As opioid overdose rates reach an all-time high in the United States, much of the public discussion is dominated by prescription opioids and the misdeeds of pharmaceutical companies. However, the reality of opioid use and overdose is more complicated, and these narratives put too much emphasis on reducing opioid prescriptions – something that was already accomplished several years ago. Current efforts to reduce prescribing are largely ineffective at reducing overdose rates, and instead serve to make these medications harder to access for individuals who truly need them, such as people with chronic conditions, disabilities, and individuals hoping to relieve their pain prior to death.
It is true that during the 2000s, opioid prescribing in the U.S. proliferated, motivated by profit rather than the needs of patients or concerns about safety. However, this problem was recognized in the early 2010s, and opioid prescribing was significantly reduced. Data from the CDC shows that opioid dispensing peaked in 2012; since then, prescriptions have dropped by 50%. Today, opioid prescribing rates have decreased to 1993 rates – which is before OxyContin, one of the main medications that fueled overprescribing, was even introduced to the market.
People with opioid prescriptions are also not the right population to focus on to reduce overdoses. The vast majority of opioid overdoses are not among individuals with prescriptions for the medication. One study found that only 1.3% of people who overdosed had an opioid prescription, while analysis of CDC data shows “no evidence of correlation between the number of opioids prescribed and the non-medical use of opioids or of opioid addiction.” Instead, opioid overdose rates have continued to increase while opioid prescribing rates have plummeted, indicating that efforts to stem overdose simply by reducing prescribing are ineffective.
Ongoing efforts to limit opioid prescribing have been counter-productive, pushing people who use opioids from safer prescription pills to more dangerous drugs like heroin and fentanyl. Current overdose numbers are being driven by concealment of strong synthetic opioids in illicit drugs sold as heroin or prescription drugs. In fact, the percentages of opioid overdoses caused by synthetic opioids other than methadone have risen from 14% in 2020 to 60% in 2017. Illicitly produced fentanyl and heroin account for the highest rate of opioid overdose rates, and current efforts to reduce opioid prescribing only fuel this crisis.
Meanwhile, an estimated eight million Americans–especially individuals with chronic pain, people with disabilities, and people receiving end-of-life-care–rely on opioids to manage pain. Focusing only on reducing the rates of prescribing opioids often translates into denial of care for communities who already face difficulty accessing needed care, particularly Black, Indigenous, and People of Color with these conditions. Policies restricting opioid prescribing have had a chilling effect on providers’ willingness to prescribe opioids and increased stigma for people managing pain.
One study found that people who manage their pain with opioids struggle to find primary care clinics that will take them as a patient and 81% of physicians are hesitant to see a patient who uses opioids to manage pain. In addition, terminally ill patients with advanced care are struggling to receive adequate pain management and are relying more on emergency departments for pain treatment.
Many of the individuals who rely on opioids to function are low-income people and Medicaid enrollees; more than one in three adults under 65 who are enrolled in Medicaid have a disability (compared with about 12% of adults under 65). In addition, prevalence of chronic pain and high-impact chronic pain are both higher among individuals living in poverty and adults with public health insurance.
However, Medicaid enrollees may face specific barriers in accessing necessary treatment, including opioids, for chronic conditions. For example, Arizona enacted legislation which limits initial opioid prescriptions to seven days for those insured by Medicaid, a policy that was criticized by some in the medical community for being too strict and not allowing for patient-centered care.
In addition, the evidence suggests that efforts to scale back opioid prescribing have resulted in people on Medicaid losing access to their medications, often with short notice. One study found that discontinuation often happens abruptly, often in 24 hours for Medicaid enrollees on opioids for more than 90 days. This results in an increased risk of adverse health events, with almost half of these cases resulting in hospitalization or an emergency department visit. In the same study, only about 1% of those with diagnosed substance use disorder prior to dose reduction were transitioned to an opioid use disorder medication. These actions are counter to CDC’s guidelines for treatment of chronic pain include opioid prescribing, which warn of the potential harms of inconsistent use of the guidelines.
In another study, researchers found that a considerable percentage of patients prescribed long-term opioid therapy are undergoing dose reduction, often at a rapid rate. Finally, two studies found that dose variability and discontinuation were associated with increased risk of overdose death. The first study found that dose variability was associated with a threefold increased risk of overdose death for patients on long-term opioid therapy. The second study found that discontinuation of opioid therapy did not reduce the risk of death and was associated with an increased risk of overdose death.
Just this past month, the CDC revised it’s opioid prescribing guidelines, acknowledged that their prior rigid standards resulted in harm, and recognized the role for opioids in pain management. The new guidelines allows for more flexibility for providers to focus on patient-centered care, and includes warnings against abrupt tapering off. This changed guidance represents an important step in the right direction. Efforts to reduce overdoses must shift their focus away from reducing prescriptions needed by chronic, terminally ill, and pain patients, and instead prioritize harm reduction interventions, including safe supply, as well as increasing access to medication-assisted treatment, the gold standard in opioid use disorder treatment.
