Is a Reduction in Access to Prescription Opioids the Cure for the Current Opioid Crisis?

There is little doubt that opioid abuse has been at epidemic levels in this country for the past few decades with correspondingly high rates of overdose deaths—rates that show no sign of abating anytime soon.¹ Although overdose deaths due to prescription opioids are still increasing slightly, the deaths attributed to heroin and fentanyl have skyrocketed in the last two years, reflecting easy access to illicit and synthetic opioids.

Much of the increase at the outset of the opioid crisis (1995–2010) was attributed to two factors: first, easy access to a growing market of prescription opioid drugs (PODs), and second, professional pressure on physicians to more aggressively treat pain with these opioids, which were falsely concluded to have low abuse potential in patients. In response to this evolving crisis, a number of programs were implemented to limit access to PODs for nontherapeutic care, such as the introduction of abuse deterrent formulations, legislative efforts targeting pill mills, a crackdown on “script” doctors, changes in physician prescribing practices motivated in part by new practice guidelines (e.g., those of the Centers for Disease Control and Prevention), and prescription monitoring programs. However, these “solutions” to the problem have had both anticipated (e.g., a reduction in specific PODs) and unanticipated consequences. The latter are so serious that they raise an important question: Is the cure (POD supply reduction efforts) worse than the disease itself (prescription opioid abuse)? I believe the “cure” may have actually exacerbated the crisis and generated an even more serious problem.

TRANSITION TO HEROIN

Faced with a shortage of the desired POD because of reasonably good supply reduction efforts, opioid-dependent users were forced to make one of two choices: (1) stop using the POD (or all PODs) in question, or (2) switch to a more accessible opioid. Regrettably, for many the choice was simple. Heroin has become an easily accessible and inexpensive alternative that is also readily accessible on the street. Although there was some initial controversy about causality, it is no longer tenable to deny that a reduced supply of PODs has led many to turn to heroin.²

The public health impact of a transition from relatively “safe” PODs to a far more dangerous one—heroin—cannot be overstated. The transmission of blood-borne pathogens from sharing needles, cardiovascular problems, and other medical complications that occur with injection or snorting of an impure, nonsterile substance represent a stark reality. Equally important, overdose deaths are far more likely for heroin than PODs because of imprecisions in estimating dose, exacerbated by the reality that there may be considerable adulterations with more dangerous synthetic drugs such as fentanyl and its analogs.

Adding to these concerns, there have been some disturbing new developments in the use of heroin. Specifically, although much of the initial increase in use was tied to the efforts to reduce the supply of PODs, there is growing evidence that new opioid users, who previously used opioid drugs as their entry into opioid use, are now increasingly being introduced to opioids by using the more easily accessible heroin as their first exposure to an opioid. This is a remarkably ominous turn, because it suggests that there is an evolving new pathway to heroin by opioid-naive, nontolerant individuals for whom the risk of overdose is considerable. It is unknown how many new initiates to heroin overdosed upon first exposure, but this needs to be examined as part of an assessment of the marked increase in opioid overdoses and deaths nationally. Additionally, the widespread intentional and unintentional exposure to fentanyl raises the specter of a new opioid epidemic on the horizon for which we need to be prepared. In short, there is good reason to believe that opioid abuse itself continues at a relatively substantial pace, with the only change being the opioid of choice. As I discuss here, unless we address the issue of how we reduce demand, efforts to reduce supply are destined to fail as they have for the past hundred years or so.

PHYSICIANS’ FEAR OF OPIOIDS

A reduction in the prescribed use of opioids is perhaps the most serious concern about supply reduction efforts. Coupled with the well-publicized epidemic of opioid abuse, prescriptions for opioids have decreased sharply over the last three years.³ This reflects either that physician education, prescription monitoring programs, and other measures targeting uninformed physicians over prescribing opioids have “worked” or, more seriously, that we have managed to scare physicians away from treating patients with opioids even if they are therapeutically appropriate. There is mounting evidence that the latter is in fact the case.⁴ Certainly the precipitous drop in prescriptions for opioids cannot, as claimed by some (e.g., Physicians for Responsible Prescribing of Opioid Drugs), entirely be attributed to rooting out bad physicians or poorly educated ones. It stretches credulity to postulate that there are that many poor physicians. Rather, it seems more likely that many competent physicians have simply stopped dealing with opioid therapy for pain—instead, just referring patients elsewhere.⁴ This is most unfortunate because we certainly do not want patients to suffer as a result of our efforts to reduce the number who would divert prescribed opioids for nontherapeutic purposes.

BALANCING RISK–BENEFIT RATIO

It should be clear that we have a history in this country of reacting to problems in a pendular fashion, going from one extreme to another until we finally reach the middle ground. Thus, in the early to mid-1990s we stressed that pain was massively undertreated even though it was claimed that we had very effective drugs to treat it (aka opioids) that lacked strong abuse potential when used in pain patients—an erroneous conclusion. This led to often-unnecessary increases in the use of these drugs (and diversion for nontherapeutic use). It appears the problem is now in danger of switching back in the opposite direction: underuse of medications that have a legitimate therapeutic purpose. We need to return to the middle ground where opioids take their rightful place as a useful treatment of certain types of pain with minimal use by nonpatients. The tricky part, of course, is defining the middle ground, and we need to refocus our efforts on achieving the appropriate risk–benefit ratio.

CONCLUDING REMARKS

A logical conclusion from the forgoing discussion is that, at this point, we have successfully reduced prescription opioid abuse, but at a considerable cost. Indeed, it can be concluded that the intended cure for the prescription opioid abuse crisis may be worse than the disease itself: the evolution of a far more dangerous opioid epidemic (e.g., heroin and perhaps fentanyl or other synthetic opioids in the near future) and, perhaps as important, denial to patients in pain of medications from which they can benefit. However, it must be stressed that I am not suggesting that all opioid supply reduction efforts have no redeeming value. They do (e.g., prescription monitoring programs), but they also have unintended consequences and, most significantly, all of them lack the badly needed focus on the demand side. Specifically, unless we address and manage the demand for these drugs, the supply will be there, as it has been for every other drug epidemic for the last several hundred years.