A Crisis of Opioids and the Limits of Prescription Control – by Stefan G. Kertesz and Adam J. Gordon – 23 July 2018
A rise in addiction and overdose deaths involving opioids in the United States has spurred a series of initiatives focused on reducing opioid risks, including several related to prescription of opioids in care of pain. Policy analytic scholarship provides a conceptual framework to assist in understanding this response.
Prior to 2011, a “policy monopoly” of regulators and pharmaceutical manufacturers allowed and encouraged high levels of opioid prescribing.
The authors then point out that the debate has been cornered by an “advocacy coalition” of anti-opioid fanatics:
This permissive policy fell apart in the face of adverse outcomes brought to public attention by an “advocacy coalition” consisting of
officials, [like the CDC bureaucrats who issued such blatantly biased guidelines]
thought leaders, [or at least those who believe they are thought leaders even without a lot of thinking – like A. Kolodny]
journalists [who have uncritically copied whatever drips out of the “thought leaders” mouths]
interest groups [like the recovery industry and stockholders of the buprenorphine business]
who shared common beliefs. [thanks to the relentless PROPaganda spread by anti-opioid activists]
I’m so happy to see this exposure of the profound bias of the CDC Opioid Guideline, which Dr. Kertesz correctly calls an “advocacy coalition”, not a proper scientific workgroup.
This coalition has generated a more cautious prescribing regime that has incentivized involuntary termination of opioids in otherwise stable patients, with resultant reports of harm.
Its emphasis on dose reduction regardless of outcomes in some ways mirrors the prior focus on minimizing pain scores, regardless of outcomes.
Central to the present analysis is that policies cannot be comprehensively rational; rather, they emerge from a range of actors and agencies constrained in their ability to
- assimilate complex data,
- objectively evaluate the data, and
- to command necessary resources
in an iterative, rapid response fashion.
The imbalance between strong prescription control and weak pain and addiction treatment expansion exemplifies the policy scholar’s notion of “bounded rationality.”
Results have been sub-optimum: opioid prescriptions have fallen, but harms to pain patients and overdose deaths have risen.
U.S. policymakers could revise course through a more thoroughgoing engagement with patients, families and communities now coping with both pain and addiction.
You can download a PDF of the article for free without any kind of payment at https://rdcu.be/3uns (that is the temporary ‘free download’ site and may expire in a while).
Here is the regular site for the article, where it’s still behind a paywall:
And here’s the press release from the University of Alabama where Dr. Kertesz works:
New efforts to control opioids become ‘funhouse mirror image’ of prior policies – July 24, 2018 – by Adam Pope
In a critical analysis of U.S. opioid policy, published today in Addiction, University of Alabama at Birmingham Professor Stefan Kertesz, M.D., and University of Utah Professor Adam Gordon, M.D., describes the swing in U.S. policies from encouragement of opioid prescribing to today’s increasingly rigid restrictions as simplistic responses to a complex human challenge.
“Neither the policies of yesterday nor those of today can be entirely rational,” Kertesz explained.
Our task was to explain how our collective irrationality has changed over time when it comes to opioids.”
The paper lays out some of the factors that lead policymakers to look for easy answers to complex problems, including pain and addiction.
The result, they write, is that insurers, legislators and other regulators are influenced by
“highly-informed advocates who can sway policy by predigesting data in ways that often reflect their own interests.”
This describes exactly what A. Kolodny and PROP have been doing. They got out in front of this crisis and managed to preset the public’s perception that the “opioid crisis” is about prescription drugs.
In the paper, Kertesz and Gordon… say the typical narrative that unscrupulous drug companies duped physicians and innocent patients is simplistic.
It neglects most efforts to understand how and why people use drugs or the communities from which they come. It presents doctors and patients as victims, rather than as people who also made decisions they may regret today.
Further, they argue, a simplistic narrative has led to simplistic policy responses, where controlling prescriptions has come to look like the easy answer.
They cite two major reports from 2017 that called for opioid prescribing restrictions. Both touched on addiction treatment, but neither demanded new funds to pay for treatment.
The result is a situation in which opioid prescriptions are “subject to an array of conflicting, high-stakes imperatives from an alphabet soup of regulators, employers and payers” who see reducing prescriptions as an easy numeric target, and very often the only target worth pursuing.
2016 Guideline on prescribing opioids from the Centers for Disease Control and Prevention… has been turned into a weapon against patients with pain, many of whom are now seen as liabilities by pharmacies, insurers and doctors.
we have also personally witnessed and otherwise appreciated an increasingly brutal effort to reduce prescriptions and reduce doses, without patient consent or in a non-patient-centric way. That’s wrong, too,” Gordon said.
The authors described a policy shift from
minimizing pain scores as the “5th Vital Sign”
minimizing “milligrams prescribed” (i.e., opioids).
“The new prescription control framework is a funhouse mirror image of the prior monopoly,” Kertesz wrote in the new piece.
“What was virtuous under the prior regime was to chase a number — the pain score — using opioid prescriptions, even as naysayers pointed out that people were being harmed.”
“What is virtuous under the new regime is to chase new numbers — opioids prescribed — even as naysayers point out other people harmed.”
The authors… favor restraint in starting opioids and greater efforts not to traumatize the patients who currently receive them.
Authors: Kertesz and Gordon are internal medicine physicians who have focused their research and clinical work on the primary care of patients with addiction and other vulnerabilities.