There is no doubt that the widespread over-use of opiods has become a serious public health problem in the US. But I worry that older adults with palliative care needs may become unintended casualties of efforts to reduce the use and accessibility of these powerful drugs.
The opiod problem is real. Nearly 30,000 Americans died from use of these drugs in 2014. Some were stolen or counterfeited, but many were prescribed by physicians who were lazy, incompetent, or corrupt. The opiod epidemic meme has even found its way into popular culture. The other day, John Oliver went on one of his famous 20-minute rants against the overuse of the drugs and who he thought was to blame (Big Pharma, in case you were wondering).
Congress has noticed. And lawmakers are putting tremendous pressure on the Drug Enforcement Administration to do something. And, as these things go, the agency has responded.
Both DEA and the Centers for Disease Control are actively discouraging doctors from prescribing medications such as hydrocodone, oxycodone, morphine, and other opioids that are classified as Schedule II controlled substances. Two weeks ago, the DEA ordered a reduction of at least 25 percent in the production of these drugs for 2017. In some cases, manufacture will be cut by as much as one-third.
Earlier this year, CDC released voluntary guidelines aimed at discouraging primary care physicians from prescribing these drugs for patients with chronic conditions such as back pain. The CDC was careful to say that it was excluding palliative care and end of life care from the suggestions, and it carefully aimed the voluntary guidelines at primary care docs rather than cancer specialists.
Yet, there are risks of unintended consequences.
First, while some doctors have been guilty of overprescribing, others have been reluctant to prescribe opiods even when they are the best way for their patients to manage severe pain. And the growing government pressure to reduce use of these drugs may only add to their reticence, even these drugs are appropriate.
Then there is the matter of access. Officials at the National Hospice and Palliative Care Organization say they’ve already heard of patients living at home being unable to get these medications at their local pharmacies, and they worry that reduced production quotes will increase that problem.
Finally, there are the patients themselves. I often talk to older patients or their family members who strongly resist using opiod-based pain-killers, because they fear addiction or side effects.
Those concerns can be real. For instance, constipation, nausea, or drowsiness can be serious side effects of opiods. Yet preventing severe break-through pain is essential to quality of life. Many patients can benefit from non-drug alternatives or from milder medications. But for some, morphine and the like are the only meds that work. If all this attention makes these patients still more reluctant to take opiods, or to take them soon enough to prevent pain, they will become victims of a well-intentioned effort to control their use.
This issue will require a tough balancing act. On one hand, we need to do a better job of reducing illegitimate uses of these drugs. But physicians need to carefully sort out who needs them from who does not. The CDC’s recommendations include some important guidelines. In 2012, the British National Collaborating Centre for Cancer published its own guidelines for using opiods for palliative care patients. It is written in language that is accessible to consumers as well as physicians.