The United States has long been plagued by drug addiction, but our current epidemic of opioid abuse, with its growing toll of overdose deaths, is starkly different.
It is partially driven by soaring rates of opioid prescribing, rather than by illegal street drugs. Deaths from prescription opioids have climbed in parallel with opioid prescribing in the U.S., which quadrupled from 1999 to 2010.
{mosads}Retail pharmacies dispensed 215 million opioid prescriptions in 2016 — enough to provide a bottle of narcotics to two-thirds of all Americans.
This epidemic calls for federal action to limit the quantity of opioids prescribed. This starts with acknowledging that the medical establishment helped create the crisis in the first place by over-prescribing opioids to treat chronic non-cancer pain.
An often-overlooked fact is that there was a marked change in the culture of prescribing on the part of physicians and other clinicians starting a few decades back.
Aggressive marketing by pharmaceutical companies played a role, as did the possibility of under-treating pain, the availability of new, long-acting opioid formulations and lack of education on the part of prescribers regarding the abuse potential of opioids. Once opioid-phobic, U.S. physicians have seemingly become liberal opioid prescribers.
This cultural shift led to exponential growth in the quantity of opioids prescribed for chronic non-cancer pain, an increase in the average length of time opioids were prescribed and higher dosages used by patients for a long period of time. Not surprisingly, our homes, schools and workplaces have been flooded with prescription opioid drugs, and millions of Americans have become needlessly addicted.
Governors and state legislatures have started taking action. A National Conference of State Legislatures report in July found that at least 23 states have passed laws to restrict prescribing. Most of the new state laws limit first-time opioid prescriptions to a supply ranging from three to 14 days.
Three steps should be adopted immediately. First, restrict first-time outpatient prescriptions to three days with one refill — only if needed — and prohibit outpatient prescriptions to adolescents. Use of narcotic painkillers before high school graduation is strongly associated with later opioid misuse, as well as heroin use.
Second, require that the lowest effective dose be prescribed in the form of immediate-release tablets. Short-acting forms and low dosages cut the risk of addiction. And third, restrict the broad range of clinicians who can prescribe opioids to specialists with demonstrated expertise in opioid management, who would work in coordination with primary care physicians.
Such sweeping federal legal or regulatory changes would require the support of physicians. While, the pharmaceutical industry has been justly criticized for its aggressive marketing of opioid drugs, less attention has been paid to the willingness of physicians to change the culture of prescribing. It’s time that we remember our duty to our patients.
Federal action could provide nationwide consistency to these state efforts. It could come from Congress as federal law, or in the form of regulation by the Food and Drug Administration or the Drug Enforcement Agency.
Alternatively, the Centers for Medicare and Medicaid Services could reduce or eliminate reimbursements to providers as an incentive to prescribe opioids responsibly.
As the carnage of addiction and death has worsened, agencies such as the Centers for Disease Control and Prevention proposed comprehensive approaches for attacking the problem, including physician education, increasing addiction treatment and improved access to naloxone, which can revive someone overdosing on opioids.
But in tackling this problem, we should not forget that it is largely driven by our prescription practices. Modifying our own prescribing behavior would go a long way to mitigate the epidemic.
Richard S. Larson, M.D., Ph.D., is executive vice chancellor at the University of New Mexico Health Sciences Center. The opinions expressed are those of the author and not the institution.