The unavoidable tension in attacking the opioid crisis is which time frame you’re talking about.
In the short term, many policies that would limit opioid prescriptions for the purpose of saving lives would cause people to turn to heroin or fentanyl.
In fact, over a 5-to-10-year period, that would increase deaths, not decrease them, according to a simulation study published in the American Journal of Public Health. The study was conducted by three Stanford University researchers, Allison Pitt, Keith Humphreys and Margaret Brandeau.
“This doesn’t mean these policies should not be considered,” said Mr. Humphreys, a former senior policy adviser at the White House Office of National Drug Control Policy during the Obama administration. “Over longer periods, they will reduce deaths by reducing the number of people who initiate prescription opioids.”
A large proportion — 80 percent by one estimate — of heroin users in the United States previously used prescription opioids. In some cases, they were directly prescribed narcotic pain relievers, perhaps after a painful dental procedure or operation. In addition, drugs prescribed to one person can be diverted to others who don’t use them for medical purposes. So restricting opioid prescriptions would seem to make sense.
But it’s not so simple. That approach reduces access to drugs for people who legitimately need them for pain, as many readers, pointing to their own predicaments, have commented after Upshot articles on opioids.
Amie Goodin, a researcher with the University of Florida College of Pharmacy who wrote an editorial accompanying the opioid policy simulation study, said, “Current policies to limit opioid prescriptions leave some pain patients high and dry, resulting in a new wave of unintended consequences for patients with untreated chronic pain.”
“In addition to other approaches to addressing the opioid epidemic, there needs to be more nuanced prescribing rather than simply cutting people off opioids,” said Laura Burke, an emergency physician with Harvard Medical School and the Harvard T.H. Chan School of Public Health.
Prescriptions could be avoided for cases of mild-to-moderate pain — think of a sprained ankle or a tooth extraction. Opioids could largely be reserved for much more severe pain — accompanying major surgery and cancer, for example. “We should rely more on other therapies to help patients handle less severe pain,” she added.
The simulation study bears this out. Reducing opioids for short-term pain saves lives in the long run, even as it leaves some patients experiencing more pain. This is the fundamental trade-off opioids present, with which we have been battling for decades. As the pendulum swung further toward treating pain, opioid-related deaths ballooned. Now to stem the deaths, it is swinging back, challenging us to treat pain in other ways.
(It’s important to point out that the simulation may not perfectly predict the consequences of policy change. It relies on assumptions and can’t anticipate unexpected societal changes. But it does show us some of the possible, unintended consequences of policies that we might not otherwise consider.)
The opioid epidemic is really a syndemic, meaning it’s composed of multiple, concurrent epidemics — driven both by prescription pain medication and by illicit heroin and fentanyl. The Centers for Disease Control and Prevention estimates that more than 70,000 people died of a drug overdose in the last year, most of them from opioids. By one estimate, over the next 10 years, opioids could kill over a half million more, two-thirds from heroin and one-third from prescription pills.
A recent study in JAMA estimated that clamping down on opioid prescribing would result in a very small reduction in opioid-related overdose deaths relative to what it would be otherwise: no more than about 5 percent by 2025.
The American Journal of Public Health study looked at the effects of 11 policies to address the consequences of opioids. These included tightening the reins on prescribing, like policies to promote greater prescription drug monitoring or limits on how many days that opioids could be prescribed — as is now expected for Medicare drug plan coverage and reflected in some private plans.
They also include policies that would reduce harm from opioid misuse, like expanding the use of the overdose rescue medication naloxone or addiction treatment.
The bad news in the short run is that no one policy, by itself, would put a substantial dent in the expected number of deaths from opioids. The most effective single policy, according to the study, is increasing the availability of naloxone. But doing so would reduce the total number of predicted opioid deaths over the next 10 years by only about 4 percent.
“Expanding access to naloxone is inexpensive and saves lives,” said Ms. Pitt, lead author of the study. “That’s an attractive combination, but we should be realistic that it will only save a small percentage of opioid deaths.” For bigger gains, more must be done.
The good news is that combining increased access to naloxone with more needle exchanges and addiction treatment could save more than twice the number of people than naloxone alone.
Policy interventions can prevent many deaths, as well as the other destruction that opioids bring to individuals, families and communities. But prescription opioids are neither all bad nor all good. Policies that sound sensible — potentially helping many people — could also cause a lot of damage, particularly in the short run.
