Oregon’s Proposal to Deny Access to Prescription Opioids Is Dangerous By Lynn Webster, M.D.

Here is the email I sent to The Oregon Health Evidence Review Commission (HERC) and its subcommittee, Value-based Benefits Subcommittee (VbBS), at the suggestion of a recent National Pain Report article:

I am writing in regards to the Oregon Health Plan’s proposal to limit access to opioids for people in chronic pain.

Certainly, opioid abuse in Oregon is a significant problem and should be addressed. But the proposed policy to force opioid tapering as a way to mitigate the opioid crisis is ill-conceived.

I receive dozens of emails from people in Oregon who struggle to find pain relief. Most of these emails are from people who have already been forced to taper, and their quality of life has greatly diminished. This story from a patient who refers to herself only as “M” is typical.

“Except for my recent surgery, I suffer pain and bed rest mostly but am not willing yet to ask for a prescription. I can walk into a store well but as the cart gets heavy my spine twists inside my body and causes so much pain I lose control of bodily functions. They know me at the store–know someone must take all my purchases out to the car. It is a life….This witch hunt is taxing the strongest of us. It is breaking so many. Life is unfair but this is just hideous.”

Stories like this one will likely increase in number if the Oregon Health Authority’s proposal to limit chronic pain patients’ access to opioids becomes law. It is important to find solutions to the drug crisis, but they must be patient-centered solutions. Complete elimination of opioids for specific pain disorders is not patient-centered, nor is it the right thing to do.

It is critical to recognize that the amount of opioids prescribed is only one factor that has contributed to the opioid crisis and may not be the primary factor. Lack of access to adequate mental health and addiction treatment have also contributed to the problem.

The Bulletin recently reported that the number of opioids prescribed in Oregon has been declining over the past several years. This is also reported on the Oregon Health Authority website (Figure 1). Prescription opioid-related overdoses represent about one half of the total opioid overdose deaths (Figure 2). According to the Centers for Disease Control and Prevention (CDC), there has also been about a 25% decrease in the rate of opioid-related overdose deaths since 2011 (Figure 3). The trends are moving in the right direction, but the proposed elimination of opioids for people in chronic pain may slow or reverse this trend.

https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Pages/data.aspx

https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/oregon-opioid-summary

https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/oregon-opioid-summary

The assumption that denying access to prescription opioids for those in severe pain regardless of the diagnosis will stop abuse is fallacious and dangerous. If Oregon implements this policy, there will likely be at least two negative effects:

First, people with a substance abuse disorder (SUD) who are using prescribed opioids for the wrong reasons are not going to suddenly stop using drugs because they aren’t readily available. Instead, they will seek other sources of drugs. People with an opioid use disorder (OUD) will turn to the streets for their opioid replacements. This may contribute to more deaths, because the streets are where the most dangerous drugs are found.

Several studies have shown the introduction of abuse-deterrent OxyContin led abusers to switch to heroin as a substitute when OxyContin became more difficult to obtain and abuse. The National Bureau of Economic Research is one such study that published a report on how supply-side strategies alone are inadequate for dealing with drug abuse in their 2017 report, “Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids.”

Second, people in pain who have been functioning on their medication without signs of abuse may lose significant quality of life. In some instances, people will feel abandoned and hopeless. It is not hyperbolic to suggest that some people in severe pain who are denied access to opioids will view suicide as the only way to escape their severe pain. Recent research suggests as many as 30% of unintentional opioid related overdose deaths may be suicides. Inadequately treated pain is a risk factor for overdoses and suicides.

The proposed alternative therapies such as physical therapy, acupuncture, and cognitive behavioral therapy are important to have as options but may be insufficient for many people in severe pain. Alternative therapies should be treatment options, but they are not necessarily replacements for opioids. Pain management must be tailored to the patients’ individual needs, and one size does not fill all. It would be an error to think that alternative therapies would work as well as opioids for all patients.

Before Oregon chooses to implement a new policy, it is imperative that metrics be introduced to measure the impact of any interventions on both the impact of drug abuse and the quality of life for people in pain. The Oregon Health Authority can improve the lives of people in pain while reducing the harm from opioids, but forcing opioid tapers is not an appropriate or compassionate solution.

Sincerely,

Lynn R. Webster, M.D.

Vice President Scientific Affairs

PRA Health Sciences

Past President American Academy of Pain Medicine

Salt Lake City

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