epidemic.”

You would think medical organizations would be rising to defend pain patients from the anti-opioid hysteria, but just the opposite is happening. At a pain care summit this week in Washington DC, hosted by the physician’s group Alliance for Balanced for Pain Management, the focus was clearly on prescribing fewer opioids.

The keynote speaker at the summit was not a pain patient or even a pain doctor, but Ryan Leaf, a failed NFL quarterback who struggled for decades with painkiller addiction, and is now in recovery after serving a prison term for burglarizing homes for oxycodone and Vicodin. Hardly the poster child for responsible opioid use.

The Alliance also released a promotional video promoting the need for “multimodal analgesia,” which is described as a “personalized, multi-prong approach” to pain management that includes nerve blocks, epidurals, injections, physical therapy, acupuncture, massage and biofeedback, among other treatments.

Opioids are only mentioned in passing, with the caveat that “they are hardly the only pain treatment or the best treatment.”