Author: Molly Jeffery PhD @mollyjeffery
Commentary about: Jeffery at al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 2018.
With all the attention that is being paid to opioid prescribing over the past few years, we wanted to know whether we’re moving the needle: are fewer people taking opioids now than a few years ago?
Surprisingly, we found that the percentage of people who take opioids hasn’t changed much since the rates started to level off in about 2012. Specifically, among commercially insured people—people who generally get their health insurance from their or a family members’ employer—and people aged 65 and older who have Medicare Advantage insurance, we have seen very little change in the proportion of people taking prescribed opioids.
In the third population we looked at—people with long-term disabilities who have Medicare Advantage—we saw minor changes, but use has been nearly flat since 2012. And in all three groups, use was higher in 2016 than at the beginning of the study in 2007.
What does this mean? The United States uses opioids in a way no other country does. We use nearly twice as much opioids per person as the next closest countries (Canada and Germany), and about 7 times as much as the UK. We don’t know the ideal level of opioid use that balances risks and benefits to patients and societies, but it seems pretty clear that we in the US are above that ideal level.
To change that, we need to address two different problems. First, we need to do a better job with opioids for acute pain, and there may be a role for emergency medicine in that effort. In earlier work (https://doi.org/10.1016/j.annemergmed.2017.08.042
), we found that first-time opioid prescriptions (that is, prescriptions for people who haven’t taken opioids in at least 6 months) written in the emergency department were for shorter durations and lower doses than first-time prescriptions written in other settings. Still, researchers at UPenn have found substantial national variation (https://doi.org/10.1016/j.annemergmed.2018.06.003) in the proportion of people being treated for ankle sprains in the ED, with state rates as high as 40% and as low as 3%.
Some health systems have had success reducing opioid prescriptions by instituting voluntary prescribing guidelines. Here at Mayo Clinic, the department of orthopedic surgery looked at their data on opioid prescribing after surgery and developed a voluntary guideline that resulted in a nearly 50% reduction in the volume of opioids prescribed after hip and knee replacement surgeries (doi: 10.1007/s11999.0000000000000292). And this was accomplished without an increase in the proportion of patients requesting refills. In other words, the new lower prescribing does not seem to have negatively impacted patient pain control.
The second problem we need to address is opioid prescribing for chronic pain. Our study found that in the commercially insured population, the 3% of opioid use episodes that represented long-term use were associated with 62% of all opioids dispensed to that group. The scientific evidence suggests that on average, long-term opioid use is not an effective treatment for chronic pain (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm). Some patients are able to achieve improved functioning and pain reduction when using opioids long term, but most are not. We desperately need more effective treatments for chronic pain and better access to non-opioid treatments we already have. For example, multidisciplinary pain programs have been found to help patients with chronic pain improve function and pain management, but they can be expensive and difficult to access, with some insurers reluctant to cover them. (http://americanpainsociety.org/uploads/about/position-statements/interdisciplinary-white-paper.pdf)
Some have suggested that we need laws or policies to cut off access to high dose or long-term opioid therapy. The trouble with that is that there is no such thing as a one-size-fits-all treatment plan for pain. Different types of pain respond to different treatments, and so do different patients. Policies that require the insurance company to sign off on an opioid dose above some level can have an unfair impact on patients with fewer resources. If you have the cash to pay, you can fill that high dose prescription written by your physician. But if you need your insurance company to pay, you may have to leave the pharmacy without your medication. You may have to spend substantial time on the phone to get the treatment approved. You may have to wait until the physician and insurance company contact each other. It’s not the right way to treat people.
Reducing prescribed opioid use is going to take time to do humanely and effectively. It will take partnership between providers and patients, but it can be done.