In Homer’s epic poem The Odyssey, sirens lured sailors to shipwreck off the coast of their island with the temptation of music and song. Recognizing the danger, Ulysses devised a plan to tie himself to the mast to guarantee restraint as he sailed by. While it proved more challenging for him and his crew than they imagined, they made it home. The wisdom of this ancient story relates to today’s battle with opioids: to get past the allure of continued and often troublesome opioid use patterns, patients and doctors need a plan in hand before the first opioid is ever used.
The proposed new federal guidelines for prescribing opioids seek to fill that gap, but they are a mixed blessing for physicians who are trying to help patients deal with pain. It is a massive document from the CDC, alternately praising the medicinal value of the drugs while warning of severe dangers.
No More Dosage Ceiling
The headline takeaway is that doctors are free to ignore a previously recommended ceiling on dosage. The new guidance says doctors should use their best judgment while turning first to non-opioid therapies in as many cases as possible. This change comes after the outcry of many pain patients who have been dependent on opioids for years and have trouble getting continued prescription orders.
The CDC analysis is comprehensive, but its endorsement of “free and clear” opioid prescribing is not accompanied by a universal strategy that a doctor can follow to ensure patient safety.
In this regard, Australia is one step ahead of the U.S. I am one of 17 members of the development group there that is drafting a new set of opioid prescription guidelines. We are concentrating on the clinical and public health benefits stemming from always having a deprescribing plan.
Before Prescribing, Draft a Deprescribing Plan
A deprescribing plan involves laying out a specific path for reducing, and then eliminating, opioid use even before the first prescription is written. It is often a way for physicians to involve other resources, including mental health care, community support, and social services to assist the patient as opioid dosage gradually falls.
Importantly, the plan should not be an act of enforcement, but rather, the product of physician and patient working together. Properly structured, the plan will give the patient confidence that an opioid prescription may help relieve pain in the short run but will not lead to dependence or addiction in the long term. The goal is to produce a better outcome for the patient than is possible with continued opioid use.
Public Health Stakes Are High
The public health stakes of devising such guidelines for general practitioners are especially high. Doctors are more naturally focused on clinical results rather than social impacts. If the CDC sticks with its recommendation to abandon the ceiling on daily opioid dosage (90 morphine milligram equivalents, which many pain specialists said was inadequate), some doctors will routinely opt for higher doses, and could well bypass devising deprescribing plans. But more prescriptions will harm families and communities. We know that opioid prescriptions spread through households. A prescription written to one family member makes it more likely that another will get one.
There are economic and labor consequences to opioids as well. A 2015 county-level study found that opioid prescribing could account for 43% of the observed labor force decline. About half of prime-age men not in the labor force were on pain medication and two-thirds of them were taking prescription pain medications. It is likely that persons in prime-age who are not in the workforce could benefit more from social services than from a bottle of pills.
Opioid Use Can Be Reduced
Of course, chronic pain itself remains a significant public health problem. But outside of those who are at the end of life, evidence suggests it is possible to reduce opioid use while managing pain and maintaining function and quality of life. That is why a well-structured deprescribing plan is essential to improve both clinical and social outcomes.
Time-pressed doctors can’t make much use of a weighty government tome like the proposed U.S. federal guidelines. Because of the potential for addiction to opioids, doctors and patients — like Ulysses — need a plan to get past the temptation before they start the journey. As we’ve seen, expecting to be able to navigate the pull of instant pain relief after the fact doesn’t work. A straightforward commitment to reduce opioid use, a specific set of recommendations to get there, and a network of support is the right prescription.
Jason Doctor, PhD, is co-director of the Behavioral Sciences Program at the USC Schaeffer Center for Health Policy & Economics and a member of the Australian Opioid Guideline Development Group.
Disclosures
Jason Doctor is a consultant to Motley Rice LLC opioid litigants.
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