Navigating the National Public Policy on Prescription Opioids

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PALM SPRINGS, CA — Medical societies such as the American Academy of Pain Medicine (AAPM) should be involved in any public policy discussions on prescription opioids in order for a reasonable balance to exist between the need for pain management and the need to avoid addiction to and overdose from these agents, said Keith N. Humphreys, PhD, in a plenary presentation during the 2012 AAPM Annual Meeting.

“It is in the public interest and in your interest to be actively involved with the development and implementation of these policies,” he told AAPM meeting attendees.

The number of prescriptions written for opioids have increased from 76 million in 1976 to 210 million in 2010. Deaths from drug overdoses have more than tripled in the U.S. since 1990, from 4 to 12 per 100,000 population, a death rate higher than the heroin and crack epidemics combined, said Dr. Humphreys, of the Veterans Administration and Stanford University, Stanford, CA. These statistics create a “basic tension between maximizing pain relief and minimizing pain addiction,” he said.

To ensure opioids can be made available without increasing addiction, he urged pain-medicine specialists to embrace five emerging public policies, codes of practice, and cultural norms:

     1. Prescription monitoring programs (PMPs).
     2. Locking doctor-shoppers into a single prescriber.
     3. Making prescription “recycling" a cultural norm.
     4. Making abuse-resistant medication approval easier.
     5. Changing opioid-related medical practice.

1. Prescription monitoring programs (PMPs)
Previously, PMP systems were slow, hard to use, and rarely accessed; however, coverage, utilization, and technological sophistication are improving, and the majority of states now have operational programs. Although PMPs are “resisted and resented by many professionals, they are inevitable,” Dr. Humphreys said, and the more prescribers participate, the better the programs will work.

Challenges to PMP use include ease of access, the need for prescribers who live on state lines to access more than one state's system, and the quality of the data. For example, a patient may have received three prescriptions from three different prescribers over three weeks, which a PMP may flag as “doctor shopping,” but the physicians may all work in the same practice and the opioids legitimately prescribed.

2. Locking doctor-shoppers into a single prescriber
Doctor shopping is common in much of the U.S., Dr. Humphreys said, and public and private payers can lock such individuals into a single provider to help prevent overdoses and deaths. In 2008, Hall et al. reported in JAMA that more than once weekly, a West Virginian died of a drug overdose while holding prescriptions from five or more providers.

Medical professionals have the credibility to ask state Medicaid programs and private insurers to start lock-in programs, which “protect you and your patients,” he said, and pain-medicine professionals have the expertise to advise payers what the standards should be.

3. Making prescription “recycling” a cultural norm
Pointing out that the most common source of misused opioids is friends and family, Dr. Humphreys added that leftover medication is found in many homes in general and even more so in particular clinical situations, such as hospice care. Prescription take-back days and recycling programs can help drain off the reserve of abusable medication.

He said physicians have the credibility with patients to explain the need to get rid of unused medications and, as a clinical practice, protect family members such as “curious or entrepreneurial teenagers” from procuring opioids. In addition, pain-medicine specialists “have the stature to encourage elected officials and health authorities to facilitate take-back days.”

Dr. Humphreys provided one example: A sheriff's office in a small town in Arkansas (population: 20,000) held a take-back day and, in four hours, collected 25,000 pills. For those for whom opioids represent a significant expense, however, the likelihood is greater that they will share any unused medications with family and friends.

4. Making abuse-resistant medication approval easier
Developing a new medication and getting it approved costs hundreds of million of dollars. Since abuse-resistant medications are treated as new applications, “drug developers thus face a massive disincentive not to work on abuse-resistant drugs,” he said.

However, the U.S. Food and Drug Administration can always use input on the importance of abuse-resistant medications and, “the more informed any new regulation is, the more pain providers and their patients will benefit.”

5. Changing opioid-related medical practice
Educating patients and fellow providers that prescribing opioids may not be the only response to pain and breaking the “30-day” prescribing habit for opioids are just two ways in which opioid-related medical practice can be changed.

Others include “communicating to patients that sharing opioids is dangerous and illegal, learning how to recognize addiction, and evaluating methods of preventing iatrogenic addiction,” Dr. Humphreys said. One example he provided is whether perioperative gabapentin can reduce the risk of iatrogenic addiction after surgery.

Creating a culture of learning and monitoring around opioid prescribing is one way to navigate the Scylla and Charybdis between treating pain while preventing addiction, he concluded.

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