New policies, educational programs help—but don't solve—problems with opioid abuse

A recent study showed that medical provider training, new clinic policies and efforts to "taper" opioid use for pain treatment could significantly reduce the level of opioid medication that patients used—a limited but positive step for a nation enmeshed in opioid use, abuse and overdose deaths.

The findings were made by researchers from the Oregon Health & Science University and Oregon State University, and published in the journal Substance Abuse. They offer some of the first evidence to show that systematic efforts actually do help constrain opioid prescriptions, while raising both doctor and patient awareness of the dangers involved.

Such help, experts say, is desperately needed, given that prescriptions of opioid medications in the U.S. have risen about 600 percent in the past two decades, and the number of people dying from either prescription or illegal drug overdoses now exceeds those killed in motor vehicle accidents. In Washington state, deaths from opioid-related overdose increased by 17 times from 1995 to 2008.

This research was done with 514 patients who had been prescribed long-term, chronic opioid therapy. In one group of patients prescribed high-dose opioids, it showed that proactive steps and opioid dosing policies helped 37 percent of the patients to taper their doses to what's considered a safer level, 120 milligrams per day of "morphine equivalent." In many cases dosages were reduced by almost half—but the research also found that women had less success with the tapering approach.

"The approach used in this study showed progress, but not enough," said Dr. Melissa Weimer, an assistant professor of medicine at Oregon Health & Science University. "We'd rather have a higher success rate. But in some cases we're dealing with a generation of patients who have been prescribed high-dose opioids for many years."

The problems, researchers said, began in the 1980s and 90s as one part of an effort to better manage pain, especially for chronic, non-cancer pain, from such health issues as neuropathy or lower back problems. At the time, some experts even advised that opioid medications were neither harmful nor addictive.

"This is now known to be an extremely serious problem," Weimer said. "We have a prescription opioid abuse epidemic in the U.S."

A primary goal of this research, which was some of the first of its type, was to find out if an aggressive program to educate doctors, patients, and promote safe tapering of opioid doses would work. The study was supported by the Society of General Internal Medicine.

The researchers found that tapering, backed by health system policies and educational programs, not only could reduce dosages, but that patients who took substantially lower doses did not report any higher levels of pain as a result. But the issue is not simple, the scientists said.

"Part of the problem with these issues is that the concern is not just opioids," said Daniel Hartung, an associate professor in the Oregon State University/ Oregon Health & Science University College of Pharmacy, and co-author on this study.

"Many of the patients who are taking long-term medications for pain management often have other issues as well, such as anxiety, post-traumatic stress disorder or substance abuse," Hartung said. "They may be taking medications for those conditions, and sometimes these combinations can be dangerous."

A close collaboration and continued monitoring between doctors, pharmacists and patients would help to better address these concerns, Hartung said. Pharmacists who are often on the front line of patient drug use and management may need to play a stronger educational role and also be heavily involved in this issue, he said.

Among the other findings or observations made in the study:

• Chronic non-cancer pain affects 20-50 percent of patients in primary care, and has been increasingly treated with opioid therapy despite little evidence to support its safety or efficacy.
• Risk of opioid overdose and death increases when patients use more than 100 milligrams of morphine equivalents per day.
• In this limited sample size, clinical outcomes of subjective pain and quality of life scores did not appear to be affected by the opioid dose limitation policy.
• Female sex was the only significant predictor of less success with opioid tapering.
• Patients with substance abuse disorders succeeded in tapering their opioid doses as well as other patients.
• The length of time providers had been in practice was linked with greater prescribing of high-dose opioids.

While recognizing that the program helped, the researchers also noted that a year after policy adoption, only a minority of patients had successfully tapered their dosages below the policy threshold.

"Educational efforts and opioid dose-limitation policies may not be sufficient to decrease opioid misuse, addiction, or opioid-related mortality," the researchers wrote in their conclusion, "but they appear to be one step in the right direction."