Opioid Prescribing Limits for Acute Pain

Opioid Prescribing Limits for Acute PainJAMA – Jan 2019

Recent studies indicate that the amount of opioid medication prescribed for acute pain often exceeds the amount of opioid actually consumed by patients

as of November 2018, a total of 32 states have enacted legislation that limits the duration of opioid prescriptions to patients with acute pain or to patients new to opioids, in most cases to a 7-day supply or less.

Here’s another push to standardize (and make cheaper) our medical care. The designers of this nonsense disregard all individual variation and create arbitrary standards for medical pain management.

I don’t understand why they are allowed to create policies that oppose the neuroscientific facts and force doctors to follow them. 

Several organizations have enacted similar policies, including

  • at least 18 large private health insurers,
  • 1 major retail pharmacy, and
  • the 3 largest pharmacy benefit managers in the United States

Thus, opioid prescribing limits for acute pain are an increasingly prominent component of the policy response to the US opioid epidemic.

Potential Design Problems

Ideally, prescribing limits would achieve their intended effect, ie, preventing excessive opioid prescribing while avoiding unintended effects such as inadequate pain control.

However, limits on opioid prescribing will likely not achieve this goal because they impose a uniform restriction for patients with heterogeneous combinations of history of opioid use and pain needs.

Because of this heterogeneity, prescribing limits may either be too high to reduce excessive prescribing or too low to avoid the potential for inadequate pain control.

Of course, such rational thinking will not stop or even slow the current drive to reduce opioid prescriptions by setting scientifically-invalid standards.

For example, a recent population-based study evaluated opioid prescribing and consumption among 2392 adults who underwent 12 common surgical procedures (including hernia repair, hysterectomy, appendectomy, cholecystectomy, colectomy, and thyroidectomy)

there was wide variation in both prescribing and consumption, with 25th to 75th percentiles corresponding to 27 to 45 pills prescribed and 1 to 25 pills consumed.

That seems direct proof that standards are not appropriate in this case, yet the cruel standardization continues because it gives a good public image even if it causes damage to patients.

The variation in prescribing and consumption among patients has important implications for opioid prescribing limits.

Yet no one making the rules is paying any attention to this variability. Every organization is rushing to create invalid standards for every aspect of healthcare because standards make the practice of medicine easier and cheaper.

If the state instead institutes a 7-day rather than a 5-day supply limit, the potential for inadequate pain control would be reduced. However, a larger percentage of patients would continue to receive opioid prescriptions in amounts beyond what they require.

In short, raising or lowering the limit from 5 days would result in a different balance between intended and unintended effects but would not completely mitigate the problems inherent in the uniform design of prescribing limits, that is, the failure of these limits to account for the heterogeneity in prescribing and pain needs among individual patients.

Implementation problems such as clinician “gaming” behavior could also impede the ability of limits to prevent excessive prescribing.

Such “gaming the system” behavior erupts whenever standard metrics are applied. If doctors are in any way graded (and compensated) on how well they adhere to standards, their patients get a lower priority than their manager’s metrics.

These behaviors may be difficult to detect and prevent, because the entities charged with enforcing prescribing limits (eg, state medical licensing boards) may have the capacity to act only in egregious instances of noncompliance.

Yet, this is exactly how it should be. The medical board should not be deciding borderline cases, but only flag doctors who are prescribing truly excessive amounts (more than 2 standard deviations from the average).

Conclusions

Ultimately, limits on opioid prescribing will likely have some desirable effects on excessive prescribing, particularly among clinicians who would not change their practice in the absence of a mandate.

However, these desirable effects will likely be small and may be offset by undesirable effects on pain control.

If the limits are misapplied to prescriptions for chronic opioid users because pharmacists do not know whether patients have acute or chronic pain, the net benefit of prescribing limits on patient care would be more uncertain.

Why is the responsibility for opioid prescriptions is laid on pharmacists when they don’t even have access to the patients’ medical records. Most pharmacists work in giant chain stores or hospitals behind the scenes and never see the patients picking up prescriptions, so how can they possibly decide if an opioid is necessary?

A more evidence-based, patient-centered approach to opioid prescribing and regulation is necessary to achieve effective pain control while reducing the risk of diversion and misuse of unused opioids.

3 thoughts on “Opioid Prescribing Limits for Acute Pain

  1. canarensis

    The limits on acute pain really drive me insane; they basically guarantee creating a huge new population of chronic pain sufferers (that the sadists will refuse to treat). The BMJ article (https://www.bmj.com/content/360/bmj.j5790) on acute prescribing makes it really clear that you can bomb the hell outta the pain –dose has no effect on addiction. Addiction starts being a “problem” after weeks of dosing…but we’re still talking less than 1% of opioid naive patients becoming addicted, & most of those have prior addiction issues.

    But still, the first sentence in even that article implies the increase in opioid overdoses is from prescriptions…ARGH.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      Considering this used to be science, it’s incredible how much nonsense gets accepted by journals. JAMA & NEJM seem the worst offenders, and when such previously “gold standard” publications are willing to publish whatever convenient story someone wants to sell, it sure seems like impartial and rigorous science is dead.

      Liked by 2 people

      Reply
      1. canarensis

        Too terribly true. As I’ve mentioned before, the utter toiletization (to coin a word) of formerly reputable scientific journals almost makes me glad that I’m not in basic research any more…what’s the point, if knowledge is irrelevant & BELIEF conquers all? I just a few minutes ago read that the number of Americans who believe in the Biblical age of the Earth is growing apace. *sigh*
        i have no problem with people who get comfort & happiness from religion –sometimes I envy them– but when belief steamrolls evidence on concrete issues, such as geology & medicine…I want to pack it in.

        Like

        Reply

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