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Will efforts to rein in ‘creeping overuse’ of opioids succeed?

Prescriptions for opioids like methadone have increased almost fourfold in the United States in the past decade.

The New York Times ran a sobering article Sunday on the ongoing efforts to stop physicians from overprescribing opioid painkillers.

Over the past decade, according to Times reporter Barry Meier, prescriptions for such powerful opioids as oxycodone (Oxycotin), hydrocodone (Vicodin), fentanyl and methadone have increased almost fourfold, making them the most widely prescribed class of drugs in the United States.

Yet, as Meier also points out, the long-term effectiveness and health risks of these drugs remains unclear:

Studies link narcotic painkillers to a variety of dangers, like sleep apnea, sharply reduced hormone production and, in the elderly, increased falls and hip fractures. The most extreme cases include fatal overdoses.

Data suggest that hundreds of thousands of patients nationwide may be on potentially dangerous dosages. And while no one questions that the medicines help countless patients and that most doctors prescribe them responsibly, there is a growing resistance to their creeping overuse. Experts say that doctors often simply keep patients on the drugs for years and that patients can develop a powerful psychological dependence on them that mirrors addiction.

But changing old habits can be difficult — for doctors and patients alike.

In Washington state, Meier reports, a new law now requires doctors to refer patients who have reached a particular dosage level of painkiller (the equivalent of 120 milligrams of morphine) to an independent medical evaluation. The evaluation is intended to determine if the painkillers are actually helping the patient — and to encourage non-opioid treatments for chronic pain.

In some cases, evidence suggests, opioids impede rather than help with recovery from chronic pain. A Danish study, reports Meier, found that chronic pain patients receiving nondrug treatments recovered at a rate four times higher than those on opioids.

‘Chasing pain’

Washington state realized it had an opioid problem in 2006 when medical experts found some troubling data among the state’s workers’ compensation claims. Writes Meier:

Thirty-two injured workers who were prescribed opioids for pain had died of overdoses involving the drugs. In addition, in just a few years, the strength of the average daily dose of the most powerful opioids prescribed to patients treated through the workers’ compensation program had shot up by more than 50 percent. The number of patients taking the drugs in large quantities had grown to 10,000.

Doctors often increase opioid dosages because patients can adjust, or develop tolerance, to the drugs and need greater amounts to get the same effect. Pain specialists, including Dr. [Russell K.] Portenoy, [chairman of the pain medicine and palliative care department at] Beth Israel Hospital in New York, had argued that it was safe to increase dosages so long as doctors made sure that patients were improving.

But the Washington data suggested that doctors were not monitoring patients; they were simply prescribing more and more. Such practices are common, said Dr. [Claire] Trescott, the official at Group Health in Seattle, because treating pain patients, who are often also depressed or anxious, is time-consuming and difficult.

“Doctors end up chasing pain” instead of focusing on treating the underlying condition, she said.

The inevitable pushback

Drug companies are pushing back on efforts like those in Washington state to restrict prescriptions of opioids. A lot of money is at stake. Sales of prescription painkillers rose from $4.4 billion in 2001 to $8.5 billion in 2011, according to Meier.

Some patients with chronic pain are worried and angry about the new restrictions as well. A patient advocacy group, the American Pain Foundation, has called the Washington state law “inhumane.” (Although that group, as Meier reports, receives much of its funding from drug companies.)

But the pendulum seems to be swinging back, and restrictions on prescription painkillers may become more widespread.

“We started on this whole thing [the medical profession’s embrace of opioids] because we were on a mission to help people in pain,” one doctor told Meier. “But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives.”

You can read Meier’s article on the New York Times’ website.

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