The unintended consequences of limiting opioids

See What the Opioid Crisis Took From People in Pain by Maia Szalavitz of The NY Times. Excerpts:

"For people with chronic pain, research is only beginning to show how widespread the damage from opioid prescription cuts is. One study examined the medical records of nearly 15,000 Medicaid patients in Oregon who were taking long-term, high doses of opioids. Those whose medications were stopped were three and a half to four and a half times as likely to die by suicide compared to those whose doses were stable or increased. Another study, which included the medical records of over 100,000 people, found that drastically reducing a patient’s opioid dosage increased the risk of overdose by 28 percent and increased the risk of mental health crisis requiring hospitalization by 78 percent.

Many opioid prescribing cuts were made under the auspices of guidelines published by the Centers for Disease Control and Prevention in 2016 to fight the overdose crisis. These guidelines recommend avoiding opioid prescriptions if at all possible and, when prescribing them for chronic pain, generally keeping the dosage below 90 morphine milligram equivalents, or M.M.E., per day — a measure calculated by comparing other opioids to the strength of morphine."

"The original guidelines were intended mainly for primary care providers, and the idea behind the recommendations was to stop communities from being flooded with painkillers. However, the guidance has been misapplied as a mandate, and all types of doctors, including pain specialists, have reduced or eliminated prescriptions.

By 2019, the authors of the original guidelines warned in The New England Journal of Medicine that they were being misused, saying, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.” That year, the Food and Drug Administration cautioned that it had “received reports of serious harm,” including suicides, associated with patients who suddenly had their medication discontinued or abruptly reduced.

But by then, states had passed legislation giving some of the recommendations the force of law. The National Committee for Quality Assurance, which provides standards for insurers, government agencies and medical organizations, made keeping doses within the guidelines into a metric — incentivizing doctors to taper or stop seeing high-dose patients. Insurers, pharmacy chains and government agencies also use the guidelines to inform restrictions, and law enforcement uses them when prosecuting physicians for running “pill mills.”

If these policies had reduced the death toll, some might argue that they are warranted. But they have not. Measured by the number of prescriptions written per capita, medical opioid use rates in 2020 were down to levels last seen in 1993, before OxyContin marketing helped spark the crisis. However, overdose deaths are still increasing dramatically, driven by illegally manufactured synthetic opioids and many who formerly got pharmaceuticals from doctors and now resort to dealers.

Even people the C.D.C. exempted from the guidelines seem to have been hurt. A 2022 study found that opioid use among patients with cancer fell between 2013 and 2018, with the steepest decline occurring after the guidelines were introduced."

"But these changes may not be enough. While the guidelines explicitly reject dosage caps, they continue to warn doctors to be wary of dosing over 50 M.M.E. per day, which could still be misread as a rule. Moreover, these revisions by themselves can’t undo all the laws, metrics and regulations that codified the old guidelines."