When opioid prescriptions drop, what happens to patients?

  | January 31, 2017

As healthcare leaders and policymakers try to tackle the opioid crisis, they can look to Massachusetts' experience as a success story — but also as a cautionary tale.

New data from the athenahealth network shows that opioid prescribing rates in Massachusetts took a sharp downward turn between 2014 and 2016, after strict state laws and awareness campaigns took effect.

But over that same time period, the Massachusetts Department of Public Health estimated that the number of opioid-related deaths in the state had reached the highest point to date. And last year, Massachusetts State Police saw a 16 percent uptick in overdose deaths with suspected connections to fentanyl.

Those numbers underscore a dilemma for the healthcare system. It's widely known that overprescription of opioid painkillers helped lead to the opioid epidemic. But some clinicians worry that dramatically restricting patients' access to opioids, without increasing alternative pain management options, is forcing vulnerable people to turn to whatever options remain: heroin, fentanyl, or other illicit drugs.

“We're seeing such a high rate of opioid-related overdoses because their prescription opioid source is being cut off," says Jeff Baxter, M.D., an addiction specialist at the University of Massachusetts Medical School. “The opiate drug abuse epidemic is really complex, but while there were concerted efforts to decrease the quantity of opioids being prescribed in Massachusetts, there was no effort to increase access to high-quality pain control."

By the end of 2016, according to athenahealth data, the opioid prescribing rate in Massachusetts had stabilized at its lowest level in two years: a 16 percent relative decline from the end of 2014, compared to an 8 percent relative decline nationwide over the same period. The analysis reviewed prescribing patterns of more than 500 Massachusetts providers across a variety of specialties.

That drop followed some big changes in Massachusetts law for prescribers, including a day-supply limit, dosage requirements, and a mandate that physicians update and check prescription drug monitoring databases each time an opioid is prescribed.

In his recent State of the Commonwealth address, Massachusetts Gov. Charlie Baker called out the medical community for prescribing 200 million pain pills in one year: “I'm a healthcare guy, and I'll stand with my former colleagues when their clinical judgment is being improperly maligned. But not this time."

But a policy-driven approach to addressing that problem has limits, some practitioners say.

"There are some really positive sides to the law," says Sarah Wakeman, M.D., medical director of the substance use disorder initiative at Massachusetts General Hospital. The initiative has been examining how to minimize opioid use — while also ensuring that patients are receiving compassionate care for pain and treatment for opioid use disorder.

“The challenge is ensuring we don't take a purely supply-driven approach to a really complex problem, as that won't be effective," Wakeman says.

Indeed, for many Massachusetts physicians, pain management has now become a black-and-white issue: Either they prescribe opioids, or they don't, says Daniel P. Alford, M.D., professor of medicine and director of Boston University's SCOPE of Pain, a program focused on educating clinicians in safe opioid prescribing for chronic pain.

The medical community is calling this "opioid-phobia," Alford says. But big changes in provider behavior haven't been replaced with education about — and coverage for — comprehensive and multimodal pain management services.

That can lead to a stalemate, Alford says, between a chronic pain patient and a physician who wants to lower an opioid dosage, but can't prescribe alternative therapies.

“If a patient truly believes the only thing that works for their pain is an opioid, then no matter what I tell them, they're much more likely to leave my care than to work with me. And it's hard to know whether those patients have an addiction or just extreme fear of returning to pain," he says.

Baxter, who treats addiction in family medicine clinics at University of Massachusetts Medical School, says he has noticed a steady stream of new patients seeking addiction treatment and counseling.

These patients are often in a gray zone between chronic pain and addiction, he says, but their prescriptions have been stopped, whether because new dosage limits have abruptly been imposed by insurance companies without coverage of alternate treatments or because physician behavior has changed.

"In the current environment, providers perceive a significant risk that good intentions could be misinterpreted," Baxter says. "In the past, when there was pressure to treat pain more aggressively, the quickest way to take care of a patient was to prescribe opioids. There was a liability to being perceived as not treating a patient's pain. But now the pendulum has swung, and there is pressure on providers not to prescribe opioids."

The rise in opioid-related deaths in Massachusetts, Baxter and other clinicians say, speaks to the lack of resources for this community of patients.

"It's why the 'War on Drugs' has failed. It prioritized tackling supply, without addressing the needs of the people who were using and why," says Wakeman. "Tackling the supply of opioids when people already have addiction is not going to reduce the number of deaths."

Chelsea Rice is a staff writer at athenaInsight. Follow her on Twitter @ChelseaRice. Illustration by Peter Pa​.

When opioid prescriptions drop, what happens to patients?